Occupational Health Risk Surveillance

Link to Ramazzini Center



Spanish: Programa de Monitoreo de Riesgos de Salud Ocupacional

OH Cross-sectional studies
Cross-sectional studies constitute an important epidemiological design in occupational medicine as well as in other medical specialties. Valuable knowledge can be provided with low economic costs by the students and researchers without long training and experience in epidemiology under supervision from skilled researchers. Also this method is prefered in countries without access for researchers to the health registers. Even where health register are available, they only tell about the health effects and not about the actual wellbeing and the hazardous workplace exposures. All professionals are invited to edit and correct these pages including linguistic corrections by following the Wiki terms of references. Help to language translations with parallel pages in other languages is mostly welcome. Please create your Username, login, edit and save (Publish) the changes. Please create your Username, login, edit and save (Publish) the changes: Create Account. So improvement of the wellbeing of the workers and safe workplaces can be provided by repeated use of interviews, observations, standard questionnaires and analysis of the reported injuries and diseases and dissemination of the results. This program was from the beginning inspired by the need to carry out epidemiological risk assessment in the maritime industry for the prevention of the health risks. However, the maritime industry is a minor part of the transport industry and the researchers are mostly isolated from other occupational health researchers. So to enforce our research activities we want to collaborate with other occupational health researchers and professionals. Now we aim is to establish ICOH Scientific Committees in transport and seafood harvesters and industrial processing workers. One of the main tasks for the health professionals is to make a continous assessment and priorities of what should be done where and how in the industries for the health and safety. A permanent monitoring of the health risks and the health conditions in different segments of the industry uses various research tools like self-reported data, clinical data, morbidity and mortality registry data. The responsibility and the initiative to implement the needed preventive actions lies on the shoulders of the industrial management a continuing education in the occupational health system is needed. The program aims to survey the work and living conditions related health risks in commercial shipping, dock workers, fishing, offshore workers and seafood processing workers. The aim is to produce the needed scientific data for the primary-, secondary- and the tertiary health prevention in the industries. The aim is also to contribute to develop the Wikibook on occupational medicine Occupational Medicine Wikibook. See also for example the interesting OH cross-sectional studies in Revista Cubana de Salud y Trabajo The Danish "Society for Survey Research" aims to be a forum for exchange of experience in relation to the promotion of research in and application of survey methods, ie. surveys using questionnaires (Dansk Surveyselskab ) The European Survey Research Association provides links between European survey researchers and their colleagues in other parts of the world

Background
A multitude of research over the latest decades show that the "human factor" is the main etiological factor for occupational accidents on board and ships disasters. "The human factor" however, is not examined by the inspections by the Maritime Authorities and either by the MLC inspectors which can be crucial for the ships safety. MLC2006 surveys include inspection of the written agreements on rest,contracts for the crew, valid certificates, sufficient number of crew etc. The ships´ conditions are questioned, but the sailors are not questioned. The lack of a systematic monitoring of seafarers working environment in action at sea means that "the human risk factors" are not inspected by the National Maritime Authorities and neither by the MLC inspections. The ships inspectors are trained in ships safety but not in occupational health and public health. Moreover the inspections are completed while the ships are in harbor, so the inspectors cannot observe the work processes and see all the risks on board. That means that the active work activities and the related possible health risk exposures cannot be assessed. The seafarers are not asked about their self-rated impression of any possible health risk hazards and improvement of the MLC program implementation related to the daily work processes at sea. The work schedule on board is often 7 days a week and 12 hours a day where fatigue and lack of good sleep is never questioned. The MLC inspections should ideally inspect that the recommended limits of hours of work, the manning and work conditions are complied. The ILO's Maritime Labor Convention entered into force August 20, 2013. There is however no effect evaluation of the implementations as there should be in such a huge ILO program. So the question is whether this really provide a comprehensive protection for all the seafarers as the video says?? or is it more like the "The Emperor´s New Clothes" ? Register based morbidity and mortality studies can answer some of this with many years delay. The method we propose can give some answers here and now about the effect of the implementation of MLC programs. Surveys on the workers self-rated evaluation of the working conditions have been used for workers on shore in decades but only in very few studies for seafarers. In Sweden, electronic questionnaires were sent to approximately 5000 seafarers with an email address in the Swedish staffing register (35% response). The noise, risk of accidents, hand / arm vibration and psycho-social factors such as harassment were frequently reported as a major safety problems in the merchant fleet A citation from one of the authors: "The web-based questionnaire was quite extensive but many questions were tailored for different job-categories on board. The results ought to be quite rewarding also for the shipping companies, unions and the maritime authority, which can target their inserts where the most needed". In Norway, questionnaires were sent by mail to all employees (2265) in the Norwegian Navy (civilian and military) (58% participated). Exposure to noise, heavy lifting, hazardous postures and work close to the antennas and communication equipment occurred frequently in this population. The most commonly labor-related diseases were hand eczema, hearing loss and low back pain. It is concluded that the project provides a basis for further action with regard to work health safety and environment within RNoN. This method has been used on shore for many decenia in the OECD countries for the benefit of the workers´health, just to mention some of them : Sweden, Norway, Finland and Iceland. "Nordic occupational health questionnaires" has been developed and used international, first on musculo-skeletal complaints and later on skin diseases, psycho-social health and safety culture. The method has been introduced over the latest ten years in Latin-America     Review of the surveys. Like in other countries, the access to the data from the health registers are restricted and under-reported. So the use of survey is the only possibility to get useful data for the prevention. During the ISMH14 some of the participants talked about the possibility to establish an IMHA-Research multi-center survey on the self-rated occupational health risk factors at sea in order to amend the gap of monitoring the human work and living conditions on board, which is crucial to prevent the negative human risk factors. The idea of this project is that each country contributes with comparable data that can be summed up for a more complete description of the human risk factors. The use of short forms with few items is supposed to give a higher response rate and students can use the survey as part of their thesis under supervision of qualified scientists. The students and the professional scientists will publish the results on their national issues and be the first authors of various publications and reports. Further the intention is to store all survey results and sum up the data in reviews to give an overall status of health and occupational health risks in different segments of the shipping industry. International collaboration in maritime health research is needed as the national research groups are often small and unable to do larger studies. Sharing the strengths will help to get more and better studies to help to obtain the best possible working- and living conditions for the seafarers. While the survey method gives useful results here and now, the register based cohort studies may be in some cases be useful as the evidence for insurance cases, but most often not for planning of intervention programs. We need to know whether these health risks exists today. An introductory review of register based studies was recently given by Forsell et al 2017: They point out that cancer, ischemic heart diseases, psychiatric diagnoses and suicides were more common among seafarers than on-shore workers at that time. However as the "responsible" health risk exposures happened 30-50 years ago, we cannot know if these exposures exist today and this underscores the need to use the survey method.

Mission
The idea behind this program is that we together take the responsibility and work for the development not only into a healthy maritime sector but also healthy onshore industries. This means that in an overall perspective we act as a responsible public- and occupational group of health professionals. This is needed in the absence of any other organ that takes an overall responsibility for the research on the health conditions for the workers globally. So we take the strategic responsibilities of health for all under the WHOs responsibilities in the programs of Health for All. Any professional specialist within our organization have to take their part of the responsibility for a quality in health in coordination with the others. This means for example that the medical personnel have to take the responsibility to survey and to help to amend any lack of validity of the laboratory results that comes from the routine health examinations, just as an example.

Aims of the survey program

 * To create an international network with the aim to monitor health and the work-related risk factors on board and onshore
 * To perform intervention programs based on the studies and evaluate the effects
 * To perform systematic literature reviews on selected problems
 * To increase the statistical strength by pooling samples with identical questions and demographic information
 * To describe the prevalence trends of the risk indicators by repeating the same questions to the same persons with years intervals
 * To ask the seafarers and dock workers about their knowledge to solve the specific risk factors
 * To provide the ships, companies, maritime authorities and the unions new knowledge about the risk factors for prevention
 * To provide the companies with new data to identify areas where it is appropriate to take steps to reduce the risks

Long-sighted aims

 * To evaluate the effect of the MLC implementation by summing up the data from all partners for a global status.
 * To strengthen and retain seafarers' working efficiency, health and job retention.
 * To contribute to the best economy and competitiveness of the companies
 * To use the data to construct job-exposure matrix for research and the management of  health, safety and environment
 * To deliver data on how the safety, health, welfare, working- and environmental environment evolve over time
 * To support sustainable shipping with respect to health, safety, economy, energy and environmental protection
 * To deliver data showing companies' improvements over time and the effects on the above parameters
 * To create a strategic intervention program on health and evaluation

Scientific aims
The aim is to help to create Health promotion Program. The goal is for everyone to benefit from the project, both for seamen and fishermen and other types of industries. The project focuses on the safety and health but we also want to consider it as a management project, which has a good impact on corporate culture in the seafaring, the fisheries sector and all industries with the benefits all parties the workers, owners and the community. The scientific aim is to produce data and publications that convey new knowledge of high validity based on the newest scientific principles for conduct of studies in peer reviewed publications. Our vision is to produce and communicate high-quality research results that are relevant for all stakeholders for the development of health and safety at large. The production of new knowledge comes from larger or small scale research projects, e.g. surveys as part of university Diplomas and Master studies and more comprehensive studies as PhD studies. In any case we recommend to use The Equator-network guidelines in well designed epidemiological studies. An honest goal is to inspire and educate younger scientists on how to do high-quality research and publications for pre-grade thesis, and postgrade Diploma, Master and PhD studies. Further the aim is to create evidence based strategic intervention programs based on the survey exposure data linked to the health outcome data from the national health registers. The first survey and intervention programs will be on mental health among seafarers and occupational health and safety for dock workers.

Expected use of the results in the workplaces
The constantly updated knowledge of occupational hazards in the working environment is expected to help employees and the companies keep pace with a good working environment. The analyses of the indicators in the different demographic variables, age, job, work area, etc., identify the most important areas for occupational health preventive interventions in the companies. The results could be used as training material and could spil over to relevant modules.

Hypotheses
It is the aims to test the hypothesis that the physical and psycho-social working environment of the companies/ships differs by ship type and size, area of work, job type of the ship and other industries onshore. Further that there is a connection between the working environment, lifestyle on board/at work and home and the health and welfare of the employees. More specific hypothesis will be launched in relation to the maritime/professional school surveys and for specific themes and questions in specific job-categories and types of companies.

The study populations
The program is intended to be useful for planning of the preventive actions in different sectors of the maritime industry: merchant seafaring, cruise shipping, ferries, small and large fishing vessel, the oil- and gas industry platforms and the dock workers. Similar programs could be useful for shore based industries. The target study populations are smaller or larger samples in specific segments in shipping, job-types and work areas on the ship with follow-up for many years where this is possible and gives meaning. The idea is that the participant countries carries out surveys annually or biannually and the data are used for 3 purposes: 1) for analysis and publication of the national sample data, authored by the national partners 2) for pooling of the data from many countries for "big data analyses" to be used in PhD studies and similar and 3) for construction of job-exposure matrices in the different segments of the industry to be used for an updated exposure assessment and for exposure information in health register data cohort studies. This include cohorts for specific type of vessels and specific job-categories for example the engineers, where the union allows for the e-mails of their members. There is good evidence that the youngest workers at sea sustain the highest incidences of occupational injury and represent a vulnerable target group for health and safety prevention   In shipping we also find the highest incidence rates of injuries at work in the youngest ages but not significantly in fishing   A dropout rate of 60% from the fishing school in Thyborøn, Denmark has been reported recently In a Swedish study about 35% of the youngest fishermen left the job of different reasons in the first three years There seems to be good reasons to give more attention to the youngest age-groups at sea to keep them healthy and safe in the job for many years and thus to establish maritime school birth cohort studies.

Study design
The self-rated and actual living- and working conditions are revealed directly from the cross-sectional study design in the surveys. The latency problem with mortality and morbidity register based cohort studies for planning of the preventive programs can be illustrated in Figure 3. In contrast the negative health effects from the actual health hazards have many years of latency after the exposure until the first symptoms appear and the more developed, diagnosed and registered diseases show up in register based long-term cohort studies So in order to plan a timely and adequate preventive intervention program, cross-sectional study design on the seafarers own perceptions of hazards in the working environment are needed. But also objective technical measurements and observations on board, are needed to supplement the cross-sectional studies. Even in the regular MLC tjeck points, the seafarers own perceptions of hazards in the working environment are not questioned. As all job-carriers at sea start at the maritime schools it seems natural and feasible to establish maritime school study cohorts also inspired by school based cohort studies in other industries adolescent health surveillance International collaboration on birth cohort studies from maritime schools would give statistical sufficient large cohorts can be fruitful completed within a few years follow-up. The research questions include drop-out prevalence rates, the causes for drop out, injury incidences, mental health complaints and the barriers to comply with the healthy eating pyramid advice. Also the students´ evaluation of the quality of the school programs and comparison of the schools´ curriculum in different countries can be done within a few years of follow-up. Extension of the follow-up time would be worth doing by pooling data from the maritime schools´ birth cohorts and link the data to the national mortality and morbidity registers regarding the fatal accidents and other registered health outcomes

Mixed Methods
The intention is to build on a wholistic approach to better monitor work related health and safety. A combination of quantitative and qualitative methods for data collection are considered. Furthermore, data collected from twining Universities will be used for cross-sectional studies with the respective countries. The research takes places with standardized, validated questionnaires. These questionnaires include: the Nordic Ergonomics Scheme, for the descrition of the ergonomic situation, the Nordic Safety Climate Scheme dealing with the safety issues in the working environment, the Copenhagen Psycho-Social Social Questionnaire (CoPSQ) reflecting besides the mental health issues, more general concerns related to the the organisation and management of the company and the General Health Questionnaire (GHQ) which gives insigt to the employees health concerns. All relevant demographic and epidemiological variables are taken into consideration for each country as well as: discipline, position, type of vessel/workplace. These allow for valid comparisons over time and between the different disciplines and types of work to identify needs for prevention interventions.

The equator-network reporting-guidelines
Prior to conducting a cross-sectional survey, the field is searched as a systematic review. Specific requirements are set for a systematic review that must be adapted to the extent of published research. There are several guidelines for how to do this, PRISMA has been the standard for many years and now the Prima-scoping guideline has been added for areas that are less explored.

The research groups
Students from the universities are inspired to do their thesis based on this program. Invitation to complete the electronic questionnaires on their mobile phones are sent by mail to the participants. Google Forms or other IT survey programs they are most familiar with. The universities have normally their own survey systems. The systems must be able to export the data in an 'Excel compatible form so that all the national survey data can be summed up in a common database for "big data" analysis. Data are collected directly from the classes in:


 * Maritime universities/schools
 * Public Health Schools,
 * Medical schools,
 * Nursing schools,
 * Other maritime and dock workers training centers

Datacollection
Data collection is done in different places. The list of e-mails for the seafarers are handed over to the researchers from the institutions that are willing to do this under the highest ethical standard for personal privacy. The shipping companies, unions, maritime authorities and seafarers medical clinics will be asked to help with the list of mails: Alternatively the institutions keep the mail addresses by themselves and they send out the mails with the link to the questionnaires, collect the answers and send the results in the Excel file without any personal ID information for personal privacy.
 * Seafarers Union members´files,
 * Dock workers, seafarers, officers and fishermen´s training centers
 * Shipping companies´ manning registers,
 * Maritime authorities
 * The Seamens´ Church and the seafarers´ homes
 * The medical clinics request the seafarers to complete surveys in the waiting room
 * The Social Media like Facebook page with the address for Google Form Survey

Survey themes and research questions
The selection of the survey themes and the research questions is based on the aims and strategy of the program and the researchers´ personal interests and not at least the existence of research groups with shared interests and willingness to offer their time for the work. The existence of validated questionnaires may also help to select the research questions. The preliminary proposed main research themes are the following:
 * Psycho-social work and free time environment and complaints
 * Knowledge on risk factors and the relation to health complaints and diseases
 * Muscular and skeletal difficulty and physical workload
 * Skin complaints
 * Occupational injuries
 * Safety culture and management
 * Occupational epidemiology, job-exposure matrix
 * Chemical working environment, toxicology, nano-safety and microbiology
 * Welfare on board, sleep, rest, free time and contact to home
 * Physical environment, noise, vibrations, heat, humidity
 * Work hour schedules, number of months out and home
 * Indicators a priori for repatriations from the sea

Experiences from the Swedish survey (Forsell et al. 2017) learned us that specific questionnaires are needed for specific segments of the seafarers and the ships. So it seem to be a feasible way that every country takes care of some specific segments of the industries and specific hazards.

The Multi-center Program Statement
The partners are requested to follow the multi-center program statement to strengthen the collaboration and the evidence from pooling comparable data from surveys in different countries
 * 1) To establish national research groups and student groups
 * 2) To use the already validated questionnaires in the questionnaire library
 * 3) To develop (modify, shorten down) new questionnaires for specific items and perform test-retest and psychometric validations
 * 4) To sample data from many countries same questionnaires, analysed as one big sample, like in the  ISAAC The International Study of Asthma and Allergies in Childhood
 * 5) To add variables about ship, person, birth year (school projects: matriculation year, type of education, maritime school, city, country) to obtain comparable data.
 * 6) To transform and edit the validated standard questionnaires for use in Google Forms and add them to the Blue Risk Survey Database
 * 7) To complete a research (re-use texts) protocol, time schedule, budget and person tasks Go to tjecklist cross-sectional
 * 8) Use the scientific statements The Equator-Network for observational studies
 * 9) Publish articles in scientific journals, upload Excel data sheet, the protocol and the published articles in the Blue Risk Survey Database (see below)

Step 1 Development of the survey tools
The plan is to develop and re-use standardized questionnaires that are validated and have been shown to be useful in similar surveys before. The Danish National Research Center for the Working Environment in Copenhagen has developed and used questionnaires for surveys with self-rated evaluation of several important issues in the working environment over 30 years. publikationer/spoergeskemaer/nosacq-50/nosacq-50-translations The validated questionnaires have been developed for use in small, medium and the large sizes mainly for research use. Over the years a long row of scientific articles on the results and the validity tests of the questionnaires are published and allowed for free use. This is very appreciated by the maritime occupational health development, that stands years behind the occupational health research behind the shore based. Most of the validated questionnaires have been developed in collaboration within the Nordic countries with support from the Nordic Counsil. Some of the standard questionnaires can now be important parts of the maritime health multi-center project and the project can now take great advantage of the great work already done in the Danish National Occupational Health Research Center. Besides there is a need to develop and validate new questionnaire specifically for the maritime workers for example on dental status. Several cross-sectional studies on maritime occupational health have been published. The authors are invited to join the program and to validate their questionnaires for a the collaborative survey program. This will be a long process and the success depends on fruitful international collaborative results.

Data reliability
Generally it is recommended to use questionnaires from studies where the validity has been tested with good results also for reasons of comparison of the results. In the Danish and the international seafarers surveillance project the questionnaire data about type of ships, position and work area on board and the number of days at sea was held up against data from the DMA that showed good comparability. Also test- retest of the questionnaires was used. In the projects the data validity also need to be evaluated. Study with the validity of The short version of COPSQ Link to pdf

Table 1 Questionnaires on single items
https://www.questionpro.com/survey-templates/boredom-proneness-scale-survey-template/

Step 2 the questionnaires are prepared for electronic survey tools
In the second step, the original questionnaires with explanations will be further edited for use in the Google Forms. The translations to different languages is needed. The process of validation is reported. The Copenhagen questionnaires are already validated and used on shore.

Data Processing and data analysis
All data are transferred from the Excel format in the Google Survey instrument to be available as a SPSS data file for statistical calculations. Data will be handled in strict confidentiality anonymously by the respective researchers and they can receive help for analysis from other centers. The data will be kept in separate databases in order to pool the data for analysis and follow-up studies later. Data Protection Agencies are informed by applicable law. After data gathering is complete, the Excel files are converted to Spss file for analysis. Tables are provided in percentages, in numbers and kind of ward/department. Each national group can analyse their country-specific data and/or they can ask for help from other countries. Statistical analyses are performed and data are checked for outliers and normality. The analyses include descriptive frequency distributions for all variables; differences between groups are tested using chi-square test, student's t-test or variance analyses. Logistic regression analyses and multi-level analyses are used to examine trends and differences among seafarer´s groups, sectors and countries.

Job-exposure matrices
Job-exposure matrices are constructed based on the cross-sectional data and the hygienic measurements on board to estimate the type and level of exposure in different job-categories. The aim is to establish a dose response relationship between the relevant exposures on different vessels- and job-types and the health effects in the long term. By assessing as an example the causes of hearing loss and tinnitus, the actual exposure levels of the crew to noise over several years in the relevant areas of the ships. This method is rapidly evolving at the work environment research among shore occupations, but has not previously been used at sea. This despite the fact that the method seems to be particularly useful for working on ships since the construction of the various types of ships globally are very similar. The possibility of a fruitful international cooperation on descriptions of the exposures is obvious. The development and the use of the job-exposure matrices and the linking to register health data in cohort studies is quite resource demanding and requires funding in the national research institutes. Rafi will take the lead of developing the strategy for this specific task.Shipbuilding traditions allow for comparability of the survey data. China, South Korea and Japan are the main constructors of merchant ships with 83% of all Shipbuilding 2015. While modern shipbuilding makes considerable use of prefabricated sections, this allows for compare of data collected in different countries. The architecture of the large container-, tankers, cruise- and passenger ships has been the same for years. Still the building year of the ships is needed to be recorded in the surveys for construct the year specific job-exposure matrices. Objective measurements should be applied to the matrices, for example on noise, heat and vibration levels. These data might exist in the shipping companies and or occupational health service files. Its an important task is to search for this type of objective measurements of heat, noise, vibrations and particles in the in-door air on the ships, in the companies or in the Maritime Authorities. This is unknown in our group and far no-one has ever asked for such measurements, even that these parameters is of paramount importance for the objective assessments of the seafarers health environment.

Informed consent
The participants will be explained the purpose and details of the study through consent from the beginning of the questionnaire before the start. All of information from the participants will be confidential and only used for scientific purpose.

Ethical requirements
The ethical rules for database research in (Denmark and for the University of Southern Denmark) are complied with. Confidentiality in handling personal information is done according to the rules set out by the Danish Data Protection Agency. There are no personal sensitive information included so approval from the Ethics Committee or written informed consent is not necessary. Data and results will be used for (the public health master thesis in the University of Southern Denmark from the period...) The supervisors take care to secure that the data is processed under the Act on medical confidentiality as guidelines for good epidemiological practice will be followed. The participants' anonymity will be protected in every way and this will be indicated in the project description and schedule. It will be ensured that the electronic table is locked so that the information can not be seen by anyone other than the researchers.

Optimal 2-3 items in each of the surveys

 * Basic information on person and ship, gender, nationality for all the surveys also for pooling of the data
 * Days at se and hours of work
 * Access to internet at sea
 * Knowledge on work related risk factors and their health effects
 * Safety culture and leadership climate on board
 * Occupational exposures on board:
 * Noise and vibrations
 * Bullying
 * Women seafarers specific environment
 * Dental health and knowledge on prevention
 * Ergonomic health complaints and hazards
 * Tobacco alcohol (on board / home)
 * Food and drink (on board / home)
 * Physical activity (on board / home)
 * Sleeping hours and quality
 * Mental health
 * Stressors and Symptoms
 * Fatigue and burn out

Analysis of trends in health and exposure to specific risks over time in the main populations strata
To apply data from repeated surveys and analyse the prevalence of indicators over the different strata of job position, work area, ship types, age, gender and nationality by logistic regression analyses like in these study examples: Due P et al. 2019 (Link to full text) Trends in Social Inequality in Exposure to Bullying at School 1994-2018 and Knoblauch AM et al. 2020: (Link to full text)Community Health Impacts of the Trident Copper Mine Project in Northwestern Zambia: Results from Repeated Cross-Sectional Surveys

Communication of results

 * National reports to the unions and funding entities
 * Scientific articles to international journals
 * Presentation of results at national conferences
 * Presentation at the ISMH´s and other international conferences

Clinical data monitoring and occupational risk indicators
The aim is to contribute to the prevention of occupational diseases in any type of industry. Method: registration of clinical data and work-anamnesis, from routine health examinations. The scheme can completed on the iphone together with the patient, who can correct directly any errors. All answers are kept in Excel format with the ID and the answers can also be printed out in Pdf or paper. Summary data are analysed without names and with no personal identification, so that all information are kept strong confidential Clinica Einstein Data monitering

Occupational health and population register data monitoring and single studies

 * 1) Data from national and regional health surveys
 * 2) Data from Metro company and other companies statistics registers
 * 3) National congenital anomaly and rare disease registrations
 * 4) Statutory notifications of infectious disease
 * 5) Laboratory reporting of microbiological data
 * 6) General practitioner clinical codes (SNOMED CT)

The Blue Public Health Surveillance and Intervention Program
The ILO introduced the SOLVE training package: Integrating health promotion into workplace OSH policies in 2012. The material covers the management of health promotion at the workplace to deal with nine topics: stress and economic stress, violence, tobacco and smoke-free workplaces, alcohol and drugs, nutrition, physical activity, healthy sleep and HIV/AIDS. The package includes a participant's workbook, a trainer’s guide, lesson plans and a CD-ROM with presentations and background material.A specific package has not been introduced for seafarers and fishermen, but is highly relevant and the program will be research based. The seafaring employees face more difficult working conditions and living conditions in the sea than the employees working on land. Their health is affected by the environment in which they live, often coupled with long working hours that contribute to eating more carbohydrate food and less physical activity in a working environment with high demands and long working hours loneliness and stress. This proposal seeks to improve the seafarers’ well-being on board that attracts the youngest seafarers to choose and to stay in the job by including the whole maritime industry. The task is to create responsibility among all stakeholders to help to create a comprehensive occupational- and public health program at sea that includes the whole maritime industry. Methods: The theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, ship owners, maritime authorities and a network of universities´ research centers and maritime health departments studies include We should establish an international comprehensive public- and occupational health promotion program for the whole shipping industry. The objective to improve the quality of life at sea by starting in the maritime schools. Theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, and a network of universities´ research centers and maritime health departments studies include:
 * 1) Repeated surveys (and new scientific studies) on knowledge, attitudes and occupational health risk factors
 * 2) Monitoring of clinical variables and exposures on board (physical, mental, chemical, ergonomic..)
 * 3) Based on that, health and risk reduction education in the whole industry
 * 4) Monitoring of health and working health risk indicators, diet and exercise
 * 5) Based on that to point out polices with the specific needs for structural changes in the workplace (ILO SOLVE)
 * 6) Implementation of best practices for health promotion in the companies and on board and follow up of the effects
 * 7) Empowerment of the youngest,training,  problem oriented learning to promote quality of life at sea
 * 8) Political and international guidelines to reduce risk factors that will not else be changed due to economic factors.

Maritime Mental Health Surveillance and Intervention Program
The seafaring employees face more difficult working conditions in the sea than the employees working on land. Their mental health is affected by the environment in which they live, often coupled with long working hours that contribute to stress, anxiety, loneliness, depression and suicide. This proposal seeks to improve the seafarers’ mental health by introducing a comprehensive, evidence-based global maritime mental health promotion program that attracts the youngest seafarers to choose and to stay in the job. Methods: The theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. Our main task is to create responsibility among all stakeholders to help to create a comprehensive occupational- and public health program at sea that includes the whole maritime industry. A joint action among the unions, the ship owners, the maritime authorities and a network of universities´ research centers in suicide prevention, public health and maritime health departments includes:


 * 1) Review studies on: 1) suicide 2) prevalence of depression, quality of life, social isolation, loneliness and associated risk factors;
 * 2) Cohort studies of students from maritime academies with baseline questionnaires and follow-up after experience gained at sea and every 5 years thereafter
 * 3) Studies of the level of knowledge and training needs in mental health and the risk factors for training development - also on diet and physical activity
 * 4) Analysis of the etiological indicators for the drop-out rates of the students and trained seafarers;
 * 5) Training methods for the maritime students, seafarers and personnel in the shipping companies in groups with problem solving and life-long learning;
 * 6) Organising the students into small groups that stay in contact via the social media and help each others while at sea and at home;
 * 7) Training the students to assist each other in difficult situations and educating them in navigating mental health environments on-board and onshore;
 * 8) Giving mental health care training to all employees and age groups through classes, online courses, information materials and through the obligatory health examinations.

The research-based background for the program is supposed to be effective with adequate amendments over time. Empowerment of the youngest seafarers through life-long- and problem oriented learning is supposed to be attractive while they are asked to help to create the quality of life at sea. Political and international guidelines will be needed to minimise those risk factors that will not else be changed due to economic factors. As mentioned in our mission, we see the maritime sector in an overall perspective where we act as a responsible public- and occupational group of maritime health professionals. This is needed in the absence of any other organ that takes an overall responsibility for the health conditions for the seafarers globally. So we take the strategic responsibilities of health for all seafarers under the WHOs responsibilities in the programs of Health for All. Any professional specialist within our organization have to take their part of the responsibility for a quality in health in coordination with the others. This means for example that the medical personnel have to take the responsibility to survey and to help to amend any lack of validity of the laboratory results that comes from the routine heatlh examinations, just as an example.

==Dock Workers Health and Safety Surveillance and Intervention Program open here== The employers have the full responsibility for health and safety in the ports. However the unions often take initiatives for better safety and health together with the university research units and the regional occupational health departments. The strength of the unions participation is that the unions and workers know the workplace hazards by own experiences better than the owners and the administrators.

Registration of Work related diseases in the clinics
Patient records in clinics are unique resources that can provide knowledge for better patient diagnostics, treatment and prevention of the working conditions. All types of clinics can participate in collection of data for research. By using the forms the physicians will identify complaints that are work related and the prevention should be done at work. For a start to complete and analyse 100 schemes would be a great contribution to better knowledge and prevention. The schemes are prepared for General Medicine, Psychiatry, Dermatology and Maritime medicine but other specialties like Rheumatology, Cardiology, Respiratory- and Neurological clinics can benefit by using these schemes.
 * Medicina Maritima encuesta sobre enfermedades del trabajo
 * Encuesta enfermedades dermatologia del trabajo
 * Medico familiar Encuesta sobre enfermedades del trabajo
 * Encuesta enfermedades psychiatria del trabajo
 * Encuesta enfermedades psychiatria del trabajo

Agenda and minutes from meetings

 * A general meeting with all partners will be held at the International Symposia of Maritime Health (Next Hamburg 2019)
 * Partners in neighboring countries are inspired to meet and have Skype meetings
 * The national partners have one of more annual meetings.
 * The minutes of the general meetings will state which standardized questionnaires are agreed to be used in the regional surveys.
 * The minutes of the national and general meetings will be posted in these pages

Finansial issues
Different types of human resources and financial support needed: 1) small scale surveys with low budget and voluntary assistance can be done as part of students´ thesis and contribute to larger pool of data  2) more comprehensive studies, based on pooled data, development of exposure matrix and register based studies in PhD studies will need larger financial support from international funding.
 * Minor surveys can be done for free by retired seafarers, retired medical doctors, scientists and others that can work "con amore"
 * Students can use the surveys to produce an article for their thesis also under a low budget
 * Unions and other organizations that want to survey some specific questions is very welcomed
 * The partner countries are responsible for human resource and/or financial support to their surveys and the coordination activities.
 * Application to national and international funds to support "non-salary" purposes, for travel, hotel and other expenses in national, regional and international meetings
 * Low budget communication with Skype meetings

DISCUSSION
Based on previous experiences, it is probably difficult or impossible to manage an active network of collaborators. However it has been shown to be realistic the students in public health and maritime educations do their thesis based on data from standardised surveys. The intention is that the students produce their thesis based on the international guidelines for reporting cross-sectional studies. In 2 cases the master thesis was later revised and published in an international scientific journal. It is important to consider the response rates for electronic questionnaires; short questionnaires seem to improve the response rates

Other possible development
Standard test sleep fatigue cognition farhadazimi@aut.ac.ir

Photo documentation
Occupational medicine aims for the prevention among workers of departures from health caused by their working and living conditions. The protection of workers from risks resulting from factors adverse to health need to be studied by epidemiological-, qualitative and other types of research, including documentation with photos. Consider photos related to health and safety at the work places, in the transport etc. in 4 aspects: 1) the health effects, the symptoms and diseases on one side, 2) the exposures exposures on the other side, 3) the combination of risk factors and health and 4) the ships medical chest etc. The photos, preferently contemporary, can then be in the categories and combinations: 1) Descriptions of different types of diseases like skin diseases, etc. 2) Documentation of the health service from the clinics, the hospitals shore, the hospitals, rescue situations with ambulances, etc. and 3) The prevention of the risk factors for health and safety at the workplaces. Often a permission to take and use the photo is needed. Photo documentation could be an important research theme, relatively easy by using the smart phone cameras. Such photos are important for the continued education of the workers, medical doctors, the companies, the occupational health services, the National Authorities', the training centres etc. Photos should be uploaded to Wikimedia Commons https://commons.wikimedia.org/wiki/Main_Page with a title and description of date, type and size of the ship, workplace or living room area on the ship, harbour, and the URL for use should be added in these pages. An exposition of the photos will be available here in this Wikiversity free available for teaching, information materials, publications and patient contacts.