# Occupational Epidemiology/Research tools/Research program for Thesis topics
## ABSTRACT

OBJECTIVE: The aim is to establish a permanent surveillance program for mapping of the workers occupational health risk indicators by the use of MScPubH students and other students theses.
METHODS: Target populations include all employed in seafaring, fishing, dock working, offshore and the seafarers wives, to be mentioned as "the maritime workers". Data will be collected every 3-4 years with electronic questionnaires consisting of three parts: 1.Demographics: person, workplace and geographic area 2. Permanent themes for comparison and follow-up (e.g.Safety and Mental health climate, occupational risk indicators: chemical, physical, psych, ergonomic and 3. Specific themes to be selected: oral health, food, sleep, tobacco and alchohol. The survey will be completed as part of the MScPubH thesis supervised by experienced researchers. When 2-3 surveys are completed over 5-8 years the results with trends will be summed up in review articles.
EXPECTED OUTCOME: The gathered new knowledge is expected to be useful to maintain the best possible working environment that will attract the most talented workers who will be able to provide the highest quality in the companies.

## INTRODUCTION

The monitoring of the health risk indicators and the occupational environment, which has been developed and implemented for shore based industries over the past 40 years, has not received the same attention in the maritime area. In contrast to that, the blue industries have so far primarily investigated morbidity and mortality, but only to a lesser extent studies on health and safety at work. We will focus on the prevention of working environment and health at sea, including bullying and wellbeing among maritime workers (in the Blue Industries). The KRAM factors (diet, smoking alcohol consumption and exercise), safety climate and the psychosocial environment are the key indicators planned to be monitored every 3-5 years together with data from injury and health exams registers. Further, the study data will be summed up within 4-6 years intervals so over time the program will provide both snapshots and developmental trends in relation to the maritime worker's occupational risk indicators, health risk indicators and job retention. The intention is to promote the martime workers health and safety and thereby to strengthen the Danish maritime sector's competence and competitiveness.

## Study populations

The study population include all men and women of all nationalities employed in seafaring, fishing, dock working, offshore and their social relations, to be mentioned as "the maritime workers"

## Purposes

* Establish a surveillance program for mapping of the specific maritime occupational risk indicators and the health risk indicators for the maritime workers
* Provide systematic and available current knowledge and the trends over time about the working environment in the maritime employments
* Utilise the MScPubHealth students research thesis work to fill out the gap of surveillance for maritime workers
* Provide scientific evidence on health risks and workplace risk indicators to be used to improve the conditions
* Use scientific methods that are well tested on land and thus can ensure valid results for maritime workers
* Collect samples of questionnaire data form Danish maritime workers in repeated surveys by the unions
* Collaborate with other countries for comparison and for strengthening of the evidence
* Persue the UN’s Sustainable Development Goals (SDGs), to support the SDU goals.
* Persue the CMSS goals

## Research questions

* How is the actual occupational risk indicators?
* How is the actual occupational health claims?
* How does the occupational risk indicators change over time in the cohorts?
* How does the health claims change over time in the cohorts?
* Which are the proposals to improve health and to optimise the working environment in the cohorts?
* How is the job retention over time?

## Hypotheses

It is the hypothesis that the physical and psychosocial work environment vary in different types of maritime workers and vary compared to shore workers with respective to work away from home, being at home and job retention.

## Seafarers

Studies over the decennia show an over-frequency of cancer, cardiovascular disease diabetes and occupational accidents in seafaring compared to other occupations;. The specific physical, chemical and psychological working environment factors on board also relate to the seafarers health conditions.;. Work-related diseases are primarily the result of physical work environment impacts in the form of noise and vibration, but also hearing damage and seasickness are well known Finally, infectious diseases, including tropical diseases, are a particular problem in certain geographical areas, where also strong exposure to ultraviolet radiation from the sun can cause sunburn and skin cancer. The quality of the mental work environment is dependent on a number of factors which have been carefully described in the past approx. 30 years, , Ships with on-going replacement of management present great challenges for both the manager and the employees and the culture at the workplace, During navigation, the sailors are often moved to very small working groups, where conflict management can be difficult. The requirements are very variable, the nature of the work requires considerable discipline and thus less self-control. Support from superiors and colleagues can be made difficult by the fact that crews come from many different nationalities. These conditions can lead to experienced stress and burnout. Fatigue is considered a significant health and safety problem. Jet lag after long flights for joining is described as part of this.(12).In the latest research Helen Sampson, director of Cardiff University's Seafarers International Research Centre, said that seafarers working on cargo ships "experience very little happiness on board". She said there was evidence recent-onset psychological disorders were increasing among serving seafarers but 55% of employers said they had not introduced any policies or practices to address mental health for a decade. The report, Seafarers' mental health and wellbeing, found that internet access would make the most significant contribution to improving the mental health and wellbeing together with other key recommendations were underscored in the report and the BBC News,

## Fishermen

The conditions of work in the fisheries sector are arduous with high rates of occupational non-fatal and fatal accidents,. Logically, the prevention activities up till now mainly focussed on accident prevention with little attention to the emerging chronic diseases, especially diabetes and cardiovascular diseases related to the specific risk factors. Several studies have shown that fishermen have a higher morbidity and mortality from cardiovascular disease, diabetes, cancer than other occupations. The results are consistent with the causal explanations in studies about obesity and related health conditions also called the metabolic syndrome. The main risk factors include alcohol, fatty food consumption, smoking and lack of physical exercise. And the negative health effects are causally related the mentioned risk which in turn relate to the specific working conditions and culture in small-scale fishing. This needs to be taken into consideration in the prevention programs.

## Port workers

Work on the ports is most often carried out outdoors in all kinds of weather, with exposure to a number of different work-related factors Diesel exhaust emission that also threatens workers' health is measured Noise is one of the major occupationally harmful factors and in other areas there is not only noise but also exposures to various harmful chemicals, including when working with containers. A cross-sectional study among port workers in three cities in Denmark, using both quantitative and qualitative methods, found that the port workers feel secure about the safety of their workplace and that a good cooperation between colleagues were the reason for the feeling of security. Most of them were very satisfied with their work and they enjoy working hours. Most of them did not find it stressful to be unemployed where there is no guarantee of work (and half had never felt stressed). The working environment of port workers has been investigated quite sporadically internationally and repeated surveys are needed.

## Offshore workers

A review of studies health and safety in the oil- and gas offshore industry concluded there is a need for more epidemiological studies in order to identify the specific areas that need attention for health and safety promotion. Besides the few epidemiological studies, there are plenty of administrative reports. However there is a problem with their quality compared to peer-reviewed publications. The methods are not always sufficiently described and the definitions of the injury inclusion criteria or the study populations are absent or unclear. Even where the research quality is good, it may be difficult to get copies of the reports. Another problem arises with reports written in languages other than English. The methodical problem hinders for a wide international use of the results and collaboration between the companies and nations and is an impediment to the establishment of international evidence based injury preventive initiatives.

## Seafarers wives

Sampson explores and sees the changes in attitudes, values and daily life among women married to seafarers from Mumbai and Goa seen as resulting from their husbands’ occupations. The isolation upon women married to seafarers has developed an independence that is recognized as unusual within their local contexts. She also notes that the access to higher incomes allows seafarers and their partners to make change their domestic living arrangements which are not available to others in the local area.

## METHODS

Data will be collected with questionnaires to be answered electronically. The content of the questionnaire will consist of two parts,
* One permanent part with the same questions that can be repeated in different segments in the following rounds among the different segments of the maritime workers. This part will be selected from the list of topics in Table 1. + some specific wishes from the union and the researchers.
* The second part will be selected from among the different items as in the list below:
* Participants' health conditions exposures in the work environment
* The self-perceived psychological and physical working environment
* Lifestyle conditions on ships and at home. Smoking, drinking, diet and exercise habits; sailing /at home.

## Design

Repeated cross-sectional rounds in a prospective dynamic cohort design. The follow up with analysis of any changes in the overall answers will be analysed for more than one time responders. In each questionnaire round the first time respondents will constitute a new cohort.

## Follow-up of the cohorts

For each of the questionnaire rounds there will be a question about completion of a similar questionnaire before. And thereby comparison by groups of workers like specific job positions, type of ship etc. The objective is to identify trends of risky work indicators, wellbeing and health claims.

## Questionnaire items

The questionnaires will be in two parts: one is intended to be repeated in each of the rounds, with some years between and the other part will be tailored to specific wishes from the students and the seafarers.
* Yale questionnaire or part wise is proposed as model to be discussed with these topics Yale General Wellness q.:
* Standard questions on age, position, type of the ship, job position etc. as used in the Yale Q.
* A question on: "Did you fill out a similar questionnaire before?" (give year) yes/no/don’t remember (needed for the follow up in the cohort)
* A permanent topic could be mental health standard questionnaire
* Another topic could be safety culture

## Specific part of the questionnaires

To be related to the specific part of the protocol as the specific research questions, based on what is needed.
* Safety culture on board
* Mental health climate on board
* Security Management
* Instruction in safety
* Compliance with safety rules
* Attention to security
* Noise, vibration and wet work
* Ergonomic loads
* Indoor climate on board
* Chemical work conditions
* Sleep on board
* Maritime workers health, including dental health
* Thoughts about to stop as a sailor
* Tobacco and alcohol on board and at home
* Food on board

## 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.

## Long-term perspectives

* Establish a database of information collected on the exposures of the workers in all maritime workers, all areas on the ships, all types and sizes of the ships
* Disseminate the results to the workers organisations, the unions and at the annual MSSM
* Construct job-exposure matrices (see below) for use in health register based cohort studies
* Collaborate with researchers in other countries on twin studies

## International collaboration

We will collaborate with other universities with Pub Health students e.g. the maritime master and university specialist programs the Cadiz university and from other universities. The international perspectives have been proposed in the Wikiversity program.

## Development of job exposure matrices

In the field of work and environmental medicine, increasing demands are placed on the fact that reliable designations of exposure are also estimated in well-designed epidemiological studies. For example, by an assessment is ring of the causes of hearing loss and tinnitus, it is essential to estimate the actual exposure of the crew to noise over several years. This program is run by the national occupational research institute (NFA), but has not previously been used at sea. This, despite the fact that the method seems to be particularly useful for working environment on ships, since the construction of the various ship types globally is very similar. The possibility of a good international collaboration on descriptions of exposures is also right.

## Participants and data collection

* The participants are maritime workers in the different segments
* The questionnaires are completed electronically
* Mail addresses are obtained via the partners: maritime schools, shipping companies, unions
* The analysis seeks to enlighten any contrasts between segments, e.g. larger and smaller ships and the various job functions.
* It is aimed that 1000 people in each survey round will fill out the forms.
* Mail is sent with a link to the questionnaire
* Personal ID, person names or company names are not collected.
* The mail addresses are supplied by the unions who take care of the updating.
* The scope of the respondents who do not wish to participate will be assessed.

## Communication

The thesis is the study final work to graduate in MScPubHealth. The abstract will be published in the Union News. The Power Point used for the exam can after some edition be reused for conferences and meetings. In some cases, a scientific article can be prepared for publication in international scientific journals.

## Pilot study

Pilot studies will be part of the research to study hwo good the questionas are understood by the respondents

## Requirements for success

Interest from the students to do this type of thesis work and interest from the unions to participate is the core needs. To obtain interest we have to make it attractive for the students and for the unions. We have to give good announcements with well prepared internal research competency courses. Concerning the unions we have to take care with good information on their benefit from participating in the surveys. We have to take care they get the results in time in easy understandable forms they can use in the member meetings and in the negotiations with the employers.

## Data processing and data storeage

Data is transferred to electronic processing during the investigation. Standardized statistical methods will be used using the latest SPSS program. Data will be handled under strict confidentiality in anonymous form in CMSS. All data will be stored in a special research database to be used for followup studies later. The Data Inspectorate is informed and current legislation is complied with.

## Data reliability

in the Danish and later international surveillance project of OH indicators questionnaire data about type fo ships and the number of days at sea was held up against data from the DMA and showed good comparability. Also test- retest of the questionnaires was used. In this project the data validity also need to be evaluated, this will be added later. The reliability is supposed to be related to the design and size of the used questionnaires. Generally it is recommended questionnaires from other studies where the validity and the answers has been tested with good results.

## Ethical requirements

Since the study does not involve blood sampling, and since participation in the study is completely voluntary after informed consent, the study does not involve ethical problems. All data are treated according to the Act on the duty of confidentiality, and the guidelines for good epidemiological practice will be followed. The participants' anonymity will be ensured in all ways and this will be apparent from the project description and the form. It will be ensured that the electronic form is locked so that the information cannot be seen by anyone other than the researchers.

## 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.
* ↑ Poulsen TR, Burr H, Hansen HL, Jepsen JR. Health of Danish seafarers and fishermen 1970-2010: What have register-based studies found? Scand J Public Health. 2014
* ↑ Oldenburg M. Risk of cardiovascular diseases in seafarers. Int Marit Health. 2014;65(2):53–7.
* ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
* ↑ Oldenburg M, Baur X, Schlaich C. Cardiovascular diseases in modern maritime industry. Int Marit Health. 2010;62(3):101–6.
* ↑ MacLachlan M, Kavanagh B, Kay A. Maritime health: a review with suggestions for research. Int Marit Health. 2012;63(1):1–6.
* ↑ Jezewska M, Leszczyńska I, Jaremin B. Work-related stress at sea self estimation by maritime students and officers. Int Marit Health. 2006;57(1–4):66–75.
* ↑ Levi L. Occupational stressors, biological stress reactions, and worker’s health. J UOEH. 1989 Mar 20;11 Suppl:480–1.
* ↑ Leka S. Psychosocial hazards and seafarer health: priorities for research and practice
* ↑ Int Marit Health. 2004;55(1–4):137–53.
* ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
* ↑ Lodde B, Jegaden D, Lucas D, Feraud M, Eusen Y, Dewitte J-D. Stress in seamen and non seamen employed by the same company. Int Marit Health. 2008;59(1–4):53–60.
* ↑ Elo AL. Health and stress of seafarers. Scand J Work Environ Health. 1985 Dec;11(6):427–32.
* ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
* ↑ Allen P, Wadsworth E, Smith A. Seafarers’ fatigue: a review of the recent literature. Int Marit Health. 2008;59(1–4):81–92.
* ↑ Wadsworth EJK, Allen PH, McNamara RL, Smith AP. Fatigue and health in a seafaring population. Occup Med. 2008 May 1;58(3):198–204.
* ↑ Seafarers mental health and wellbeing SIRC research Nov 2019 https://www.iosh.com/media/6305/seafarers-mental-health-wellbeing-summary-report.pdf
* ↑ BBC news on maritime mental health advice based on the research Nov 2019 https://www.bbc.com/news/uk-wales-50315080
* ↑ Case SL, Lincoln JM, Lucas DL. Fatal Falls Overboard in Commercial Fishing - United States, 2000-2016. MMWR Morb Mortal Wkly Rep. 2018 Apr 27;67(16):465–9.
* ↑ Jensen OC, Petursdottir G, Holmen IM, Abrahamsen A, Lincoln J. A review of fatal accident incidence rate trends in fishing. Int Marit Health. 2014;65(2):47–52.
* ↑ Kaerlev L, Dahl S, Nielsen PS, Olsen J, Hannerz H, Jensen A, et al. Hospital contacts for chronic diseases among Danish seafarers and fishermen: a population-based cohort study. Scand J Soc Med. 2007;35(5):481–489.
* ↑ Frantzeskou E, Jensen OC, Linos A. Health status and occupational risk factors in Greek small fisheries workers. Int Marit Health. 2016;67(3):137–43.
* ↑ Wang Y, Zhan S, Liu Y, Li Y. Occupational hazards to health of port workers. Int J Occup Saf Ergon JOSE. 2016 Jul 18;1–5.
* ↑ Debia M, Neesham-Grenon E, Mudaheranwa OC, Ragettli MS. Diesel exhaust exposures in port workers. J Occup Environ Hyg. 2016 Jul;13(7):549–57.
* ↑ Baur X, Budnik LT, Zhao Z, Bratveit M, Djurhuus R, Verschoor L, et al. Health risks in international container and bulk cargo transport due to volatile toxic compounds. J Occup Med Toxicol Lond Engl. 2015;10:19
* ↑ Nielsen NO, Nielsen SRG. Dockworkers’ health and safety. A cross-sectional study of self-perceived safety and psychosocial work environment amongst Danish dockworkers. Int Marit Health. 2019;70(3):171–179.
* ↑ Jensen O, Laursen LH. A review of epidemiological injury studies in the oil-and gas offshore industry. Ann Public Health Res. 2014;1(1):1–4.
* ↑ Sampson H. Left high and dry? The lives of women married to seafarers in Goa and Mumbai. Ethnography. 2005;6(1):61–85.