# Occupational Epidemiology/Maritime Mental Health Surveillance and Intervention Program
## Abstract

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 basic theoretical background. A joint action among the unions, ship owners, maritime authorities and a network of universities´ research centers in suicide prevention, public health and maritime health departments includes:
Methods
* Review studies on: 1) suicide 2) prevalence of depression, quality of life, social isolation, loneliness and associated risk factors;
* Cohort studies of students from maritime academies with baseline questionnaires and follow-up after experience gained at sea and every 5 years thereafter
* Prevalence studies of the level of knowledge and training needs in mental health and the risk factors for training development
* Analysis of the etiological indicators for the drop-out rates of the students and trained seafarers;
* Training modules for the maritime students, seafarers and personnel in the shipping companies in groups with problem solving and life-long learning in mental health and prevention of NCDs
* Organising the students into small groups that stay in contact via the social media and help each others while at sea and at home;
* Training the students to assist each other in difficult situations and educating them in navigating mental health environments on-board and onshore;
* Giving mental health care training to all employees and age groups through classes, online courses, information materials and through the obligatory health examinations.

## Background

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. Studies on the health profile of the seafarers show worse health in almost all indicators as compared with those of the general population Standardized mortality rates show higher rates of accidents, suicides and liver cirrhosis while hospitalization records show higher rates of cardiovascular diseases, cancers, and injuries.
The seafarers face more difficult working conditions at sea than the employees working on shore. Among other difficulties, they report struggling with long periods away from their family, circular working hours, limited communication capabilities with their own social networks and limited choices for healthy food and physical exercise. Their health is affected by the environment where they live and work, but also by the ports, they visit during their trips. These occupational factors can have an impact on both their individual health behaviour (e.g. smoking, alcohol consumption, unhealthy diet) and their exposure to occupational risks (psychosocial, biological, chemical, and physical factors) depending on ship type ,. Organisational aspects, such as unreliable contracts and long working hours, contribute to stress and depression. Depression and suicides have devastating consequences not only for seafarers’ families, but also for fellow employees and the industry. Neuropsychiatric conditions represent the second highest disease burden in DALYS on populations’ health globally; among seafarers, depression and suicide rates are higher than the general population. Iversen reported that from1960–2009 among 17,026 seafarers’ deaths, 1,011 seafarers died as a result of suicide (5.9%), which is more than three times higher than the respective suicide
rates of the most western countries. Their findings also indicate that seafarers are 2.5 times more likely to commit suicide
,. A 2015 survey by ITF highlighted seafarers’ perceived physical and mental health. According to this, more than half of the sample showed signs of anxiety and depression and the main causes identified were loneliness, long separation from home and family, unreliable contracts and long working hours. They urged the International Transport Workers’ Federation (ITF) and the respective stakeholders to take action to address this issue. ITF called for researchers and maritime health research centers and other professionals to address these issues.

## Theory- and evidence-based health promotion

The program is based on the WHO theories on empowerment and the inclusion of all stakeholders in a public health prevention strategy applied for the shipping industry. The WHO’s comprehensive mental health action plan WHO 2013-2020 Action Plan calls for a change in the attitudes that perpetuate stigma and discrimination that have isolated people. The program calls for an expansion of services in order to promote greater efficiency in the use of resources. This program for the shipping industry will focus on the youngest seafarers´ knowledge, competencies and needs for training and for quality life on board in order to attract them to shipping and to hold on them in the future. Evidence-based medicine has developed over the last half century and was formally defined by Sacket et al. in 1996., Later the evidence-based health promotion was developed to include planning interventions based on solid scientific knowledge and planning for public health programs including mental health promotion to be applied here. The intention is to produce the needed scientific research for promotion of quality of life and prevention of social isolation, mobbing, harassments etc. and suicide. Experienced scientists from the university centres for suicide research and their international network will be invited to participate in the research. Scientific experts from the universities public health centres, the maritime health research canters and the pedagogical institutes will be invited to carry out the planned research tasks and intervention programs. Tenders to be announced for the specific research tasks.

## The study populations

The study populations include: the maritime students, the experienced seafarers, the employees in the shipping companies, the maritime authorities, the maritime medical doctors, the Radio Medical doctors, the maritime school teachers and comparison groups onshore.

## The research questions

The research questions focus on the youngest seafarers´ knowledge, competencies, their needs for training, for quality life on board and how to prevent mental health illness and suicide. The research questions, the objectives and the methodology are specified in the research sections: systematic reviews, cross- sectional- and cohort studies and include the working- and living environment in the study populations in Table 1-3.
* What do the navigators, the cooks, the deck and engine room personel, the owners, the authority personel - know about healthy diet, physical activity, mental health
* How do the ship owners try promote mental health for all the employees, on board and on shore?
* Are there programs that can be recommended?

## The Blue social Kapital

Social Kapital is an integrated part of the occupational and mental health Social Kapital project draft

## The project objectives

The planned program corresponds well to the requirements for Mental Health in the Workplace with a duration of 4-5 years. The program will be multi-institutional with the aim to create a mental health prevention culture in the maritime industry that can be an ideal model for mental health promotion in other industrial branches. The “Mental Health in the Workplace” in Horizon2020 emphasize the need to focus on the preventive perspectives which is exactly our intention based on existing relevant competencies in relation to the demands:
* The project will be planned as a series of intervention(s) information and
training program, that the employers/organizations can take and use to promote good mental health and prevent mental illness in the workplace be based on diagnostic studies.
* The interventions, both structural, educational and organizational will address
important challenges and risk factors in mental health in all types of EU workplaces.
* The interventions will be assessed in terms of direct and indirect individual and
collective health outcomes, cost-effectiveness, implementation facilitators and barriers.
* The Research will be multidisciplinary, including social sciences and the
humanities. The stigma attached to mental ill health will be considered as well as other social and cultural factors which may be relevant to improving the working environment.
* The project will involve key partners such as employers and employees in the
private and public sector, policy makers, insurers, social partners and civil society in the developing initiatives.
For the review studies, the objectives are related to suicide, intervention methods, mental-health related risk factors and quality of life on board and in the maritime schools (Table 1).
For the cross-sectional studies, the objectives are to study the prevalence of the risk factors, the relationship between the risk factors and the mental health indicators and to study the knowledge, skills and needs for training (Table 2).
For the cohort studies, the objectives are to study which intervention methods are effective for mental health promotion among the youngest and the elderly seafarers (Table 3).

## Project methodology

The project will consist of the following parts:

## I: DIAGNOSTICS

* Literature Reviews as part of the knowledge base will include reviews on:
* Suicide, depression, quality of life, social isolation, loneliness and associated risk factors among the seafarers and other industrial branches.
* Study on the actual knowledge and needs for training among cook, students, navigators, shipping employees of health diet, and physical activity to prevent NCDs
* Cohort studies of students from maritime academies with baseline questionnaires and follow-up after experience gained at sea and every 5 years thereafter.
* Studies on the level of knowledge and training needs in mental health and the risk factors for training development in the different strata of the maritime industry.

## II: DEVELOPMENT OF TRAINING PROGRAMS

A comprehensive multi-faceted intervention program will be created, implemented and evaluated in the European maritime universities, schools and the international research network. Training materials on mental health promotion will be developed from those universities and the maritime schools
* Programs related to the promotion of good mental health
* Programs related to the promotion good health, especially how to prevent NCDs

## III: IMPLEMENTATION AND EVALUATION OF TRAINING PROGRAMS

The training programs will be implemented and evaluated in the maritime schools, training centers for seafarers and employees in the shipping companies.

## IV: DELIVERABLES

* 500–1500 maritime students in 5-10 countries will be trained every year and later all maritime students will be trained in mental health promotion and inspired for life-long learning.
* A module book with instructions on how to use problem based learning with evaluations will be developed for use in the maritime academies peer reviewed articles
* 10 surveys will be executed among the students and the seafarers’ union members on the knowledge and skills to improve mental-health environment.
* 5 intervention cohort studies in maritime schools will be completed and published. Internet-based information pages at ITF, IMHA-Research pages and the network for the maritime schools.

## V: EXPECTED HEALTH OUTCOMES

* Over 5-10 years, the number of suicides, number of tele-medical consultations and repatriations due to mental health problems will be reduced by 20%.
* The reduction of suicides will be documented by register based cohort studies, before and after the intervention. Health register based studies will be used to document the reduction in hospitalizations and reports from the Radio Medicals will be used to document the reduced number of calls, repatriations and deviations of the ships due to mental health complaints.

## THE STUDIES
### The review studies

The review study on suicide is based on national-health register cohort studies on mortality that includes suicide in shipping as compared with other workers (Table 1). Intervention study reviews are based on cohort studies in shipping and cohorts of other workers. The review study on risk factors, include single risk factors and the combinations of different risk factors, especially interpersonal and organisational factors. The review study of learning materials, include studies that have shown to be useful and effective in mental health promotion in shipping and other settings. The PRISMA Statement will be adapted for systematic reporting of review studies .

### The cross-sectional studies

The studies will use validated standardized questionnaires. Students in 10-20 maritime schools in 10–15 countries will complete questionnaires before and after their sailing periods. Frequency and regression analysis will be used in accordance with the STROBE initiative for systematic reporting of the studies (13). The best methods for mental health promotion discovered in the review studies will be used. Methodological support is given in the Wikiversity learning sites; the Blue Risk Survey Program and validated standardized questionnaires will be used “Open Blue Risk Survey Program“ (Table 2). Surveys on knowledge, quality of life, attitude profile and the perceived training needs. Gap-analyse, will show potential areas, for in-depth guidance of the training programs.

### The cohort studies

Students from the maritime schools and academies will be enrolled in the cohort studies and complete surveys before and after being at sea. Study groups of 4–5 will form intervention study groups at the schools that will be educated in mental illness prevention and trained to give support to each other whenever this is needed and to keep in close contact. They will receive an educational course of 50 hours about maritime mental health and receive brush-up sessions together with experience sharing. Surveys on their knowledge before and after the courses and the tours at sea will be conducted. The selected education and training programs and materials will be based on the literature reviews and the epidemiological studies. The education and training programs will form the basis of a strategic primary prevention program together with the monitoring of the outcomes. Regression analysis will be used in accordance with the STROBE initiative for systematic reporting of the cohort studies.

### Expected health outcomes

The research project will be initiated creating the relevant knowledge base for the Mental Health Promotion Program. Based on this research, a comprehensive multi-faceted intervention program will be created, implemented and evaluated. The expected deliverables over 5-10 years are as follows:
* The number of suicides will be reduced by 20%
* The number of telemedical consultations and repartriations due to mental health problems will be reduced by 20%
* The reduction of suicides will be documented by register based cohort studies, before and after the intervention
* The reduction in the number of telemedical consultations and repatriations will be documented by analysing the annual reports from the radio medicals
* A global network for maritime mental health promotion with the maritime unions, the maritime schools and the IMHA-Research network in 5-8 countries.
* A variety of online training materials on mental health promotion will be available
* Standard survey questionnaires to evaluate the training in the schools will be tested and available.
* 5 maritime schools/academies/universities in 15 countries will include compulsory training modules on maritime mental health promotion.
* 5 training courses on mental health promotion will be completed in the maritime schools
* 15 surveys will be executed among the students and the seafarers’ union members on the knowledge and skills to improve mental-health environment.
* 10 intervention cohort studies in different maritime schools will be completed
* Internet-based information pages at ITF, Imha-Research pages and the network for the maritime schools the learning materials will be updated
* 1000 maritime students will be trained every year and later all maritime students will be trained in mental health promotion and inspired for life-long learning.
* A module book with instructions on how to use problem based learning with evaluations will be developed for use in the maritime academies
* 15 International peer reviewed articles will be published (see below)

### International articles to be published

* literature reviews on suicide, risk factors and effective intervention studies in mental health
literature review on scientific validated and useful training materials
* articles based on the planned cross-sectional studies
* articles based on the cohort studies on the risk factors and the causes for leaving the industry
* articles based on hospitalisation and death registers to document the reduction in suicide will be published
* article on the reduction of tele-medical consultations and repatriations due to mental health will be published
* article on the training knowledge impact before and after the courses
* article will map mental health risks knowledge and gap analysis of the needed training.

## Discussion

A global, evidence-based comprehensive program for mental health promotion at sea will be launched for the first time. The program will focus on the youngest seafarers knowledge, competencies, attitudes and needs in order to attract and to hold on them in shipping in the future. The aim is to educate and to empower primarily the youngest seafarers and the different segments of employees in shipping to reduce the mental health risks and to improve the quality of life on-board. The empowerment theories and the intervention mapping for developing evidence-based health education programs constitute the main applied theories, The health policy includes an active participation from all significant employee segments in shipping: the seafarer doctors, the seafarers, the maritime students, the Radio Medical doctors and the staff in the shipping companies. This is in order to improve the occupational health prevention based on scientific knowledge from surveys for all segments of the employees. The training programs will be tailored for each of the specific groups of employees based on the literature reviews and the surveys in all groups of employees. The education and training programs form the basis for the strategic prevention program followed by the monitoring of the outcomes. The need for new national and international guidelines and recommendations will be disclosed to minimise some risk factors that will else not be changed due to economic factors. Decisions in the shipping company, for example the manning on-board, numeration and the competencies of the seafarers, can have a significant impact on the quality of life and the mental health environment on board. Education and training of the whole shipping community is included in the health promotion programs with particular focus on the younger seafarers. The training teaching method will be mainly group work with problem solving. Their knowledge and attitudes will be surveyed and the gaps will form the basis of the mental health instruction to be provided. Decisions in the shipping company, for example the manning on-board, numeration and the competencies of the seafarers, can have a significant impact on the quality of life and the mental health environment on board. The youngest crewmembers are the most sensitive persons with great expectations, and they will form the future demands and criteria for the best working and living conditions at sea. It is worth to note that studies of mental health risk factors in shipping and no studies at all are seen for maritime schools.
Problem based – and lifelong learning
Problem-Based Learning (PBL) is a pedagogical approach that could be an excellent way of learning mental health promotion in the maritime academies. Learning is driven by open-ended problems with no one “right” answer,. Students work as self-directed, active investigators and problem-solvers in small collaborative groups (typically of about five students). Rather than having a teacher provide facts and then testing students ability to recall these facts via memorization, PBL attempts to get students to apply knowledge to new situations and are asked to investigate and discover meaningful solutions. The term “lifelong learning” is a term that aims to put learning in a broader perspective than schooling. Learning can be seen as something that takes place on an on going basis from our daily interactions with others and with the world around us. Modules on how to do problem based learning, group works and lifelong learning, will be developed to be used in the maritime schools mental health promotion courses. The aim is to enhance critical appraisal, skills in literature retrieval, evidence based health promotion that encourages continuous learning in a team environment. It is a special strength that the program will be performed in joint action among the ITF, the local union representatives, the IMHA-Research and the network of the maritime schools, including the cadets and the more experienced seafarers. The program for health promotion in shipping, like “The International Seafarers’ Welfare and Assistance Network” (ISWAN), does not include a scientific health promotion and evaluation like in this project. Neither are the program targeted at the youngest seafarers the maritime schools and the universities. Moreover, the previous programs were not based on sound scientific research, they had no evaluation of the effects, and they were not supported by the strongest workers’ organisation, the ITF. None of the existing maritime organisations, including the MLC 2006, the IMO, and the national maritime authorities, have launched evidence-based programs for mental health promotion in shipping.
This program is outstanding primarily by filling out the gap of mental health research based promotion, in the maritime industry. The basic target population is the youngest seafarers with the intention to train them at the maritime schools in mental health promotion. The training will be in groups of 3–5 with problem solving. The groups will stay in contact at the school and while out at sea the first times and later in life. They will be trained to identify the risk factors and how to solve the problems to maintain an attractive and healthy working environment on board to promote a supportive mental health environment. The network of ITF officers who are dedicated to improve the seafarers´ health and decent working conditions will lead the program in collaboration with the IMHA/Research group. The inclusion of the network of the universities through IMHA-Research is another important asset for an evidence-based mental health promotion network. A specific network for mental health in shipping organised by ITF with high quality teaching materials will allow for global support. This will promote relevant training of all sub-groups in the maritime industry.
Strengthening the network coordination
The maritime schools and all other stakeholders will have access to the learning materials developed for global use. The web-based information pages at ITF together with the Imha-Research Wikiversity pages will be the main information platform. One of the participating universities with proved experience in similar international projects will undertake the finansial administration together with the ITF. A steering group representing all Network groups will undertake the running coordination. One of the participating universities with proved experience in similar international projects will undertake the finansial administration together with the ITF. In kind assistance will be given in data collection for the research, training activity as part of the schools curriculum and data collection as part of the students´ thesis for example.
* The maritime students will by themselves establish the strong networks through the social media and the maritime schools. The maritime school epidemiological cohorts are needed of scientific reasons but this will also enforce the networks. The millennium generation represent a vulnerable group for health and safety with specific demands for the mental health environment in shipping and they will know how to express their needs.
* The global network of national maritime unions will be established through the ITF with the objective for mental health promotion. This will strengthen mental health promotion internationally and pave the way for conducting long-term intervention cohort studies and training in mental health promotion for seafarers and all professionals in shipping.
* The network of the teachers in maritime schools will be established. All teachers in the maritime schools will be trained in mental health promotion. A permanent international Board of Maritime Schools will be established to disseminate the training materials throughout the entire shipping industry over the next decenias.
* The IMHA/research network with skilled researchers from the universities´ research centres in suicide prevention, public health and maritime medicine undertake the research projects, help to develop the training materials and be teachers in the training courses.
* The shipping companies, the unions, the maritime authorities and seafarers’ medical clinics will be asked to help with the list of mailers for the cross-sectional studies. They will also be asked to help develop the training materials and to develop training courses for their employees, some will be in kind.
* The international maritime organisations and the national governments will recommend that 1–2 % of the training in shipping is dedicated to training in mental health promotion. They will recommend that the external environments to be adequately adjusted for optimal mental health promotion in shipping.

## Conclusions

* The aim is to educate and to empower the youngest seafarers and all the different segments of employees in shipping
* To reduce the mental health risks and to improve the quality of life.
* The planned research program will enable for a strategic evidence-based mental health promotion in the context of the international recommendations and national regulations.
* Educate and empowerment the young seafarers through life-long- and problem oriented learning.
* The policy implications emanating from the program will request adequate training programs in mental health tailored to all sub-sets of employees in the shipping industry.
* The comprehensive descriptive and analytic research enable for a successful strategic mental health promotion, minimizing the mental health risk factors.
* Political decisions and international guidelines are required to minimise the risk factors that will not otherwise be changed due to economic factors.