# Maritime Health Research and Education-NET
## Introduction

The Maritime Health Research and Education-NET MAHRE-Net is a non-profit network of researchers, seafarers and other workers, maritime students composed of four parts.
* Research, based on standardized, health questionnaires
* Screening for T2 Diabetes mellitus and Hypertension in the fit-for-duty medical examinations
* Health promotion program integrated with the T2DM & HTN screening program
* Systematic Literature Reviews and Reviews of Systematic Reviews.
The primary target study populations include maritime students, seafarers, fishermen, port workers, offshore workers, divers, and their social relations, and other industries. The aim is to provide a foundation for the evidence base for the identification of health risks to foster safe and healthy preventive strategies and policies within the UN Global Sustainable Goals. We will follow and support the young people from the maritime schools in their care in the cohort design strategies. The method is that we ask the classes of maritime (or other) students to fill out a standardized questionnaire in one of the four themes at the beginning of their studies on their mobile phones. The surveys in the maritime schools complete part of the diagnostics of a global mental health program at the schools and workplaces in the WHO health-promoting school-framework for improving the health and well being The research program includes monitoring of the main topics of the EU-Occupational Health strategy:
* Mental health
* Ergonomics
* NCDs Screening for Hypertension and Diabetes Type 2, accurate diagnosis and prevention at the medical examinations
* COVID-19 and other infectious disease
* Safety climate
When they start their practice times at sea, they complete the same questions to identify the influence on their well-being on board. We measure how many of them leave the sea profession and we ask them how they think the profession can continue to be attractive to young people. It is intended to suggest and assist in the implementation of preventive measures based on the results. Later, we continue to ask them at some year intervals with the same questionnaires to assess whether the efforts have helped. We give the same questionnaires to the maritime students in other countries for comparison and learn from their proposals to get the best working conditions. Also, we ask what is needed of teaching to help the industry give them the best condition to stay safe in the job. Different cohort data sources like pre-employment medical health examination data can be tried out for feasibility and validity. A "Cohort" is defined in epidemiological science as a group of people who share the same characteristic, in this case, more or less the same birth years and we take several contacts to them over their life. Cohorts are also started with maritime workers through unions, other organizations, and shipping companies:

## Objectives

* International prospective exposure and health risk cohort studies with maritime students and workers
* All other industries are invited to promote the similar research and education goals
* Using the standard protocols with different themes
* Harmonise exposure and outcome information by using standard questionnaires
* Objective and subjective assessments of workplace hazards exposures
* Develop and validate Job-exposure Matrices
* Systematic reviews and pooled studies from the cohort rounds
* Cohort-Linkage to pre-entry and follow-up health exams and other health registers
* Use routine health exams for early diagnosis and primary/secondary prevention of Pre-diabetes and Pre-hypertension
* International workplace research- intervention plan based on the ILO Guidelines integrated health testing VCT@WORK
* Make training materials based on the cohort study and the clinical study outcomes and other scientific sources
* OHS training to maritime doctors, seafarers, fishermen, students, and others
* Integrate research methodology in the supervision of student’s thesis work
* Adapt to the OMEGA-NET on data sharing and reporting cohort meta-data
* Keep the Excel data file copies safely (producing country and supervisor)
* Disseminate the knowledge in publications and organize seminars/webinars/symposia
* There is a close relation to the Maritime Health Portal

## Contributions to the Industry

* The maritime doctors and other maritime health professionals receive updated knowledge on the health risks at sea for the specific jobs and work areas
* Systematic dissemination of knowledge in work environment-e.g. STAMI Specific project
* Job-Exposure Matrices will support the needed evidence to the health examinations according to the requirements in the ILO/WHO Guidelines
* The companies receive updated knowledge that enables for strategic and thus more cost-effective prevention efforts also in the Job-Exposure Matrices
* The MAHRE-Net supports the international organizations with the updated scientific evidence for updating the international conventions and regulations
* The MAHRE-Net supports the Flag states to comply with their obligations to monitor the working and living environments regularly according to ILO Conventions: MLC2006 for seafarers and C188 for fishermen.

## Contributions to Health Risk Prevention

The cohort studies can be seen as the diagnostic part of the prevention related to each of the specific items. Guidelines for the prevention for each of the standard questionnaires will be included in the Cohort Protocols

## Phases of the preventive program for single industry

* Epidemiological standardized questionnaire studies
* Occupational therapists investigate troubled job positions
* Occupational Medical Doctors supply with their patients from the workplace
* Statistics of work accidents in the specific areas of the workplace years
* Dialogue with companies to improve safety and ergonomics positions
* Improve and continue if they have done well

## Ethical requirements

The ethical rules for database research in the respective Universities and the ICOH Code of ethics are complied with. Confidentiality in handling personal information is done according to the rules set out by the national Data Protection Agencies. The European General Data Protection Regulation GDPR is complied with. All supervisors and the students are obliged to be familiar with the GDPR through a course. None of the research projects collect "personal data" as defined in the GDPR regulation and no personally sensitive information is included. All questionnaires ask for informed consent as the first question. The supervisors take care to secure that the data is processed under the Act on medical confidentiality as guidelines for good epidemiological practice. The participants' anonymity will be protected in every way and this will be indicated in the project description. It will be ensured that the electronic table is locked so that the information cannot be seen by anyone other than the researchers. The researchers respect individual ownership of the data and share publications and the data where this is convenient and keep always good partnerships as described in The European Code of Conduct for Research Integrity for self-regulation in all research in 18 translations The English version Types of experiments not to be notified: Questionnaire and interview surveys; Registry research surveys; Quality assurance projects; Non-interventional drug trials

## Publishing Ethics

The Elsevier publishers Guidelines include duties for the Publishers, Editors, Reviewers and the Authors corresponding to the international well-agreed different types of duties. Authorship should be limited to those who have made a significant contribution to the conception, design, execution, or interpretation of the reported study. Only those who made substantial contributions should be listed as co-authors. Others who have participated in certain substantive aspects of the paper e.g. language editing or medical writing should be recognised in the acknowledgements section.

## Contribution to UNs 17 Sustainable Development Goals

Goal 3: Good health and well-being for all workers
Goal 4: Quality Education Goal 5: Gender Equity Goal 8: Decent Work and Economic Growth Goal 10: Reduced Inequity (Compliance with MLC2006 and the C188) Goal 12: Responsible Consumption and Production (Ships’ SOx and NOx emissions) Goal 14: Life underwater observations on compliance with good waste management
Goal 17: Partnerships to achieve the Goals

## Integrated Mental Health and Work Policy OECD's recommendation

To monitor and improve the overall school and preschool climate to promote social-emotional learning, mental health, and wellbeing of all children and students through whole-of-school-based interventions and the prevention of mental stress, bullying, and aggression at school, using effective indicators of comprehensive school health and student achievement; Promote and enforce psychosocial risk assessment and risk prevention in the workplace to ensure that all companies have complied with their legal responsibilities. Develop a strategy for addressing the stigma, discrimination, and misconceptions faced by many workers living with mental health conditions at their workplace

## Contribution to quality education
##### For the maritime workers and the industry

The updated scientific evidence on the prevalent health risk exposures and health conditions on board will qualify the prioritization of the preventive actions in the Safety Committees on board, in the companies, and the worker's organizations. The workers will benefit from the updated maritime doctors to better understand their possible claims and symptoms that call for adequate clinical and laboratory diagnostics and possible notification as occupational diseases.

##### For the maritime doctors

Guidelines for early diagnosis of hypertension and diabetes type 2, the use of the Excel reporting scheme and follow-up of the new diagnosed seafarers. The outcomes of the cohort studies will be an important part of the continuing training of the Maritime Medical doctors and the training for fishermen and seafarers. https://en.wikiversity.org/wiki/Maritime_Health_Research_and_Education-NET/MARITIME_HEALTH_PORTAL Without this knowledge, the medical doctors cannot perform their obligations adequately and give adequate advice for the seafarers and fishermen according to the ILO/IMO Guidelines on the Medical Examinations of Seafarers and act adequately with possible notification of occupational diseases

##### For the students

Preferably we use our maritime health and safety research outcomes as the basis for our teaching for the MSc.Pub Health and the Maritime students. They learn the research methods in occupational maritime health with an assessment of reliability, generalisability and different types of bias in the scientific context including clearance of the ownership of the data. They learn how to apply the research methods in their coming professional tasks and search the scientific-based knowledge to solve practical problems in their professional life. The maritime students get interested in searching and using the scientific-based maritime knowledge for use in their professional positions as leaders on board. Personal data as defined in the EU GDPR regulation is not used in this research.

## Strengths and Weaknesses

In many countries, the interest for a seafaring carrier among young people is rather low. It is a strength to start with the young seafarers at the maritime schools because they can bring fresh perspective and a different way of thinking to the maritime business and help to attract the young seafarers. According to Unicef, most of them are eager to learn, build their experience and apply their skills in the workforce.Unicef: 6 top benefits hiring young talents The method used is easy to implement in a low budget. It is a strength to use the method that immediately identifies risk elements in the work environment that is not seen by the shipping inspectors in the harbors to be amended for the benefit of the seafarers and the companies. In contrast to the register-based studies, these studies identify actual risk elements in the work environment that will never be learned from the register-based studies. Simple frequency analysis is very useful to start preventive work. In addition, the results in graphics are very useful for basic and advanced education. By using standardized short questionnaires, a good response rate is obtained. The General Data Protection Regulation (GDPR) enforced in EU since 2018 can be very complicated to manage in the research. The general survey data we use focuses on the general exposure data in the work environment and not personally identifiable information. Still, an assessment on GDPR data is always needed and in most cases, our survey research do not apply to the same ethical rules as for clinical database research. The students learn how to apply the research methods in their later professional tasks and search the scientific-based knowledge for solving practical problems in their professional life. The maritime students get interested in searching and using the scientific-based maritime knowledge for their professional positions as leaders on board. Among the weaknesses is that the response rate might be too low from the start, that they change their mail address so we have no contact and they are not willing to participate or have no time in the later rounds. Another weakness is that the cross-sectional design cannot identify the causal relations in the single studies. However, by comparison of different questionnaire rounds, the health risk hazards might be present in some cohort parts and not in others and thereby contribute to identifying the causal relations.

## The preventive maritime occupational health strategy

The maritime occupational and environmental health strategy in development will be based on the need for new knowledge of the main OH indicators. A continued accumulation of new knowledge from MAHRE-Net constitutes the base for continued development of a preventive maritime OH strategy for "constant care" of the workers at the sea. Based on the national and international OH strategies, e.g. the EU-OSHA EU Strategy , The US-CDC and the WHO, ILO OH strategies we selected the four most important OH areas for constant systematic monitoring in the MAHRE-Net: 1. safety-climate, 2. mental health, 3. musculoskeletal risk and 4. Chemical risks. Besides these four main occupational health indicators the following public health indicators can be/are included in each of the surveys: height/weight for Body Mass Index, Smoking, General Health, Alcohol and questions on prevention The validated and international standard questionnaires are available with no extra costs for the student's thesis writing that seems to be an ideal way to make good progress despite the scarce financials. We profit from the results of the outstanding scientists from the Nordic countries and other countries who developed and validated the standardized questionnaires over the latest thirty years. We offer supervision and methodological support for the Bachelor and MScPubHealth graduation thesis and the thesis students in the maritime universities and other health educations like nurses, medical doctors, pharmaceuticals, etc. Data from the Radio Medical services and the seafarer's health examinations are also included. The intention is to obtain a win-win situation with the students getting inspired to continue to do more advanced studies. However, other types of research design apart from the monitor program are encouraged to be made by enthusiastic researchers based on paid clinic time, private time, or funds. Projects with pooling of data from many countries and trends analysis and combining of different questionnaires will require experienced researchers and fundings. One more very important research issue was added in May 2021, to establish early diagnosis of diseases, especially pre-hypertension and pre-diabetes, with evidence that in that time window of disease development, good effect of prevention. Altogether the research activities in MAHRE-Net are intended to be very wide from the most basic levels to the highest levels of competencies with constant education and learning in a preventive perspective.

## Sharing research data

As a researcher, you are increasingly encouraged, to make your research data available and usable. However, interviews with researchers revealed a reluctance to share data included a lack of confidence in the utility of the dataData-sharing is the desired default in the field of public health and a source of much ethical deliberation. Sharing data potentially contributes to the most efficient source of scientific data, but is fraught with contextual challenges which make stakeholders, particularly those in under-resourced contexts hesitant or slow to share For example, the Global Body-Mass Index (BMI) Mortality Collaboration1 published their work on BMI as a predictor of all-cause mortality. The investigators pooled individual participant data from 239 prospective studies, with none originating from Latin America or Africa, Also collaboration through OMEGA-NET will enhance the scientific output from individual studies and facilitate pooled studies, data sharing, and transfer of tools and skills to make greater and more efficient use of existing cohorts. Researchers from countries outside Europe can participate in COST Actions based on ascertained mutual benefit. Mehlum, Ingrid.

## Links to relevant organizations, documents, and funds

ICOH International Commission on Occupational Health EPICOH Scientific Committee on Epidemiology in Occupational Health COST explained in Wikipedia The OMEGA-NET Cohorts and COST DiMoPEx (CA 15129) Links to OMEGA-NET Scientific Publications The HERA network for an environmental, climate and health research agenda The COST mission vision and values The European Survey Research Association European Working Conditions Surveys (EWCS) The European Social Fund == https://www.fi-compass.eu/esif/emff Nordic Council Ministers Funding NGO Co-Operation Baltic Sea Region
Funding Nordic Council Ministers Nordic Council Ministers Funding-opportunity Nordic-Russian Co-Operation
ITF Seafarers Trust Nippon Foundation

## Novo Nordisk Found

Project Title Project Summary Statement of Problem (scientific justification) Justification and Use of Results (final objectives, applicability) Theoretical Framework (argumentation, possible answers, hypothesis) Research Objectives (general and specific) Methodology Type of Study and General Design Operational Definitions (operationalization) Universe of Study, Sample Selection and Size, Unit of Analysis and Observation: Selection and Exclusion Criteria Proposed intervention (if applicable) Data-Collection Procedures, Instruments Used, and Methods for Data Quality Control Procedures to Ensure Ethical Considerations in Research Involving Human Subjects Plan for Analysis of Results Methods and Models of Data Analysis according to Types of Variables Programs to be Used for Data Analysis Bibliographic References Timetable Budget Annexes (data-collection instruments, elaboration on methods and procedures to be used, and more).
Bibliographic References.