F.5.1 What is health promotion?
The World Health Organization's (WHO) 2005 Bangkok Charter for Health Promotion in a Globalized World defines health promotion as ‘the process of enabling people to increase control over their health and its determinants, and thereby improve their health’. 
The WHO definition includes health education to improve knowledge about how people may improve their health and this has been the core of most seafarer interventions to date. However, education is only one component and other important aspects include:
- Securing health promoting behaviour changes at either the individual level based on personal risk factors, for example, weight management or smoking cessation, or more commonly, including the whole target population, for example, exercise.
- The development of health promoting support networks between members of the target group, but also including those they interact with. An example is seafarer peer group initiatives on health such as exercise targets and family members’ engagement in diet and exercise programmes during leave periods.
- The provision of measures that assist the group in developing and maintaining health promoting behaviours, for example the development and training of seafarer peer group health educators, the provision of suitable food on board for those seeking to reduce calorie intake, the provision of on board exercise equipment and recreational facilities, making arrangements for sporting events when ashore.
- The modification of environmental or working conditions to reduce risks to health, for example, avoidance of exposure to hazardous working conditions, the management of working hours to avoid fatigue.
- Empowering participants to help them secure support networks on board and ashore, to ensure provision of exercise facilities and healthy food options when on board and to be a voice on the management of health risks from maritime working and living conditions.
F.5.2 Application of health promotion methods
A key feature of effective health promotion is that people participating in such activities have a feeling of personal ownership and feel that they are empowered to take action. The need for empowerment is often given a low profile in workplace based health promotion initiatives as it can be seen as disrupting employer/employee relationships. Fear of empowerment can result in health promotion being limited to health educational initiatives.
Several techniques can be used promote health.
- Awareness and publicity campaigns, using a range of media.
- Personal contacts, for example during clinical consultations such as seafarer medical examinations, or as part of a health promotion initiative to explain risks or to encourage action.
- Group interactions to help secure behaviour change and develop support networks to maintain health-promoting behaviours.
The contribution of these techniques to each of the components of health promotion as listed above has been analysed based on experience ashore. 
In practice, health promotion initiatives have often been framed in terms of the control of a specific risk to health in a target population. The focus may either be on the control of one particular risk factor, such as diet or smoking, or on one particular disease, such as arterial disease or cancer. In the shorter term, similar approaches may be used to improve food hygiene or to prevent transmission of an infectious disease. However, there is now a growing recognition that interventions that integrate all aspects of the health of the target group and which aim to develop a healthy overall lifestyle, rather than to prevent a specific condition, may be more acceptable and effective. They may also make a more positive contribution to a person’s sense of wellbeing.
F.5.3 Maritime health promotion
One of the greatest challenges has been how to deliver interventions to a mobile and often isolated group who spend a part of each year at sea, in port and at home on leave. Most initiatives have focused on awareness and education, few have sought to change behaviour patterns or to improve the opportunities for maintaining and improving health on board or ashore.  To date, such initiatives have not taken advantage of onshore experience in health promotion, where there is now a good evidence base.
Three questions need addressing when developing a strategy on health promotion for seafarers.
- What matters? Risks to seafarer health, their frequency, severity, variability and timeline.
- What works? Available forms of intervention, their relevance, deliverability, effectiveness and timeline.
- Who cares? Aspirations of seafarers for better health and wellbeing, the importance attached to better seafarer health by those able to support maritime health promotion interventions.
These questions need to be considered from different perspectives:
- the seafarer whose health is at issue
- the ship owner who is responsible for working and living conditions on board and
- the health professional who is aware of patterns of health and disease and of the validity of different approaches to health promoting interventions.
Collaboration between seafarers and their representatives, ship owners and health professionals is essential to define answers. The answers to the questions ‘what matters?’ and ‘what works?’ have both scientific and attitudinal components. ‘Who cares?’ is a socio-political issue, but one that will determine whether any initiative has a hope of being successful.
F.5.4 Seafarer recruitment and patterns of work
Serving seafarers are a selected group. They have self-selected into the profession, an employer has selected them and they have had their medical fitness to work at sea assessed. They are also a survivor group, in that all the selective factors that apply at entry continue to apply throughout their working lives. By contrast, illness may be more prevalent in those who have recently ceased to work at sea, as it is one of the reasons for leaving the industry.
The global recruitment of seafarers influences health as seafarers are:
- prone to similar patterns of disease to those found in the populations they come from,
- share their beliefs about health with their home population,
- may be unable to access the diet of choice,
- at risk of exposure to infections not present in their home country,
- liable to mental distress from clashes of culture and from isolation from seafarers from their own country.
The pattern of work for seafarers can make delivery of health promotion difficult. There are three different settings in which most serving seafarers, apart from those on local coastal shipping, can be found:
- On board for 50-80% of the time.
At sea, work occupies a large part of the waking hours. Exercise is determined and work demands may constrain participation, food is provided and choices may be limited. Access to support and monitoring of compliance with programme goals is limited and the culture and ethnicity of the crew may determine attitudes to behaviours such as smoking or voluntary exercise in leisure time.
- In port, but away from home for 0-10% of the time.
Crewmembers often have more work demands placed on them when in port. If they have leisure time this may expose them to health risks such as traffic accidents, overconsumption of alcohol, casual sex and unhygienically prepared food. However, in some ports they will have access to welfare staff and facilities that provide both support and opportunities for sport and to communicate with home.
- On leave for the balance of 10-50%.
Returning home is often a time for celebration and caring relatives and friends are likely to signal this by providing rich food and plentiful alcohol. Exercise patterns established at sea are often lost, unless efforts are made to continue them. Time at home does provide an opportunity to obtain advice on health and has the potential, given co-operation from those close to the seafarer, to allow action to be taken to maintain or improve fitness.
This three-part pattern of life poses challenges to anyone aiming to create viable seafarer health maintenance programmes. In effect, it means that it is the individual seafarer who must recognise the elements of such a programme and keep them in place. This is highly dependent on positive and collaborative attitudes by both employers and those close to the seafarer while they are on leave.
F.5.5 Motives for health promotion in seafarers
All parties have an interest in healthy seafarers, however their priorities differ:
- Seafarers can be expected to have an interest in living a long and healthy life. However, the pattern of working and living at sea, as well as the opportunity to feel that leave is a time to treat yourself, does mean that many adopt lifestyles that form the basis for long-term ill health.
- Employers need healthy and efficient crews but, in the current pattern of short-term crew contracts, may not see the prevention of long-term risks as important, or the costs of healthy diets and exercise facilities as a priority.
- Maritime insurers, including the P & I Clubs, share the employers’ interest in crew health and have taken the lead in some recent health education initiatives. However, their focus is often on the exclusion of those who they consider may present risks from ill-health while under contract, as they are seen as more likely to require costly medical treatment and repatriation for which the insurer will be liable.
- Maritime regulatory authorities have responsibilities under the Maritime Labour Convention, 2006 and other conventions to introduce regulations aimed at maintaining certain aspects of health and wellbeing in seafarers on ships that registered with them.
- A range of organisations and groups concerned with seafarer health and wellbeing all have their own perspectives on health promotion. These include the seafarer missions, port welfare service providers and maritime doctors.
F.5.6 Developing health maintenance programmes for seafarers
A rational programme of health maintenance for seafarers should be based on estimates of the frequency of different medical conditions in the population concerned and, more importantly, on evidence about the effectiveness of any proposed interventions. Intervention may be directed at working and living conditions, lifestyle or indicators of individual risk.
- Working and living conditions at sea are, in essence, matters for ship operators, while living conditions on leave depend on social factors in the seafarer’s home country.
- Lifestyle is, to an extent, a matter for the individual. However, individuals need to be both informed of behavioural and other risk factors and to be motivated to take action to adopt ‘healthy behaviours’ that will reduce risk. Often this requires additional support, for instance those who are overweight need to be able to have a satisfying low calorie diet while on board, on leave the same pattern needs to continue with similar calorie control.
- Individual risk is often identified in the course of seafarer medical examination or because of an episode of ill health. It may be amenable to action by lifestyle modification but will also often need medication, for instance for raised blood pressure or type 2 diabetes.
To date there have been few commercial ship operators who have actively engaged with an overall programme of health maintenance, but there have been initiatives by maritime health and welfare organisations to provide the background information needed to initiate such programmes. Individual seafarers may also be motivated to actively manage any health risks because of both personal self-esteem and the possibility that a risk that is not effectively managed will lead to a condition that prevents them from continuing their career at sea.
F.5.7 What is the pattern of health and wellbeing risks in seafarers?
Despite the lack of an extensive knowledge base on seafarer health, the available information indicates that the predominant causes of serious illness and death in seafarers are broadly similar to those in the same socioeconomic group in their country of residence. The most common causes are the arterial diseases and cancers.
Widespread but non-fatal conditions include musculoskeletal pain, often with limitation of movement, and psychological distress as well as other mental health issues that can be disabling for the individual and may lead to the early termination of a career at sea. Musculoskeletal and psychological problems may be attributable to personal factors, to duties and job demands on board or to a combination of both.
Other significant contributors are occupational diseases and accidents. These are not considered further here, as there are well defined frameworks for the management of these risks that ship operators are required or recommended to follow. Further information on risk assessment and risk management is available in Ch 2.5.
In addition, the harm from several other risks, such of those from hot and cold climates, from sexually transmitted infections, including HIV, and from exposure to food, water and disease vectors while in port are all largely preventable. Further information on infectious diseases is available in Vol 8.
F.5.8 Feasible maritime health promoting interventions
Many conditions have an evidence base for health promotion in other, shore side settings. It is possible to use this evidence to justify and shape intervention in the maritime setting, for example:
- Arterial disease: smoking, diet/obesity, exercise, additional clinical interventions to identify and treat high blood pressure, raised blood lipid levels and diabetes.
- Cancers: lung and several other cancers have smoking as a causal factor and the effect increase with is concurrent or past asbestos exposure. Sun exposure increases the risk of skin cancer, dietary components can contribute to bowel cancers.
- Musculoskeletal disease: regular training to improve fitness can reduce risks and rapid mobilisation in some conditions such as low back pain can reduce long term disability. There is a parallel need for sound systems of work to ensure that musculoskeletal demands from routine duties do not exceed accepted weight, reach or frequency criteria.
- Psychological distress: improved understanding of the effects of personal crises and overload or boredom at while at sea, with acceptance that such effects occur and are best discussed, can ameliorate distress. Specialised social networking sites for those in distress, supported by online or face-to-face counselling are promising developments. Port welfare providers may also have a role.
Evaluation of any interventions needs to be published to guide others and different methods include measures of:
- Distribution or access to materials used in the programme.
- Awareness of the intervention programme, both in the direct target group and those who need to support the group, including family members during periods of leave.
- Intentions to change behaviour or to provide the support services required to help individual participants.
- Actual behavioural change, its speed of uptake, the proportion of those targeted who are complying, the persistence of the change.
- Maintaining behaviour changes as measured by secondary markers such as weight, smoking habit, participation in exercise programmes.
- Effectiveness of the programme in terms of primary markers: disease incidence, disability, loss of employment, death.
 The Bangkok Charter for Health Promotion in a Globalized World. https://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/ (accessed 10 April 2019).
 Davies M, Macdowall W (Editors). Health Promotion Theory. Maidenhead, OUP. 2006.
 Macdowall W et al. (Editors). Health Promotion Practice. Maidenhead, OUP. 2006.
 Macdowall W. Personal communication 2016
 Carter T, Karlshoej K. The design of health promotion strategies for seafarers. Int. Marit. Health. 2017; 68: 102-107. https://journals.viamedica.pl/international_maritime_health/article/view/IMH.2017.0019/40815 (accessed 10 April 2019)
 Seafarers’ Health Information Programme, International Seafarers’ Welfare and Assistance Network. https://www.seafarerswelfare.org/seafarer-health-information-programme (accessed 10 April 2019)
 Healthy Living at Sea, Videotel. Release in 2017. This is a series of ten vidoes covers different aspects of seafarer health.
https://videotel.com/videotel-programme-focusing-crew-health-promotes-good-practice-aid-ship-efficiency/ (accessed 10 April 2019)
 Mellby A, Carter T. Seafarers’ depression and suicide. Int. Marit. Health. 2017; 68: 108-114 https://journals.viamedica.pl/international_maritime_health/article/view/IMH.2017.0020/40816 (accessed 10 April 2019)