Integrated occupational health care for seafarers across the continuum of primary, secondary and tertiary prevention.

This is also relevant for the further development of integrated occupational health care. Occupational health care is to some extent an integrated curative and preventive health care system. However, the possibility for further integration is relevant, and an analysis of the needs and goals for the seafarers health care system could serve as the basis for policy development. Unfortunally, a special issue of this journal on integrated occupational health care was cancelled, but with this letter we would like to make a contribution to the discussion in this field.


Integrated occupational health care for seafarers across the continuum of primary, secondary and tertiary prevention
The article recently published in this journal by Gail D. Armitage and her colleagues concluded that, "It is important for decision-makers and planners to choose a set of complementary models, structures and processes to create an integrated health system that fits the needs of the population across the continuum of care" [1]. This is also relevant for the further development of integrated occupational health care. Occupational health care is to some extent an integrated curative and preventive health care system. However, the possibility for further integration is relevant, and an analysis of the needs and goals for the seafarers health care system could serve as the basis for policy development. Unfortunally, a special issue of this journal on integrated occupational health care was cancelled, but with this letter we would like to make a contribution to the discussion in this field.
The main objective of the occupational health care system is to help reduce employees' exposure to hazardous conditions, to establish diagnoses after identification of causal factors and to assist with workplace adjustments for patients' rehabilitation and insurance compensation. The research aims to establish evidence for these activites, including studies of the positive effects of workplace risk prevention interventions. Integrated occupational health care involves different stakeholders, such as various medical specialists, occupational health services, employers, trade unions, insurance compensation systems and labour authority systems. The growing interest in health promotion could be strengthened by integrating occupational health care as well, which is also included in the World Health Organization's occupational health care programmes.
For example, the unique occupational group of seafarers represents about 1.4 million people, for whom an integrated health care system has been described for some countries [2][3][4][5][6][7][8][9]. The integrated occupational maritime health care system includes pre-hospital treatment, medical first aid functions performed by navigators on board, assistance from the telemedical radio medical services, mandatory training courses for navigators in medical assistance, medical guide books on the ships, standardised medicine chests, health examinations for all seafarers every other year and a search and rescue system, involving helicopters and rescue vessels.
Due to the rapid development of structure and technology in the maritime industry, there seems to be a need for an updated and systematic description of the existing health care system for seafarers. The seafarers' health and safety training system has mainly been concerned with safety at sea and training for medical first aid. However, there is a growing interest in primary prevention of the chronic diseases related to diet and physical activity, including drugs, alcohol and tobacco in the communities in order to minimise curative health care. The challenge is to support the health promotion activities in the community by including supplementary activities among seafarers, shipping companies, maritime authorities and health professionals. The activities include prevention of fatigue, stress and loneliness with supposed impact on health, safety and wellbeing. The risk factors are supposed further to impact directly or indirectly upon the fitness for duty of seafarers and on the profitability of enterprises.
As a basis for the integration of curative and primary health care programmes for seafarers, there is a need to analyse the existing system. Such an analysis has been further actualised, as the European Commission recently launched 'An Integrated Maritime Policy for the European Union' which results from the growing impact of the transport of goods by sea [9]. However, an adequate policy for the health and safety care at sea is so far missing. Also, the 'Superconvention' or 'Seafar-ers' Bill of Rights', adopted in 2006 by the International Labour Organization, underscores the need for occupational health and safety promotion programmes, but no specific policy of how to develop such programmes has been established [10]. The challenge is to develop the best possible health and safety conditions at sea as a precondition for the desired maritime industrial development.
The analysis of the need for and potential of a better integration of health care at sea according to a health and safety policy could be systematised in relation to the three parts of the prevention continuum: primary, secondary and tertiary prevention. The stakeholders in the different divisions of maritime health systems should be asked how they actually integrate the different stages of health care in their respective sectors. For example, the teachers in the courses on first aid at sea should be asked how they actually teach the seafarers on health promotion and prevention of stress and fatigue. Another example: how do the biannual health examinations follow and prevent the development of diseases related to weight gain and obesity over the years? How is the development of pre-hypertension and pre-diabetes actually treated as primary prevention without the use of pharmacological means? A related issue for the ship owners and the cooks on board is how the non-pharmacological treatment for some seafarers can be followed on board. Yet another question for all stakeholders: if they see any possibilities for bet-ter integration of the different stages and how can the activities be evaluated? A survey with these types of questions distributed among the key stakeholders in different countries can serve as the basis for developing strategies for better integration of curative care and primary prevention in seafaring. This method may be used in other occupational areas and other communities to strengthen integrated health care throughout the whole continuum of prevention. This could also be the basis for a special issue of this journal.