Views of primary healthcare physicians on occupational health.

Introduction: The incorporation of occupational health action in healthcare units is a major public health challenge.
Objectives: This study aims to the perceptions of primary health care (PHC) physicians about occupational health.
Methods: This is a qualitative exploratory-descriptive study was conducted in a municipality located in the central region of the state of Rio Grande do Sul, Brazil. Data were collected through individual interviews using a semi-structured questionnaire, whose first part focused on participants' sociodemographic profile and to professional training, and the second one was specific about the researched theme. Research participants were physicians working in PHC. Professionals with an experience of less than 6 months and those absent during the data collection period due to vacation or sickness were excluded.
Results: Ten physicians met inclusion and were therefore interviewed. The main results indicated that the interviewed participants agree that work is an important health condition. They also reported difficulties in taking measures to prevent and promote occupational health and lack of training on the theme. Conclusions: In general, physicians' perception about the theme is based on the implementation of measures mostly targeted at treating users' symptoms, rarely addressing aspects related to prevention or rehabilitation in daily practices. Training about occupational health is insufficient.

INTRODUCTION

Work has a central position in society and in individuals’ lives because it composes human subjectivity and may lead to physical and psychic illness. Furthermore, work inserts people into the social environment, representing an aspect of personal identity, and may have a close relationship with health-disease processes.[

Since there is a strong relationship between work and health, the relationship between work, wellbeing and individuals’ quality of life must be highlighted. Given the fact that primary health care (PHC) and the Family Health Strategy (FHS) are gateways to the health system, developing actions in the field of occupational health (OH) through the local team may be an effective health promotion strategy.

To this end, it is essential that healthcare professionals recognize work as a conditioning factor in the health-disease process and, thus, an influencing factor of the population’s morbidity and mortality profile.[ However, although important advances have occurred in the understanding of work as a social determinant of health, the training of many healthcare professionals is based on a biologicist logic, which does not understand the importance of environment to health. This often leads to difficulties in registering and managing work-related diseases,[ causing situations such as underreporting, a problem that repeats itself inside and outside Brazil.[

Since OH and PHC share the same holistic view and a comprehensive interest in people, rather than only in the remission of their disease, there is the need to study the extent to which healthcare professionals perceive these intersections and have acquired knowledge on care to worker populations.[ Therefore, the aim of this study was to analyze PHC physicians’ perception on OH.

METHODS

This qualitative exploratory-descriptive study was conducted in a municipality of Rio Grande do Sul, Brazil. The study sample consisted of all physicians from the 14 FHS teams of the municipality. The following inclusion criteria were applied: physicians with an experience of at least 6 months in the FHS, with different types of employment contracts and different working hours, who did their academic training in Brazil, with a graduate degree, and professionals who concluded medical residency or not. Physicians who were absent during the data collection period due to sick leave, leave of absence, work leave, or vacations were excluded. Of the 14 physicians, three had an experience of less than 6 months e one was on vacations. Thus, the final study sample consisted of 10 physicians.

The individual interview was conducted in participants’ workplace. The data collection instrument consisted of a two-part questionnaire, whose first part focused on their sociodemographic profile and professional training, and the second one was specific about the researched theme. The following questions were as asked: “How do you perceive your practice in primary health care with regard to OH?”; “Do you usually relate health disorders to work activities? If yes, what is the strategy adopted to deal with physical, mental, or psychosomatic diseases?”; “Are you familiar with the current public policies on OH? If yes, which ones?”; “Do you find it difficult to deal with the OH theme? Justify your answer.”; “Do you find it important to take patient’s occupational history on medical records?”; and “Have you participated in training programs in the institution that address this area of knowledge?”.

After reading the Informed Consent Form, all participants decided to participate in the research. The interviews lasted for approximately 25 minutes and were recorded and subsequently transcribed. The process of data analysis was conducted by all the five researchers, who are trained to apply thematic content analysis.[ In this method, which is divided into pre-analysis, material exploration, and treatment of the obtained results, there is the systematization and aggregation of data according to their frequency in the discourse. Data were collected and analyzed during the second quarter of 2017.

Based on the analysis of discourses, three thematic categories were developed to guide the understanding and interpretation of interviews: physicians’ understanding on OH; physicians’ practice in PHC with regard to OH; and physicians’ training in the field of OH.

Ethical aspects were observed for the development of the research, according to Resolution no. 466, of December 12th, 2012, by the National Health Council. The project was approved by the Research Ethics Committee of Universidade Integrada Vale do Taquari de Ensino Superior (CAAE 62796316.0.0000.5310), process no. 128633/2016. In order to ensure respondents’ anonymity, their names were replaced with codes. Therefore, the interviewed physicians were mentioned in the text as “P” followed by a number from 1 to 10 (P1 - physician 1, P2 - physician 2, and so on).

RESULT AND DISCUSSION

The sociodemographic profile of the interviewed physicians is detailed in Table 1.

Table 1

Sociodemographic profile of interviewed physicians

Aspects	Percentage (%)
Sex
Female	70
Male	30
Age (years)
Mean of 27.5	50
Mean of 45	30
Above 60	30
Place of residence
In the municipality	80
In neighboring municipalities	20
Graduate degree in medicine
Yes	50
In gynecology and obstetrics	30
In homeopathy	10
In occupational medicine	10
No	50
Time since graduation (months)
12	60
18	40

Thematic categories were organized as follows:

PHYSICIANS’ UNDERSTANDING ON OH

Physicians’ perception on OH was somewhat unanimous in understanding that work is an important health determinant. However, some physicians believe that the understanding of the work-health relationship is based on premises that point to a paradigm focused on a curative health model, understanding that it is not possible to change work conditions to which the user is exposed, as shown in the speeches below:

I believe this is a way to perceive workers’ health, identifying that the cause of that problem is work, but changing the work of that person is more complicated, so you end up treating the symptom, but the cause is still there, it’s no use. (P3)

They often have already tried some type of treatment but were unable to improve. Most of them have chronic diseases that eventually aggravate, and we end up coming at the time of treatment. (P10)

I observe that all we can do is local work, trying to minimize the effects that may occur during working hours. We don’t have the authority to go and try to change the work environment of that worker. (P7)

The understanding - on the work-health relationship and on potential approaches in health care - expressed by the interviewed professionals are opposed to the range of individuals considered workers by the Brazilian Unified Health System (Sistema Único de Saúde, SUS), since it covers the execution of paid and unpaid activities, in the urban and rural area, with or without employment contract, insured and not insured by Social Security, working in the formal or informal economy sector, among others. Furthermore, curative care, centered on the symptom and not on work exposure or working condition, leaving gaps that are detrimental to what has been proposed as comprehensive OH care.[

In many circumstances, work is a risk factor that increases the probability of developing a disease.[ Since PHC is considered the coordinator of the healthcare network, physicians and the health care team need to adopt a sensitive look to recognize users as workers and work as a health determinant of the assigned population, acting according to the principles of SUS established by Organic Law no. 8080.[ Notifying work-related injuries, providing guidance on social security and labor rights and on health and safety in the workplace, performing the productive mapping of the assigned area together with the healthcare team, and implementing therapeutic and informative groups on OH are indirect ways to help workers within the attributions of healthcare professionals.[

It was observed that respondents were able to, with relative ease, relate users’ health diseases with their respective work activities. Physicians were found to know the pathological mechanism that sometimes affects workers in the formal sector (industries, stores, drugstores) and self-employed workers (seamstress, farmers, housekeepers).

Patient’s complaint already leads you to think of something related to work. When a patient comes complaining of musculoskeletal pain, the following question immediately comes into my mind: - What do you do for a living? I’ve always made this analogy. Of course, concerning other complains, like, the patients come with abdominal pain, fever, you can’t make an immediate association. (P3)

It’s not possible to separate one thing from another. Many people spend 8 hours a day working, so, a large number of problems start there. I always try to associate, I relate, I always ask what the patient does for a living. Many people are self-employed, seamstresses that work at home, some people work from seven in the morning to midnight, there are also many farmers here, then there are many self-employed, it’s occupational, but not in a company. (P1)

Blue-collar workers, who work under the sun all day long, often come with skin cancer. What I see is much stress, people with too much workload. (P9)

There are many diseases related to professional activity. We see women who work standing all day, they are shop assistants in drugstores, stores, bookstores, and this will worsen their circulatory problem. The type of professional activity will make it worse. (P5)

The OH field innovates in this aspect because it takes into account the social genesis or the subjective interpretation of the health-disease process. This is proposed by the National Policy for Workers’ Health,[ which also considers workers those who perform unpaid activities, such as interns, and those who are not working due to disease, retirement, or unemployment. Seeking explanations for this illness caused by work, analyzing work processes and its interconnection with socioeconomic factors, lifestyle, and behaviors, is one of the main objectives of OH.[

Since Family Health Units are closer to peoples’ lives and to their workplace, professionals who work there will be able to understand the various forms of work organization, such as structural unemployment, informal work, domestic work, farmers, housekeepers, and the growth of the service sector.[ This is the first step to implement OH in SUS. Therefore, there is an evident need of PHC teams to build a productive mapping of the territory where they work, in order to know the main exposures and the risks derived from users’ work environments in each health unit. Approaches aimed at workers’ health prevention and promotion may be planned based on this mapping.

The analysis of labor risks and of the epidemiological profile of work-related injuries in the territory is important to support intervention actions on work and life conditions of the assigned population, allowing to give priority to activities with the greatest number of exposed workers, which expose workers with greater vulnerability, or whose health impacts are potentially more severe, entre other criteria.[ Some physicians believe that OH is also related to maternal health, pointing that the gestational period may lead to changes in workers’ routine and that these situations require special management.

Sometimes, when a pregnant woman has some problem, especially in slaughterhouses, I write a small letter asking the occupational physician to relocate the patient. Many pregnant women are self-employed... I always write [what she does at work] in order to know when she’s going to need maternity leave. (P1)

When pregnancy is not planned, prenatal care is hard. Another thing, they work in companies where they have to carry weight, their back is going to hurt more. Having to carry a box and also a pregnant belly is going to worsen the symptoms. In some cases, you can send a correspondence asking the employer to change the type of professional activity. (P5)

Because I work a lot in prenatal care here, we know a very complicated reality with regard to OH. They have to achieve production targets, are not allowed to use the restroom, work in a cold chamber, so, these are unhealthy environments. Vulvovaginitis, urinary tract infection, pyelonephritis, pregnancy, preterm labor, miscarriage, there are many things to which work itself may contribute, depending on where they work. Sometimes, if it is a pregnant woman, we send a report asking to change her from another sector or to refer her to examination. Pregnant women have to undergo prenatal care, need to have an appropriate environment to breastfeed, but it not always happens in all companies. (P6)

Female workers have several rights in labor relationships, including job stability from the time of conception to 5 months after delivery, permission to be absent from work for the time necessary to attend at least six medical appointments, and maternity leave without affecting workers’ employment and wage.[

These labor maternity benefits are ensured only to women with formal employment contracts. Another difficulty is that workplaces are not obliged have spaces that support breastfeeding, which hampers workers’ adherence to some maternal health policies,[ such as exclusive breastfeeding during the first months of child’s life and as complementary feeding for 2 years or more.[

PHC PHYSICIAN’S PRACTICE WITH REGARD TO OH

Most physicians reported to record user’s occupation and emphasized the importance of knowing user’s occupation. Some participants reported to detail user’s working conditions according to complaint.

When I observe that there is a strong relationship, I write exactly what the patient does, but I usually write that the patient works at so-and-so company, in so-and-so position, doing so-and-so thing. For example, the patient works at so-and-so market, is a cashier, and works seated, moving only the trunk, or sometime there is information in the electronic medical records, we open these records, and they say if the patient is pensioner, does not work, is retired, or a farmer, a driver, so, it usually appears there. If the patient is a bricklayer, for example, there is exposure to some products. Some mechanics have contact with welding. It’s like asking people if they smoke or drink, these are basic questions, you ask their age, allergies, and what they do for a living. (P1)

Sometimes, the complaint has to do with work. If a woman comes here complaining of mastalgia, first we check if it’s a hormonal condition or not. Then, sometimes we see that it’s a muscular pain, it’s not related to breasts, but we see that it’s a muscular pain and then we start asking “what do you work with?.” Sometimes she works at a slaughterhouse, in the cold. We see that there’s a greater risk for certain conditions, disorders, diseases, and pathologies. Then we provide guidance, refer to a specialist. If it’s an infection, we’re going to dismiss the patient from work, give them a sick leave, and provide appropriate treatment. In environments of large-scale production, are the patients who need more guidance, and we know the reality of these patients, so we advise them here, and sometimes they’re not able to follow the treatment. (P6)

I find it very important because, you know, it’s the area where patients spend most part of the day. I ask their occupation , where they work, how many hours a day, if they are satisfied, I liked exploring this aspect very much. (P9)

Indeed, knowing user’s occupation provide the main direction to assess the relationship between complaint and work; thus, completing the occupation field in all tools of SUS (user’s registration, notifications of diseases, etc.) is essential, being one of the health indicators stipulated by the Brazilian Ministry of Health.[ Therefore, it is crucial to hear when workers talk about their impressions and feelings about their work, about how their body reacts inside and outside work. This is because, whereas some OH risks are easily identifiable, such as work accidents or contact with toxic substances that cause acute reactions, others risks are more silent, causing symptoms that generate chronic diseases and may be confounded with symptoms of non-occupational diseases.[ This is corroborated by the Brazilian Ministry of Health, which states that the main instrument for investigating the relationships between health, work and disease is occupational history taking, an instrument that systematizes the collection of previous and current user’s working conditions.[

The aim of occupation history taking is to identify OH demands. Therefore, physicians should ask about users’ work activity, duration of their current occupation, their current work method, and how work activities are performed. Moreover, the team is responsible for identifying precocious work among children and adolescents.[

It was found that medical practice is mostly guided by the treatment of user’s symptoms or by the implementation of palliative measures in situations of chronic diseases. Few physicians mentioned that they referred patients to specialized care in secondary health care. Some respondents reported difficulties in management after diagnosis:

Most patients have spine, shoulder, and musculoskeletal conditions. Those who are self-employed, performing cleaning services, have low back pain, disc herniation, arthrosis, and shoulder tendon tear. Mental disorders, sometimes just one person is causing the problem, some people have conflicts at work, is bullied, when they are at home they feel ok and go to work having to bear this situation. (P1)

We observe a progression in these pains and how most patients did not undergo appropriate treatment, they seek the doctor only after a series of repeated injuries. Then it’s harder to treat, but there’s much of the patient’s psychological part, of not being where they wanted to be and having to work every day because they have to earn their living. We always try to resolve the situation here. I try my best not to refer the patient. If, by any chance, we see that we can’t deal with it and the patient should have a more specialized healthcare, then we refer them. (P2)

Ah, I’m a driver, I work seated, I have back pain, or I’m a teacher, I have too much workload, I’m under psychological distress, I’m underpaid, I find it very hard to correct that. You treat the symptom, but the cause... Sometimes people like what they do, they don’t want to change their job, but it’s causing them distress, so I always try to show alternatives to these people... but, when you identify that they have a work-related disease, to whom do you refer these patients? (P3)

Although healthcare professionals did not report difficulties in recognizing occupational diseases, none of the respondents mentioned the notification of diseases on the available health information systems. A study conducted in Spain showed that lack of appropriate training is considered a major factor for physicians’ lack of knowledge on certain OH actions,[ such as registration on health information systems for epidemiological surveillance purposes.

According to the protocol of OH in PHC, physicians from health units should, in addition to suspect and diagnose diseases caused or aggravated by work, asking the company to issue a Work Accident Communication (Comunicado de Acidente de Trabalho, CAT) form, when it comes to workers with an employment contract. It is necessary to complete the medical certificate regarding diagnosis and to provide certificates and reports to the medical examination team of the Social Security National Institute (Instituto Nacional do Seguro Social, INSS) or to the social security entity to which the patient is affiliated.[ Therefore, it is necessary that PHC professionals plan different actions directed to worker patients who seek the health unit.

In respondents’ speeches, there was a recurrent mention about the importance of prevention measures. However, some respondents reported difficulties in working in this area. The following portions of interviews showed that some physicians provided guidance on health education and promotion in their consultations.

We were trying to do a very good job related to farmers who use agrochemicals. I’ve started a work with chronic pulmonary diseases due to aspiration of charcoal powder. (P4)

You have to ask patients to change their lifestyle, to perform activities to relieve pain, to reduce weight load, if they’re a blue-collar worker, to avoid certain movements related to that symptom and repetitive movements, to take breaks, to get, to stretch, if they spend too much time sitting down. (P3)

I try to take preventive measures, but you can’t prevent because patients already come with injuries, especially musculoskeletal ones. Sometimes, we try to promote some postural re-education, for example, bending the knees rather than the back when getting down, but patients already come with back injuries. My part is mostly diagnosing and prescribing treatment, there’s no prevention. I try, but it’s hard. (P1)

Other respondents understood prevention actions as biosafety activities, actions usually attributed to the Specialized Service in Safety Engineering and Occupational Medicine, an entity that is restricted to workers of the formal sector. One of speeches mentioned actions that are part of the programs implemented by Brazilian Ministry of Health for the general population, which are not specifically targeted to workers.

I used to give lectures in order to promote the prevention of the damages caused by agrochemicals and, kind of by ourselves, we monitored the roads if there was someone working. I wish I could have done more, I wish I had more protection item, PPE for them. (P4)

I work with primary healthcare, routine tests, prevention of cervical, breast cancer … so, through this test, we practice preventive medicine to improve workers’ quality of health, contraception, prenatal care, we perform our work in the health unit through this. Because we don’t work with occupational medicine here. (P6)

Within the scope of competence of SUS, OH actions are understood as a range of activities aimed at health promotion, protection, recovery, and rehabilitation of workers exposed to risks and injuries derived from working conditions.[

Global, emphasis has been placed on the need to protect and promote occupational health and safety by preventing and controlling the risk factors present in work environments. The International Labor Organization (ILO), in the 1981 ILO Convention, established the institution and implementation of a workplace safety in the signatory countries.[

Again, it bears emphasizing that the most effective actions to promote, prevent and protect workers’ health are those targeted at the collective domain and not those that attribute to individuals the responsibility for their physical and mental integrity. Therefore, it is recommended to prioritize the improvement of production models, ensuring health and safe workplaces, as corroborated by Santos & Lacaz.[

With regard to the difficulties in working with prevention, some authors have mentioned the lack of appropriate training during and after academic studies, arguing that students should have greater training in the area of OH, which helps in their professional practice.[

The results of this study may subsidize the planning of actions in this area, to be developed by all spheres of SUS administration. These actions should broaden the understanding and knowledge of healthcare professionals with regard to the National Policy for Workers’ Health and to the components of the Healthcare Network in the municipality where they work, with the regard to the expanded autonomy and to the empowerment of PHC teams, and with regard to need of the Municipal Health Council to institute and implement the Intersectoral Commission on Workers’ Health, as provided in SUS regulations.

CONCLUSIONS

Based on the main results, it was possible to observe that, for some professionals, the relationship between work and health is based on a curative and little preventive health model, focusing on biosafety activities and treatment of user’s symptoms, to the detriment of health promotion, surveillance, and rehabilitation actions. It was also found that PHC physicians lack training on relation to OH, with reports of difficulties in dealing with health inequalities, chronic diseases, and prevention measures.

There are valid reasons to consider that the possibilities of implementing and strengthening OH in PHC are varied and should seek to overcome the epidemiological silence with regard to work-related diseases and to implement strategies to articulate actions aimed at healthcare, surveillance, disease prevention, and health promotion, using inter-sectoriality and inter-institutionality to improve population’s quality of life.