Aldo Pacheco Ferreira; Mariana Tramontini Grams; Regina Maria de Carvalho Erthal; Vania Reis Girianelli; Maria Helena Barros de Oliveira
BACKGROUND: Hazards in the working environment might cause damage to the health and integrity of workers as a function of their nature, intensity, length of exposure and concentration, and the susceptibility to them.
OBJECTIVE: To analyze national and international literature on risks in the working environment relative to the working conditions and their impact on workers’ health.
METHOD: Literature review conducted in databases Latin American and Caribbean Health Science Literature (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) and US National Library of Medicine National Institutes of Health (PubMed), and electronic libraries Scientific Electronic Library Online (SciELO), Virtual Health Library (VHL) and Nursing Database (BDENF). Studies were categorized according to the reported risk factors and/or health problems as "work accidents," "occupational diseases" or "work accidents and occupational diseases." Results: Physical hazards mentioned included excessive noise, inadequate temperature, poor air quality, and exposure to sunlight. Chemical hazards involved exposure mainly to pesticides, medications, solvents and disinfectants. Biological hazards exclusively concerned healthcare professionals, especially via contact with patients.
CONCLUSION: Health problems among workers are intertwined with several types of hazards. Workers are exposed to material, physical, chemical, biological, cultural and organizational factors as a part of the work process. An integrated approach to the working environment might favor less fragmented actions, and serve as grounds for legislation and public policies respectful of the actual conditions and dignity of workers.
Keywords: occupational hazards; working conditions; working environment; occupational health.
INTRODUÇÃO: Os riscos no ambiente laboral podem causar danos à saúde e à integridade física do trabalhador devido à sua natureza, suscetibilidade, intensidade, tempo de exposição e concentração.
OBJETIVO: Analisar, na literatura nacional e na internacional, os riscos do meio ambiente de trabalho quanto às condições laborais e o impacto na saúde do trabalhador.
MÉTODO: Trata-se de uma revisão da literatura nas bases de dados de Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) e US National Library of Medicine National Institutes of Health (PubMed) e nas bibliotecas eletrônicas Scientific Electronic Library Online (SciELO), Biblioteca Virtual em Saúde (BVS) e Banco de Dados em Enfermagem (BDENF). Os estudos foram divididos em riscos e/ou agravos de acordo com o que foi enfatizado no trabalho, como "acidentes de trabalho", "doenças ocupacionais", "acidentes de trabalho e doenças ocupacionais".
RESULTADOS: Os riscos físicos mencionados foram ruído excessivo, temperatura inadequada, má qualidade do ar e exposição a raios solares. Já os químicos se dão pela exposição — as principais cargas químicas mencionadas são os agrotóxicos, medicamentos, solventes e desinfetantes. Quando aos biológicos, estão relacionados estritamente aos profissionais da saúde, com destaque a contato com pacientes.
CONCLUSÃO: Os agravos à saúde do trabalhador apresentam-se imbricados com diversos tipos de risco. Os trabalhadores ficam sujeitos à exposição a aspectos materiais, físicos, químicos, biológicos, culturais e organizacionais nos processos de trabalho. Uma abordagem integrada do ambiente de trabalho, nesse sentido, propiciaria ações menos fragmentadas, servindo de base para legislações e políticas públicas que respeitem a realidade e a dignidade do trabalhador.
Palavras-chave: riscos ocupacionais; condições de trabalho; ambiente de trabalho; saúde do trabalhador.
In the present-day world, human life is signaled by increasing uncertainty and a feeling of weakness in regard to hazards and vulnerabilities to which everybody is directly or indirectly exposed. These aspects also influence work, as it represents one of the axis around which human life is structured. Issues related to risk and/or vulnerability are even more significant for healthcare professionals, as they are routinely exposed to a variety of chemical, physical, biological and psychosocial hazards1.
The working environment is defined as the place where workers perform their job. Within the context of labor relations, the working environment/conditions are in a highly aggressive economic scenario centered on improving productivity by means of continuous technological innovations. The deterioration of the working conditions is evident in the new forms of organization of work, flexibilization of the working hours (longer and/or irregular), precarious employment relationships, increasing underemployment — especially for the outsourced workforce, and job instability — compelling workers to constantly seek new jobs2.
Interventions on the working environment and working conditions should be based on judicious and thorough analysis of the organization of work, including the task content, modes of operation, workstations, pace and intensity of work, mechanical factors, physical aspects of workstations, production standards, shift work, psychosocial and individual factors, and relationship with supervisors and coworkers. Further aspects are the collective and personal protective measures implemented by employers, and the collective and personal defensive strategies implemented by workers3.
The working conditions have significant impacts or repercussion on political, economic and social aspects, and also reflect the degree of development of a country4.
In regard to prevention targeting workers, article 4, item 2, of the International Labor Organization (ILO) Convention 155 — concerning Occupational Safety and Health and the Working Environment — states that one of the goals to be achieved is "to prevent accidents and injury to health arising out of, or linked with or occurring in the course of work, by minimizing, so far as is reasonably practicable, the causes of hazards inherent in the working environment.5"
Juridical grounds to protect the working environment are provided in the Brazilian Federal Constitution, particularly: Title VIII — On Social Order, Chapter II — On Social Security, Section II — On Health, article 200, VII and VIII: "In addition to other actions defined in the law, the unified health system is entitled to: VII–participate in the control and supervision of the production, transport, storage and use of psychoactive, toxic and radioactive substances and products." Title II — On Fundamental Rights and Guarantees, Chapter I — On Social Rights, article 7, XXII: "The [following] are urban and rural workers’ rights, in addition to others aiming at improving their social status: XXII — reduction of hazards inherent to work by means of health, hygiene and safety standards.6"
The historical antecedents of the knowledge on the relationship between work and its effects on health were gathered from graduate dissertations, especially in regard to the period when publishing in journals was rare5-7. Such studies promoted greater engagement of learning institutions and investigators in the performance of research to improve the efficacy of the application of results into practice, likely to achieve outcomes compatible with the dignity of and guaranteed health in the workplace. A prevention-centered culture focused on a healthy quality of life is indispensable for effective protection of the workers’ health6,8,9.
Occupational health is a field of knowledge and practices, which theoretical-methodological approach, in Brazil, emerged from collective health. Its goals are to investigate and interfere with the relationship between work and health/disease, having as core reference the emergence of a new social actor, to wit, the industrial working class, within a social context characterized by profound political, economic and social transformations10.
The aim of the present study was to analyze the national and international scientific literature on occupational health dealing with hazards related to the working conditions and their impact on the health of workers.
STATE OF THE ART: REGULATORY STANDARDS
According to the 8th National Health Conference (Conferência Nacional de Saúde — CNS) final report11, from 1986: "dignified working conditions, workers’ knowledge of and control over work processes and environments are a core prerequisite for full access to health."
The Federal Constitution of 1988 gave rise to a new notion of health, considered in article 196, which states that health is a right of all people and the government’s duty, ensured by social and economic policies to reduce the risk of diseases and other health problems. Article 200, items II and VIII, further state that especially as concerns occupational health, the Unified Health System (Sistema Único de Saúde — SUS) is charged of "Performing health and epidemiological surveillance, and occupational health actions" and "collaborating in the protection of the environment, including the work [environment]"12.
Legislation on protection of workers includes Administrative Ruling no. 3,21413, which comprises a series of regulatory standards (RS) which consolidate the labor laws relative to the Environmental Hazard Prevention Program. Hazards are categorized in RS no. 9, which defines as environmental hazards physical, chemical and biological agents in the workplace, which as a function of their nature, concentration or intensity and length of exposure are able to cause damage to the health of workers14.
RS 9 item 9.1.1 makes implementation of the Program by employers mandatory, aiming at preserving the health and integrity of workers by anticipating, recognizing, evaluating, and consequently controlling present or future hazards in the workplace, including protection of the environment and natural resources. As a result, five categories of hazards should be included in the Environmental Hazard Prevention Program, to wit: physical, chemical, biological, ergonomic and related to accidents.
Physical agents are the various forms of energy to which workers might be exposed, including: noise, vibration, abnormal pressure, extreme temperatures, ionizing radiation, infrasound and ultrasound. Chemical agents are substances, compounds or products which might penetrate the body through inhalation, in the shape of dust, fumes, fog, mist or vapors, or which as a function of the nature of the activity associated with exposure, might come in contact with or be absorbed into the body through the skin or ingestion. Biological agents are bacteria, fungi, bacilli, parasites, protozoa and viruses, among others13-16. Psychosocial hazards of work are the workers’ perceptions and experiences, some of personal nature, others concerning their expectations of economic reward and personal development, and further others relative to human relations and their emotional aspects17. Thus, they represent interactions between work and the working environment, job satisfaction and the organizational conditions, on the one hand, and the personal characteristics of each worker, their needs, culture, experiences and perception of the world on the other.
This is the framework within which attempts are made at detecting elements of the working conditions likely to cause damage to the health of workers. The approach to risk factors involved in occupational health must face a high level of complexity, which mandatorily demands going beyond monocausal analyses of risk7.
Similarly, Geller18 emphasizes the high complexity of the risk factors associated with work accidents, as according to him, they never stem from one single cause, but from many, which accumulate until one, i.e., the last, precedes the immediate action which triggers an accident.
We chose to perform an integrative review, as it is a method which affords a synthesis of the knowledge available including the applicability of significant studies into practice19,20. A synthesis of the available knowledge is relevant given the increase and complexity of the information on occupational health, and its potential to contribute to the definition of more concise methodological steps, and make better use of the evidence provided by scientific studies21,22.
The first step of the study consisted in the formulation of the research question: What are the risks posed by the working environment, concerning the working conditions and their impact on the health of workers?
The second step involved the definition of inclusion and exclusion criteria for studies, and a literature search in databases Latin American and Caribbean Health Science Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde — LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), US National Library of Medicine National Institutes of Health (PubMed) and electronic libraries Scientific Eletronic Library Online (SciELO), Virtual Health Library (Biblioteca Virtual em Saúde — BVS) and Nursing Database (Base de Dados de Enfermagem — BDENF) along the first semester of 2017.
The following controlled terms were used: “ambiente de trabalho” (“working environment”), “saúde do trabalhador” (“occupational health”), “condições de trabalho” (“working conditions”) and “riscos ocupacionais” (“occupational risks”). Also operator AND was used. Eligible studies should have been published from 2007 to 2015, in Portuguese, English or Spanish, and have their full text available.
The process evolved as follows: search based on the selected keywords; definition of publication period and languages; and thorough analysis of titles and abstracts, which led to the inclusion of studies which met the review aims and criteria and the exclusion of all others.
The inclusion criteria were: original articles; with full text available open access; included in the selected databases and electronic libraries; having Brazil as country of interest; and published from January 2007 to December 2015. Duplications, review articles, graduate dissertations, essays, reports of experiences, case studies, and articles unrelated to the subject of interest were excluded.
In step three we extracted the data using an ad hoc form, which included categories: name of author(s), title, publication year, database, study design, types of hazards, and place where study was conducted. Step four consisted in thorough analysis of the studies to find answers to the question posed. Step five involved the presentation of results, which was done in tables including detailed analysis of the information gathered, categorized in themes as per type of hazard.
Risk factors were most commonly investigated by means of validated instruments for specific factors, such as anxiety, history of depression, life events, social support and stress, among others.
To facilitate organization and understanding, following the analysis of the main results of each study, we tabulated the data according to five preset domains of analysis, to wit: publication year, author(s), journal, study design, and main results. Both analysis and synthesis of the data extracted from studies were performed in descriptive manner so as to analyze, quantify, describe and categorize them to reunite the information on the subject of interest.
The sixth and final step consisted in the presentation of the review, in which we clustered the main results of the analysis of the selected studies.
RESULTS AND DISCUSSION
The search and selection in the analyzed databases and electronic libraries allowed retrieving 29 scientific studies which met the review aims (Figure 1).
Many of the main results reported in the studies did not point to health problems as direct consequence of poor working conditions. It should be noticed that in some cases two or three aspects had been addressed at one time23-28.
Among the physical hazards evidenced, excessive noise29 and inadequate temperature30,31 stood out. In regard to the quality of the air, lack of ventilation and presence of smoke or pollution were mentioned31. Excessive exposure to sunlight — among workers with outdoor jobs — deserves special mention28,31,32.
About 20.69% of the studies mentioned chemical hazards resulting from the handling of a wide variety of substances. The most exposed populations were rural workers32, painters33 and healthcare professionals. Independently from the chemical involved, inadequate labeling was a factor with considerable contribution to exposure, as worker sare deprived from proper information on risk. The main chemicals mentioned were pesticides, medications, solvents and disinfectants.
Biological hazards were mentioned in 31.03% of the studies34-41, and usually concerned healthcare professionals, as such agents might be transmitted through direct or indirect contact with patients — directly, through the hands or use of non-sterile materials; indirectly, through the air or contaminated objects. It is worth calling the attention to the relationship between biological risk factors and sharps injuries. As a function of the complexity of the risk factors involved in work accidents, the latter never result from a single, but always from several causes, which accumulate until one, i.e., the last, triggers the immediate action resulting in an accident42,43.
Technical and material factors gradually become intertwined with human factors in the analysis of occupational hazards. Indeed, studies which analyzed the influence of working conditions and the organization of work on the occurrence of accidents and illnesses point to a working environment with physical, chemical and biological factors unfavorable to the health of workers44-46. Acknowledging one single action as causal link between the conditions for production and occurrence of health problems masks the actual violence represented by the organization of work imposed to workers.
Chart 1 describes all the articles included in the present review according to the following categories: publication year, author(s), journal, study design and main results.
The largest proportion of studies were published in 2013, 17.24% (n=5) (Figure 2).
About 41.38% of the studies (n=12) were conducted with healthcare professionals, 27.58% (n=8) corresponding to nursing professionals; 24.24% (n=7) with informal workers (fishermen, street vendors); and 24.24% (n=7) with other professional categories, among which two with teachers and physicians, in addition to industrial workers, radiotherapy technicians and flight controllers — n=1 each (Figure 3).
The results show that scientific research still has a fragmented approach, and focuses on the better organized occupational categories: 12 of the 29 studies analyzed health professionals. A wider perspective is needed for the working environment, given the adjustments needed to truly understand the actual working conditions in the face of the perverse logic of the capitalist system, which prioritizes profit at the expense of the principle of the dignity of the human person and the social value of work47,48.
The results further show that some occupational categories remain invisible and not protected by the law, as is the case of informal workers. Within this context, we emphasize underreporting, which hinders estimations of the actual situation of events and problems affecting the population. In addition, the Brazilian occupational health information systems are restricted to severe cases requiring hospital admission, and as a rule leave out accidents and deaths among informal workers, i.e., not registered with the social security system49.
In the analysis of the main results of the included studies we identified two main lines: studies which merely described risk factors, and studies which reported occurrence of events, such as work-related diseases and accidents (Figure 4).
Policies targeting integral workers’ health and focusing on the quality of life of workers need support4. According to ILO, efforts should be invested in the prevention of work-related accidents and health problems. Term working environment denotes a more general view not restricted to the study of the occupational safety, health and hygiene regulations included in the Consolidation of Labor Laws (Consolidação das Leis do Trabalho — CLT) or some functional statutes5.
We stress the relevance of public policies for occupational health to improve the working conditions. Occupational hazards and the vulnerabilities which befall on workers are mainly due to shortage of resources to perform work, physical and moral violence, and emotional exhaustion derived from the socioeconomic and cultural context within which work is included.
Health problems among workers are intertwined with several types of hazards in the working environment. Workers are exposed to material, physical, chemical, biological, cultural and organizational factors as a part of the work process. An integrated approach to the working environment might favor less fragmented public policies.
The results of the present study might serve as evidence to ground the formulation of more efficient preventive legislation and public policies targeting the relationship between work and health, as indicated in article 4, item 2 of ILO Convention no. 155. To remind, upon addressing occupational health and safety and the working environment, this convention demands prevention of accidents and harms.
Given the magnitude of health problems derived from lack of safety and harmony in the working environment, and acknowledging that improvements are difficult to achieve in this case, occupational health should be approached from an integrated perspective, rather than as a mere addition of individual factors. This approach will allow overcoming the model which continues to be reproduced, but which might be complemented with new views to achieve working environments respectful of the dignity of workers.
To make advances in the scientific knowledge on risk factors to which workers are exposed, studies should seek to explore the working environment in a fully encompassing manner. Lack of integration in the approach to the full context of working environments leads to failure in the attempts to arrive at a reliable understanding in the sense that environmental, sociocultural, biological and psychological phenomena are intimately interrelated.
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10 de Maio de 2018.
Aceito em 21 de Setembro de 2018.
Fonte de financiamento: nenhuma