article 4649 DOI: 10.1590/1413-812320141912.12732014 - - - - - This paper the issue of addresses mental bstract 1 tices include should and identify generating com ponents of theseThe diversity negative of aspects. illnesses caused work by and conditionsprocesses majorcalls for ascertain investment to and change the situations that give rise such to illnesses. sur Health health and work, Mental words Key Occupationalveillance, health work (RENAST). Some theoretical Some approaches work (RENAST). experiencesand practical in mental and health systematicallywork are presented and discussed A survey is also conducted of po in this essay. tential strategies mentalintegrate to health into view is our actions. It that the origins of VISAT illnesses and ensuing harm closely to are linked in work organizationthe elements and involved surveillance prac Consequently, management. A health in the Occupational Health Surveillancehealth in the Occupational Health seeks present theoretical to It context. (VISAT) aspects and institutionalpolicies contributing to the incorporation of mental health dimensions in view process, of the pressing VISAT the into attendneed this demand to to that is becoming increasingly important the occupational in health especially withinarea, the scope of the National Net Occupational Healthcare Comprehensive he issue ofThe issue health healthmental in occupational surveillance 2 Centro de Estudos da Estudos de Centro Grupo de Estudos Estudos Grupo de 2 1 Luís Henrique da Costa Leão Leão da Costa Henrique Luís Gomez Minayo Carlos Saúde do Trabalhador e Trabalhador do Saúde Escola Ecologia Humana, Pública Saúde de Nacional Fiocruz. Sergio Arouca, Ambientais e Saúde do do e Saúde Ambientais Instituto Trabalhador, Coletiva, Saúde de de Federal Universidade Fernando Av. Grosso. Mato Boa Esperança. Corrêa 2367, MT 78060-900 Cuiabá Brasil. [email protected] 4650

Introduction chiatric or psychological specialists10. These are procedures concerned with treating the illness, The issue of mental health at work is current- without an analysis of the causative factors or an

Leão LHC, Minayo Gomez C Gomez Minayo LHC, Leão ly one of the most pressing demands facing the intervention with regard to them. occupational health services. The technical and Apart from the low number of diagnoses, social features of the way work is currently man- causes identified and cases notified, some Cerests aged and organized are responsible for a series of deal with mental health as a collective problem11. physical, psychiatric and social illnesses1-4. They organize various events for the purpose of Complaints relating to bullying and psycho- training their own team and local health units logical assaults are on the increase, along with ev- and for establishing partnerships with Caps and idence of unhappiness, exhaustion, and continu- mobile mental health and psychiatric clinics so ous illness. There is also evidence of more serious as to diagnose cases of illness, treat workers and conditions, leading to depression, post-traumatic build up the notification network. And some stress, work neuroses and even cases of suicide. steps towards health surveillance and rehabilita- Matters such as these are already considered tion are taken. to be a public problem in the European Union, Even though we do not have a complete pic- because they affect 28% of the workforce and are ture of programs for mental health and work un- responsible for 25% of absenteeism, represent- der SUS, there is evidence as to how much this ing a loss of around 20 million euros to Member topic figures in the agendas of the Cerests and in States5. the concerns of the Ministry of Health (MH). At The matter is also cause for concern in Brazil. the same time, we note the absence of programs During the first decade of the 21st century, 33% of for systematic and continuous action, governed the economically active population suffered some by guidelines and principles which will assist form of bullying6, and in 2010 mental and behav- health surveillance strategies. ioral problems were the third most important The occupational health section of the MH reason for the grant of sick leave on the grounds has been leading a discussion process for the pur- of incapacity7. This situation brings with it the ur- pose of formulating guidelines for care, preven- gent challenge of including mental health ques- tion, promotion and monitoring, with the pro- tions within the scope of Occupational Health gramming of meetings, seminars and workshops. Surveillance – Visat. For this purpose, there is Generally speaking, under SUS, occupational a need to widen the context of interventions by mental health practice is more directed towards adopting strategies for identifying and taking ac- care and towards the recognition, diagnosis, no- tion with regard to illnesses originating in work tification and treatment of work-related mental processes at different levels, so as to include men- problems12,13. In this context, there has also been tal health in health surveillance programs. a formulation of a “schedule of work-related The matter is urgent because, in addition to mental illnesses” which envisaged the possibility the increase in problems, the Reference Centers of diagnosing and establishing a causal nexus be- for Occupational Health (CEREST) are encoun- tween the mental illness and the work concerned tering difficulties in implementing programs in and directing care towards those suffering from this respect8. Some teams receive requests to inves- illness14. tigate professional categories and sectors where In the light of these developments, this arti- the problems have manifested themselves with cle aims to contribute towards the full inclusion the greatest intensity, for example in the fields of of mental health in Visat, and to introduce some education and health. Much of the response has theoretical considerations for developing policies concentrated on an attempt to establish causes in this respect within the National Comprehen- for the increase in the number of notifications sive Occupational Healthcare Network – Renast. under the Notifiable Illnesses System (Sinan) and The reflections and suggestions set out here to provide help for the worker suffering from ill- are the result of a systematization of theoretical ness. In some cases, in the absence of guidelines, and practical approaches in mental health and only psychological assessments are made, using work in the academic and institutional fields, tests, clinical anamnesis and certain treatments9. in the principles of the National Policy for Oc- The most common procedure is the acceptance cupational Health, and in the experience of the and registration of cases, which are then referred authors in taking part in forums, meetings and to Psycho-Social Care Centers (Caps) or to psy- debates on the subject. 4651 Ciência & Saúde Coletiva, 19(12):4649-4658, 2014

Theory and practice Approaches to occupational mental health in occupational mental health Various views of differing persuasions have The first point to consider when we contem- analyzed the causes of work-related illness, influ- plate the integration of mental health within Vi- enced, among other things, by the development sat concerns an understanding of the mental as- of psychology, psychiatry and psycho-analysis, pects of occupational health. Under the influence and also by the conditions in each region. We of Cartesian thought, the idea arose of the mind see more behaviorist views in the USA, a medi- as a kind of interior life, separated from external cal-physiological approach in Nordic countries, events. This led to the classic division between a sociological analysis in Latin countries and a mind and body, in accordance with which certain unified approach in France. illnesses were located in the body, while feelings, During the course of these analyses, human images, hallucinations were phenomena particu- suffering has been at one time or another inter- larly related to the mind. preted as illness, pathology, disturbance, neurosis Other strands of thought, originating in or depression22, so that another problem should Freudian psychoanalysis, introduced the idea of be raised here: the medicalization and the result- a psychic apparatus and the notion that the pro- ing individualization, assignment of blame and cesses responsible for behavior, anxiety and ill- victimization of problems where the cause is not ness were unconscious and functioned relatively in the body (biological) or in psychic factors, but independently from corporal and cerebral pro- in social and work relationships. cesses15-17. Soares and Caponi23, in their research on More recently, through the advances in tech- depression, identified the transformation of dif- nology and the neuro-sciences, the idea has ferent forms of suffering into individual pathol- gained ground of the mind as a data processing ogies, measurable and homogenized through the machine, understood as a set of chemical pro- use of diagnostic criteria. The authors also en- cesses and neuronal connections. And there has visaged the application of “potentially universal been a growth in psycho-pharmacological com- therapeutic resources”, aimed at the individual, panies which control subjectivity through the with a special role for anti-depressants, intro- use of tranquillizers and anti-depressants, lead- duced as a privileged therapeutic option. ing to exorbitant profits for the pharmaceutical On the contemporary scene, therefore, many industry, as an expression of bio-politics and of illnesses which would formerly have been con- bio-economics18. sidered as different manifestations of life expe- These conceptions have influenced the modes riences now take on the features of pathologies of comprehension and action in the field of oc- – depression, stress, etc. One consequence for cupational mental health, and have tended to re- workers, given the competitive nature of the strict the mind or psyche to simply a place where world in which they live, is a tendency to develop disturbances occur19, the sphere of impact of and maintain high levels of performance, sup- working conditions within the individual. Con- pressing or hiding any symptoms of illness. sequently, the cause of the illness is ascribed to Many of the illnesses of workers, being diag- the characteristics, history and personality of the nosed as stress, which is a pathological mental worker concerned. The remedy for such prob- and behavioral disturbance, tend to produce sick lems is essentially therapeutic and psychiatric20, individuals/workers, resulting in the targeting of and little consideration is given to the processes, care and health surveillance, whilst overlooking environment and organization of work which interventions with regard to the social determi- may have caused the illness. Psychiatric reform nants for the illness. Pathologization and medi- itself criticizes psychiatric institutions as being calization stand out at a time marked by an in- asylum-like and mentally disturbing, viewing the tolerance of illness and a demand for permanent illnesses of patients as a mode of existence and good health. The individuals concerned end up not simply as a mental disturbance of the indi- by being socially conditioned towards the medi- viduals concerned21. calization of their illness24. 4652

Currently there are the following approach- recommendations relate to work organization, es to the relationship between work and mental such as the organizational culture, the control health: clinics at work, focus on stress, bullying and autonomy enjoyed by the worker in his job

Leão LHC, Minayo Gomez C Gomez Minayo LHC, Leão and psychological aggression; the psycho-pa- and hours of work, interpersonal relationships, thology of work and of psychiatry, including the communication, social support, remuneration, trend towards mental exhaustion; psycho-sociol- recognition and home-work conflicts. ogy and institutional analyses; and organization- Stress, as the principal focus of concern, is al and subjective approaches. viewed as a set of emotional, physiological, be- Despite the diversity of the existing theoret- havioral and cognitive reactions connected with ical interpretations and approaches, some prac- the content, organization and context of the tice concentrates on the alternatives for lower- work26. On this basis, rules have been established ing stress and seeks to equip workers with tools and political agreements reached, such as the which can help them to deal with situations of European Pact on Mental Health and Wellbeing, stress at work. In other words, we are talking the Edinburgh Declaration on the Promotion of about a collective offer of guiding principles for Workplace Mental Health and Wellbeing27, and finding individual solutions to the problems of the Framework Agreement on Work-Related mental health. They are prescriptive interven- Stress28. These are important resources for en- tions, directed towards the person, and they use abling the European Union to achieve the ob- techniques of muscular relaxation, meditation jectives of the Lisbon Strategy, which was aimed and training in cognitive and behavioral abilities. at confronting low productivity and economic Above all, they seek to change the evaluation of stagnation29. the stress-producing factors or teach people to Bruchell and Robin30, after three decades deal with the symptoms. of research, seminars, consultations and inter- In this connection, mention should be made ventions, introduced into the discussion some of “coping” (strategies for adapting to adverse important elements as regards constructing a circumstances), and techniques of stress man- healthy working environment. They emphasized agement, such as counselling, gymnastics, recre- trust as an essential element, based on credibility, ational and artistic activities, generally following respect and justice, and these are strengthened a cognitive/ behavioral pattern. Various organi- where there is open communication, compe- zational programs also aim to reduce the cogni- tence and integrity in maintaining the vision of tive evaluation of stress factors and their subse- the company. Other measures are support for quent effects. professional development, demonstrations of Few of these interventions are designed to appreciation, working together with the employ- produce changes in the principal stress factors of ee in decision making and attention to aspects of the organization of work. There is a tendency to his personal life, as well as impartiality, equitable explain and attribute organizational successes and dealing and the absence of discrimination. failures to the individual characteristics of the per- Even though the main aim may be to increase sons involved, and a habit of blaming personality productivity, it is impossible to ignore improve- and life style factors of employees for their ab- ments in those aspects of work which are condu- sences from work or health complaints. Moreover, cive towards the mental wellbeing of the work- psychology and medical care at work have both force. traditionally focused on the individual25. These aspects are to be found in the guide- Strategies for implementing mental health lines issued by bodies such as the World Health surveillance Organization, the International Labor Organiza- tion, the Occupational Safety & Health Adminis- What are the methods for including mental tration, the National Institute for Occupational health at all stages of planning, preparation, real- Safety and Health, the European Parliament and ization and evaluation of health surveillance pro- other national institutions. cedures, as regards the origin of the different lev- In general, these guidelines also recommend els of illness to be investigated? Given that these measures to improve working environments as illnesses occur at the interface of material, tech- regards stress, violence, bullying, psycho-social nical, social and organizational relations with risks and mental disturbance, as well as the con- the employees, it will be necessary to analyze the struction of psychologically healthy companies. actual conditions of each working context and The crucial point to make is that most of the situation. The question of mental health may be 4653 Ciência & Saúde Coletiva, 19(12):4649-4658, 2014

the central focus of an intervention or just one aspects of work procedures which should be the of the aspects to be considered during the health object of health surveillance. surveillance process. When in the practice of interventions there As regards the collection, production and is a rigid distinction made between the objective analysis of information for the purposes of im- and subjective aspects of work, this is a simpli- plementing health surveillance programs based fication of reality. And mental health ends up on different data sources, reliance should be by being considered a problem of the workers, placed initially on the procedures and informa- a subjective, interior, individual question, and tion which already exist under SUS for the re- this works in favor of blaming and victimizing cording of work-related illnesses, mental prob- the symptoms of illness on the part of workers. lems and general behavior. Included among these Moreover, this compartmentalization of mental illnesses are cerebral lesions, personality changes, health as part of the “internal world” can con- dementia, delirium, minor cognitive difficulties, tribute towards maintaining the invisibility of organic mental difficulties, depressive episodes, those aspects of the work process which cause fatigue syndrome, chronic alcoholism, post-trau- pressure and lead to the outbreak of illness. And matic stress and adaptation syndrome, profes- at the same time it contributes towards the con- sional neuroses, sleep disturbances and profes- tinuation of psychologizing and medicalizing at- sional exhaustion syndrome12,13. titudes, to the extent that it refers to the clinic, Important information can also be obtained on the one hand, the problem of understanding from cataloguing and interpreting individual de- and treating subjective aspects (difficulties, ill- mands and from referrals of workers suffering ness and disturbances) and, on the other hand, it from illnesses to a Cerest or from complaints made resorts to health surveillance to identify objective by labor organizations. Although psychic conflict, aspects. anxiety, irritability, apathy, low self-esteem and A holistic analysis of the work process avoids other types of psychic and psycho-social illnesses creating a dichotomy in analysis/intervention are less widely recognized, they can result in the between the physical, material, objective aspects emergence of physical symptoms31. And these ill- and the subjective, mental-interior, psychological nesses can be a sign of collective exposure to work aspects. Thus Visat needs to surmount the seg- processes which are responsible for various man- regation between “the outside and the inside” of ifestations of discontent or dissatisfaction, which subjects. are crucial for health surveillance. This holistic analysis of the work process in- A fundamental strategy to improve the re- cludes a general assessment of the processes of cording of attendances, and therefore the collec- production (political, economic, technological tion of information on mental health problems and social), the specific characteristics of work – just as with other types of injury or illness – processes (raw materials, artefacts, procedures, is to be found in the permanents links between etc), the burdens and risks of the workplace the Cerests and basic care services, family health (physical, chemical, biological, ergonomic), the teams and other units and programs in the local aspects connected with the organization of labor and regional health network, more particular- (the division of tasks, hierarchy, management ly the Caps. It will also be necessary to establish methods, working hours, shifts, rhythm and in- inter-sectorial connections in a similar manner tensity of tasks, breaks), the level of the activity to the consolidated experience already gained in and real work (relationships, creations, illnesses, some sectors of production32. defenses, production of new rules). In our view, this integrated approach provides Integrated analysis of the work process support for collective negotiations and the initia- tion of changes in work processes for the benefit Mental health phenomena – various illness- of mental health. On the other hand, to isolate es, melancholy, sadness, depression, bullying, mental health from the other problems which ex- stress, disturbances, etc – are specific conditions, ist in the work processes which are the subject of but they can be interlinked with problems aris- intervention could leave the Visat professionals ing from exposure to various kinds of risk in the deprived of support for referring actions to the work environment, as well as the occurrence of competent bodies and could make it difficult to work-related accidents. It is this complex inter- implement effective changes to the work. Obvi- face between workers and the material, physical, ously mental health has its specific aspects, but it chemical, biological, cultural and organizational cannot be treated in an isolated manner, because 4654

every material, symbolic and social aspect of the sanctions, requirements of operators and safety work is interlinked with the subjects. and protection mechanisms, and medical control. The wholeness of work, as a social, econom- WO, whether in manufacturing industry, ser-

Leão LHC, Minayo Gomez C Gomez Minayo LHC, Leão ic-material and psychological-symbolic ques- vices or agriculture, is shaped by technical and tion, should not be split up to assist the success social considerations, and in theory unites mate- of interventions in one or other aspect of reali- rial elements (raw materials and objects of work), ty. A dismissal, excessive charges, accidents, new technical and technological features (machinery, rhythms, relationships, working hours, salaries, equipment, instruments), and social and cultur- among other matters, affect the pictures the al aspects (divisions, groups, status, recognition, subjects have of themselves, of others and of the power relationships, interpersonal relationships, work. Work arouses various feelings – satisfac- values, beliefs, habits) with the characteristics of tion, frustration, fear, indecision, doubts, sadness the subjects. – among workers and all collective manifesta- Each work context, therefore, shows a specific tions of illness ought to point health surveillance conjunction of these elements, and therefore has towards the work, in order to understand its con- its own characteristics in the form of positive or tradictions and propose effective changes to im- negative interference in the health-sickness pro- prove wellbeing. cess and in the appearance of illness. It is there- These assumptions as to the transversal na- fore necessary to stress these elements of work ture of work – mutual interplay between subjects organization to legitimize intervention with and working environment – contribute towards regard to their constituent aspects, such as the the adoption of more holistic practices, avoiding relationship between management and workers, compartmentalization in the analysis of work abusive rules, excessive demands, productivity processes. criteria, and injustices in relationships, among other matters. This means progress as regards the Aspects of the organization of work de-naturalization of the organization of work. In order to change aspects of the organiza- In our view, the intervention process, whether tion of work it is necessary to carry out a critical or not the main focus is on mental health, means analysis, including the observation of work rela- a thorough scrutiny of the work process, that is to tionships and daily working details. For this pur- say, an assessment of the whole work system, by pose, open interviews can be held with workers looking at all its components: environment and and management, and larger meetings between work process, premises, equipment, characteris- workers representatives and specialists in that tics of the workers, operations, activities, flows, type of work. The overall intention is to generate inventories, management mechanisms, organiza- dialogue which will lead to an understanding of tional culture. All these elements are crucial and the day to day aspects, the sources of problems actions which seek to minimize illnesses need to and the possible solutions. give more importance to the organization and One fundamental question is a proper assess- management of work, because this is the element ment of the type of sector and the management which defines the rules and functions for making process. If there is management which concerns the whole system work. itself with programs for quality of life at work, By work organization (WO) we do not mean for example, if it already has this kind of sensibil- a place, an institution or an environment, but the ity, health surveillance will deal with other man- ways of devising the work process, the technical agement which is more open to making changes. and social arrangements which standardize be- Here there is a platform for dialogue, because havior, establish targets, objectives, aims, culture there are convergences and a possible readiness and values, and organize and train personnel. to review processes, procedures and relation- Among the various elements of WO are hier- ships. In the same way, if a company is resolved archies and the rules of superiority, the routines to change its image for reasons of marketing or and prescribed activities, the division of tasks, the because of falls in productivity and high staff rhythms of production, the mechanisms for the turnover rates, such concerns can run contrary control of production, the sequence of produc- to what health surveillance is looking to do. In tion flows, the working hours, shifts and breaks, such cases, health surveillance can fulfill a more alternation, substitution and replacement, oral educational role. and written rules and instructions, formal and in- At the same time, an assessment must also formal communication, systems for bonuses and be made as to whether the problem also lies in a 4655 Ciência & Saúde Coletiva, 19(12):4649-4658, 2014

“culture of disorganization”, where there are no efforts of workers to resolve problems, incentives collective mechanisms for decision making and for improving their lives, and opportunities for the rules are defined by a rigid and personalized promotion. After all, it can be very wearing to hierarchy, or whether one is dealing with a culture have to face a long and tiring working day, a long which is more democratic and open to dialogue. journey between home and work, and an au- We set out below certain elements of the or- thoritarian management, along with all the other ganization of the work process which health sur- problems. This is an ample field for relationships. veillance should look at, as initial markers for af- The health surveillance process proceeds to iden- fording a closer view of the sources of problems. tify the greatest possible number of work organi- They can be grouped under eight headings: (1) zation elements, so as to obtain the closest view organization of time and intensity of production; of the situations faced by the workers every day, (2) management practices; (3) organizational because it is they who will be showing the symp- culture; (4) interpersonal relationships; (5) ac- toms of problems. These symptoms may express tivity and autonomy; (6) relationship of subjects themselves as situations of discontent because with their activities; (7) situations relating to the they are not being heard, dissatisfaction with employment relationship; (8) matters outside the management, discouragement through working work process. in a poor environment, without the necessities The first aspect deals with the rhythm of for the full and proper performance of their tasks work and the workload, including the length and owing to the lack of materials, equipment or per- intensity of the working day, whether there is a sonnel. system of shifts or other situations which could Another area which produces problem situa- cause tiredness or exhaustion, changing the be- tions is undoubtedly interpersonal relationships. havior of the workers and potentially provoking It is in this area that we find abusive behavior, psy- serious crises. Excessive workloads, the speed at chological and symbolic violence, unequal pow- which tasks must be performed, the demands of er relationships and disciplinary mechanisms. night work, for example, when analyzed in an in- Included here are incentives for competitiveness tegrated way, supply indications as to the extent or for collaboration and teamwork, relationships the work can cause disturbances for the subjects. with others and respect for differences in sex, Management practices are also an essential age, function, color, ethnic origin and religion. aspect, because they are concerned with all the Relationships between workers can produce sit- ways that the actions of some affect others. They uations of (dis)trust, (in)justice, lack of recogni- define the methods by which workers are select- tion and humiliation. These relationships can be ed, trained, paid, awarded bonuses and incen- the source both of suffering and of resilience. The tives, and evaluated. They also involve the kinds support of the group, the forging of friendships of technology employed, the demands/targets or a spirit of comradeship, are certainly factors for productivity and payment by production, which contribute towards an improvement of and the procedures for the assessment of perfor- mental health among workers. mance and results. These procedures, irrespective The autonomy and other aspects of the activ- of their extent and degree of qualification, and ity of workers are also important to assess. It is whether carried out informally or by qualified a question of the control enjoyed by the worker professionals and specific instruments, have re- over his tasks, the clear definition of his role and percussions for those subject to them which are what is expected of him, and the balance between crucial for health surveillance. capabilities and requirements. It is very import- Another important point involves the com- ant to pay attention to the existence or lack of au- ponents of the organizational culture: the most tonomy and freedom of choice, decision making, common forms of communication, such as op- problem solving and even the management of portunities for workers to explain their grievanc- work times. This item also includes the pride of es and take part in the decision making process, the worker in the type of work that he does and the values, habits and beliefs to be found among in the product, and even the feelings produced the workforce in daily working life, and the or- by the task he has to perform, such as feelings of ganizational structure itself, including the aims, inferiority or low self-esteem. mission, history and vision for the future of the There is also a level which deals with the actu- organization. One aspect of health surveillance al relationship of workers with their activities. It tries to discover if there is transparency in man- includes the emotional pressures on the worker, agement, respect for people, appreciation of the the feeling of capability/incapability for the task, 4656

the underemployment of his knowledge and considerations are collective bargaining process- abilities, and the meaning and significance of the es, sectorial agreements and the mechanisms for work for him, among other aspects. implementing changes in the organization of

Leão LHC, Minayo Gomez C Gomez Minayo LHC, Leão Even the type of employment relationship work. The aim is therefore to recommend, carry has its influence in generating health problems. out and monitor changes based on the analysis Instability in employment, temporary contracts, of the elements previously identified. It involves informality and the threat of job loss lead to anx- more than simply obtaining evidence of links in iety, fear and conflict, because they threaten the a causal chain between a subject and an illness, actual subsistence of the worker and his family. the idea is to overcome positivist and biomedi- Harmony between private life and work, or the cal emphases to deal with the manifestations of lack of it, also has repercussions as regards illness, health problems. as do the actual conditions of housing and trans- More than generating administrative process- port and the pay received. es, the aim of health surveillance is to systematize Many of these matters are central historical the required changes and track their introduction complaints of workers to ensure improvements and effectiveness in a dialogue with the respon- in their living standards and work. It is very im- sible personnel. From this standpoint, the incor- portant to focus on them to identify and reduce poration of knowledge and experience is a basic the causes of illness. For this purpose, whatever requirement at all the other stages of the health methodology and instruments are employed, surveillance process. The mobilization of work- there is a fundamental requirement to listen to ers and their representatives for the identification the arguments of workers, safety experts, man- and resolution of situations which give rise to agement and others involved in the work. This is mental health problems at work is a crucial step because many situations that give rise to health forwards. It is essential to strengthen strategies for problems are invisible to third parties and can assisting workers and to take advantage of their only be understood through what the workers say leading role in identifying and analyzing their and how they behave and express themselves33. work, with a view to changing aspects of the way These elements may be considered for the their activities are organized. The recognition and purposes of understanding the reasons for com- better identification of the origins of problems in plaints, so that interviews with workers are not elements of WO depends more on the role of the simply an opportunity for confessions, but a way workers than that of the technical experts. to identify the principal problems in work rela- The effective participation of workers as the tionships. real protagonists at all stages of action contrib- In a similar manner to other health surveil- utes towards changing the role of the worker as a lance practices, it is also important to identify mere means of production at the work level, an and analyze documents relating to health and object to be cured at the health level, and a recip- safety – absences from work, rates for the fre- ient of assistance at the social security level, so as quency and seriousness of accidents and occu- to strengthen his autonomy when the subject of pational illnesses, medical control practices for changes. mental health, resolutions of the CIPA (Internal Committee for the Prevention of Accidents), existing quality programs, rates of absenteeism Final considerations and staff turnover – and also those relating to management practices, such as company mission In this article, we have sought to present the the- statements, written codes, incentive and bonus oretical aspects and institutional policies which mechanisms, management reports and produc- contribute towards incorporating mental health tivity indices, among others. considerations in occupational health surveil- All this information will allow the construc- lance processes. There is a need to respond to this tion of a kind of map for the organization of demand, which is becoming increasingly explicit work, with the input of workers, technical ex- in the area of occupational health. It is our view perts, managers and public health workers, so as that the causes of illnesses and threats to health to locate the most obvious and immediate rela- bear a strict relationship with the elements which tionships and causes of problems and to identify comprise the organization and management of the critical points to be addressed. work. Thus, health surveillance actions must in- As to the methods for evaluating, initiating clude and identify the factors responsible for these and monitoring the results of action, relevant threats. The diversity of health problems caused 4657 Ciência & Saúde Coletiva, 19(12):4649-4658, 2014

by work conditions and processes demands a big Finally, it should be stressed that to make investment in investigating and transforming the the results of worker mental health surveillance situations which give rise to such problems. effective is not merely a technical question. To At a national level, it is important to en- intervene in the management and organization courage the inclusion of worker mental health of work means entering an area where there is a problems in legislation and the technical rules conflict of mutually antagonistic interests at var- governing health surveillance. Similarly, it is nec- ious levels, and there are therefore limits to such essary for the Ministry of Health to issue specific actions. It is consequently necessary to think of guidelines to achieve advances in health surveil- means and strategies to negotiate changes which lance programs. will lead to greater work satisfaction. Clearly the To make progress in this direction is an enor- workers themselves must play a fundamental role mous challenge, principally because we still do at all stages of health surveillance to ensure the not have sufficient consolidated experience of implementation of changes. health surveillance in this field.

Collaborations

LHC Leão worked on the research and the initial version of the article; C Minayo Gomez worked on the concept and the final version of the article. 4658

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