Analysis of the implementation of Hearing Conservation Programs

Purpose: to assess the implementation of hearing conservation programs in two large companies. Methods: an evaluative research that analyzed a type 1b implementation. The study was conducted in three stages, namely: establishing the company’s degree of implementation, analyzing the companies’ policies and structures, and lastly, analyzing the influence of the companies’ policies and structures on their degree of implementation. The following analyses were conducted to collect data: interviews, document analysis, and observation. Results: the hearing conservation program in Company A was classified as imple mented (91.1%), while in Company B, it was partially implemented (62.7%). The context in Company A was favorable to implementing the program, whereas in Company B, the context was considered unfavorable, due to disadvantageous categories. Also, the characteristics of the implementation context influenced the placement of the pro gram either positively or negatively. Conclusion: there were satisfactory results regarding the implementation of the hearing conservation program in both companies assessed.


INTRODUCTION
Noise-induced hearing loss (NIHL) is still one of the most prevalent occupational diseases worldwide. It affects workers in a wide range of businesses and industries, as a result of continuous or intermittent exposure to high-intensity noise, slowly developing throughout many years 1,2 .
In Brazil, every company is obligated to implement an Environmental Risk Prevention Program (PPRA, as abbreviated in Portuguese). If the program detects a high sound pressure level as a risk agent, the company must organize a hearing conservation program (HCP), as established by the regulatory norm no. 9 3 .
The HCP is a set of actions aiming to prevent or stabilize occupational hearing losses through continuous improvement processes. Based on the knowledge of a multidisciplinary team, it is developed with planned and coordinated activities involving the various sectors of the company 3 .
Among the HCP actions, the following are highlighted: measures to monitor and control the environmental noise at the workplace, selection and provision of hearing protection devices, audiometric monitoring, workers' training and instruction, updated records, and program assessment 4 .
For the HCP to be feasible and effective, all the stages must be properly carried out and coordinated. Also, it must count on the active participation of health professionals, safety personnel, managers, human resources, and especially the workers 5 .
Considering the complex and broad components of the HCP activities, assessing it is an emerging need, taking into account each company's context and structure particularities.
The assessment via implementation analysis is a tool that helps understand how the HCP is being put into effect in the companies. It provides information on the dynamics of the program as actually implemented, also considering the influence of contextual factors that either facilitates or hinders their implementation. Such an assessment offers the basis to plan and develop the program's activities 6 .
It is important to emphasize that the results of an assessment can help in decision-making regarding the continuity, modification, or interruption of the actions being developed, organization of the work, and the practice of the professionals involved in the HCP.
Few papers are found in the literature approaching the assessment of HCP in companies. This may be due to difficulties found when implementing it or the little experience in assessing programs on the part of those responsible for the HCP 5 .
The study on HCP implementation analysis is part of the effort made by speech-language-hearing and public health researchers to develop evaluative pieces of research. Their purpose is to list the multiple aspects involved in the processes of implementing health policies, programs, and services 7 .
Hence, this study aimed to assess the implementation of the HCP in two large companies in the state of Pernambuco, Brazil.

METHODS
This evaluative research, conducted from March to November 2019, analyzed type 1b implementations. Its objective was to understand the variations observed in the degree of implementation and its context 6 . The study was approved by the Research Ethics Committee of the Universidade Federal de Pernambuco, Brazil, under evaluation report number 3.197.976.
The strategy used was the study of multiple cases at the same level of analysis 8 to investigate complex social phenomena and preserve holistic and significant characteristics of real-life events.
The selected cases were two large companies, one from the public sector (Company A) and the other from the private sector (Company B), both located in the Recife Metropolitan Area (RMA), in Pernambuco, Brazil. The cases were chosen based on the following inclusion criteria: having an HCP for at least five years and being a large company 9 (more than 100 employees). The exclusion criterion was the company's not having an occupational medicine department responsible for the HCP activities.
The study was conducted in three stages, namely: (1) establishing the company's degree of implementation; (2) studying the companies' policies and structures; and (3) analyzing the influence of the companies' policies and structures on their degree of implementation.

Stage 1: Establishing the company's degree of implementation
The HCP actions logical model (LM) 10 and the HCP analysis and judgment matrix (AJM), developed and validated by specialists 11 , were used to establish the degree of implementation.
In this perspective, it is essential to consider the HCP basic components in order to establish the degree of implementation -i.e., it involves a phase with explanations of the resources employed and their organization (structure) and the services or goods produced (process). The LM furnishes a visual organization of how the program works and what the causal relationship between its elements is 6 .
The AJM presents criteria, structure and process indicators, verification parameters, and the score expected for each indicator, thus providing a quantified value for the HCP. The AJM items were used as a basis to construct this study's collection instruments. To obtain the degree of implementation (DI), three sources of evidence were used: interviews, document surveys, and direct observation.
Initially, interviews were conducted with a structured questionnaire based on the indicators listed in the AJM. The goal of the questionnaire was to gather information, such as data about the company (business, number of employees, existing health programs, and so forth), and data on the HCP structure and processes (actions) in the companies. In this stage, the key contacts for information were the occupational physician (Company A) and the occupational nurse (Company B). Both were chosen for being directly related to the hearing health activities in these companies.
The direct observation was carried out in both companies by the researcher to verify the human resources and material employed in the HCP, as informed by the administrators. The document survey aimed to verify the record of the actions developed in the HCP, complement them, and compare them with the data obtained in the interviews.
The documents made available by the administrators and assessed by the researcher were the reports on the Occupational Health Medical Control Program (PCMSO, as abbreviated in Portuguese), Environmental Risk Prevention Program (PPRA), and HCP, copy of the audiometry, PPE approval certificate, clinical-occupational anamnesis form, accidents at work notification form, and occupational health certificate.
All the said stages were carried out in person at the companies. The researcher was welcomed to the administrators' office, where they were asked to answer all the questions and were informed that the interviews would be recorded.
Based on the data obtained from the sources of evidence, each company's DI was established, using a system of scores with a cutoff according to criteria that referred to the structure and process indicators listed in the AJM.
When the indicator reached the stipulated parameter, the full score was given; when it did not reach it, no score was given. In case the key contact did not know the answer to the question, or the activities related to that indicator, a score was not given, either. When some activity did not apply to the company's situation, the indicator was considered not applicable (NA). The score referring to this indicator was subtracted from the expected score and the final DI score.
Given the importance and complexity of the processes implemented in the HCP, the weight of these components' scores on the analysis was six, whereas that of the structure components was four. Since the number of criteria varied between the components, the score was presented in percentages for the comparison.
Hence, the score was calculated as percentages in relation to the expected score for each indicator -100% was the highest expected percentage, using the formula presented below in Figure 1.
These data were obtained with a semi-structured interview with these companies' PCMSO administrators (both were occupational physicians) to analyze what strategies are offered to fully perform the program. The interviews were voice-recorded for future transcription and analysis. They were centered on the investigated theme cores, originated on the analysis categories of the policy and structure context developed for other programs, and adapted to the HCP 14 .
The main theme cores investigated by category were: a) Formalization of the sector responsible for planning the PCMSO and/or HCP; b) Profile of the HCP administrator; c) Attention given to innovation; d) Size; e) Centralization; f) Formalization; g) HCP planning and assessment; h) HCP implementation investments; i) Familiarity with the HCP; j) Familiarity with and follow-up on the financial resources available for the HCP actions; and k) Priority given to implementing the HCP in the company.

Stage 3: Analyzing the influence of the companies' policies and structures on their degree of implementation
To analyze the influence the context had on the DI of the HCP, the pieces of evidence found in information gathered from the different data collection methods were mutually crossed. To judge the company's DI value, four cutoff scores were considered, as proposed by Samico 12 : < 25.0% -not implemented; 25.1% to 50.0% -incipient implementation; 50.1% to 75.0% -partially implemented; > 75.1% -implemented.

Stage 2: studying the companies' policies and structures
The parameters used to judge the context in which the HCP was implemented in the companies were based on the Policy and Contingency Model, inspired on the policy and structure models, and classified as "favorable" or "unfavorable" to the implementation of the HCP 13 . This model is guided by some questions, which were assessed as either favorable or not, based on the criteria considered and listed in each category of the analysis. The reference for the criteria established for contextual analysis is the actions considered favorable to the implementation of the HCP.
Captions: Σ E¹ = Sum of the scores obtained in the indicators that made up the "Structure" dimension; Σ P¹ = Sum of the scores obtained in the indicators that made up the "Process" dimension; Σ E² = Sum of the scores expected in the indicators that made up the "Structure" dimension; Σ P² = Sum of the scores expected in the indicators that made up the "Process" dimension.    The dimension with the best scores among those assessed ( Table 2) was "hearing health administration" in both companies. "Assessment", on the other hand, obtained the lowest scores in both companies   The results of the analysis revealed that Company A's implementation context was favorable, as most of the analysis categories were presented as favorable to implementing the HCP. In contrast, Company B's was unfavorable, as most of the analysis categories were presented as disadvantageous to it.
In both companies, the structural context proved to be less favorable to the HCP implementation, with fewer favorable categories than the policy context. The "Attention given to innovation" and "Centralization" were the ones that were considered unfavorable in both companies.  In the "Search for partnerships with other networks to develop Occupational Hearing Health actions", under "Attention given to innovation", the administrators did not know whether there was any partnership with other health networks. In its turn, "HCP actions give priority to all the planned stages", under "Centralization", was considered unfavorable, as the administrators informed that the audiological monitoring stages are given priority, whereas others, such as health education and HCP assessment, were little explored or not given any attention.
In "HCP actions are fully carried out or support from third-party company(ies) is required", under "Size", although both needed such support, only Company A's HCP administrator knew the speech-language-hearing therapist responsible for performing audiometry, who annually discussed with him its results.

DISCUSSION
Given the complexity and variability of the HCP actions, it is necessary to conduct assessments that consider the implementation context in which the program takes place. This type of analysis was chosen because the evaluative processes need to consider the different stages planned in the program, thus identifying and understanding the aspects that affect its results and effects 6 .
Even though the DI achieved by Company A was considered implemented, some gaps were still found in it (such as in "Assessment") -as well as in Company B, since neither of them invests in sturdier assessments that specifically consider the HCP actions and their variabilities.
In this regard, this seems to be a limitation of assessments that only consider the audiological results, which would possibly not be able to fully expound the effectiveness or quality of the HCP actions. The combined qualitative and quantitative assessments contribute to a more concise evaluation of the HCP quality and effectiveness 15,16 .
Among the dimensions assessed, "Hearing health administration" was the one with the highest score. This may be explained by the concentration of audiological monitoring actions in this dimension, as the companies often focus their attention almost entirely on these actions.
Although the audiometric examinations (which are the main tool to monitor the workers' hearing) are important hearing health indicators to the HCP, it must be taken into account that they are only functional when they aim preventive actions and measures. Also, audiometric monitoring alone does not characterize an implemented program 17 .
The companies' DI results allow for an association between the characteristics of the organizations (companies) and of the administrators as elements that can either positively or negatively influence the implementation of the HCP.
It was observed that the DI was influenced by the context, as the more favorable the context (as in Company A), the higher the DI was. This contrasted with Company B's unfavorable context and lower DI. Such findings are coherent with the results of other studies 18,19 , in which the implementation of other health programs was influenced by the context, with these two variables occurring in direct proportion.
The structural context proved to be less favorable to the HCP implementation than the policy one. Theoretically, an organization's structural characteristics work either antagonistically or synergically to the implementation of the program 13 . Even though Company A had some unfavorable categories in the structural context, its HCP was well-coordinated and planned, with satisfactory final results, based on the collected evidence.
Company A's policy context was completely favorable, unlike that of Company B. According to Company A's program administrator, they care for their workers' health and invest in it. It was also stated that they do not face many program decision-making and administration limitations, as the company's Formalization of the sector responsible; Profile of the HCP administrator; Attention given to innovation; Formalization; Familiarity with the HCP; Familiarity with and follow-up on the financial resources available to the HCP actions; Considers the HCP implementation a priority in the company.

Unfavorable
Source: Authors of the paper. Caption: HCP -Hearing conservation program Figure 6. Relationship between each company's degree of implementation and the context of implementation organizational structure enables the actions to be planned and carried out in a decentralized yet coordinated way.
According to Chiavenato 20 , centralization and decentralization refer to the hierarchical level in which decisions are made within an organization. Centralization means that decision-making takes place at the top of the organization, whereas in decentralization it takes place at lower levels of the organization. In the study of organizations, decentralization is more valued, as it helps decisions to be made faster by the very people who put the actions into effect; also, those who make the decisions are the best-informed ones about the program.
In the case of Company A, decentralization appears as a positive quality. Besides the decisionmaking autonomy given to the HCP administrator, such decisions are shared and coordinated with other sectors of the company, which facilitates the implementation of the program.
In Company B, on the other hand, the decisions related to Safety and Occupational Medicine are made in another sector of the company. Moreover, the administrator stated that the very actions of the program are centralized at the unit in the state's capital. Hence, other working units located inland are given little attention and investment for the program, due to the geographical distance and the delayed or inexistent communication between the units' administrators.
Therefore, centralized decision-making and actions seem to be limiting factors for HCP implementation. These findings corroborate other studies, in which decentralized occupational health actions help them to be integrated and positively contribute for results to be achieved 21,22 .
Another limiting aspect of Company B listed by the administrator was the lack of agreement between the Safety and Occupational Medicine sectors, as the quantitative noise analysis data are obsolete -i.e., they had not been updated in the company for 10 years. As a consequence, those involved in the health actions refuse to continue the HCP actions because the quantification of the noise levels at the various work settings is not updated. Those responsible for the Occupational Safety sector do not give priority to updating these quantitative noise analyses -a limiting factor for the continuity of HCP actions, generating an unfavorable context for the implementation of the program.
In this scenario, these results agree with the study by Rabinowitz et al. 16 , whose authors found a significant association between the HCP administrators' commitment and the program's effectiveness. They further highlighted that it is important that managers give priority and be committed to the implementation of preventive actions at the workplace, so the effectiveness of the HCP is not affected.
In short, companies can implement effective programs; however, all the people involved must effectively participate in it. The health professionals and administrators must instruct and encourage the workers regarding the importance of hearing health 23 .
As for the follow-up of HCP costs and investments, Company A's administrator said he was familiar with and followed up such resources. This is a favorable category, as the available resources are proportional to the necessary HCP services. In contrast, Company B had no specific resources for the HCP, only for the Occupational Health sector as a whole, which includes the costs with audiometry and hearing protection devices provided to the employees.
Financial resources must be directed to the HCP to ensure human resources and material. A study assessed the cost and investments related to the HCP in 14 American companies 24 and concluded that the cost and adequate investment distribution are related to the positive HCP results. In other words, the greater the company's investment, the less prevalence of hearing losses among the employees.
Also, there is evidence that even after the HCP had been implemented in companies there is a substantial risk of hearing loss, as the implementation does not ensure effectiveness because the planned actions may not be fully carried out. More rigorous observation of the country's existing legislation regulating HCP actions and the more effective participation of the professionals involved in the program may reduce the noise levels at the workplace, improving the effects of the program in the long run 25 .
In many countries, companies must meet the requirements of governmental regulations to control noise exposure at the workplace and implement HCP 26 . However, despite these regulations, evidence shows that the HCP still needs to be continuously improved, and innovative strategies need to be developed, assessed, and disseminated 27 .
In the Brazilian context, the situation is not different. In the few studies that portray HCP assessments, the results present a distance between what is required and what takes place 28,29 . This reinforces the importance of all those involved in the program increasing their efforts to achieve better results, preventing the main problem, the occupational hearing loss.

CONCLUSIONS
Satisfactory results were verified regarding the HCP implementation in both companies assessed. "Assessment" was the dimension that obtained the lowest scores in both companies, which reinforces the need for greater investments and knowledge of health program evaluative processes in companies.
Despite each company's particularities, characteristics of the implementation context either positively or negatively influenced the functioning and results of the HCP. Context characteristics such as investments to implement the HCP, administrator's profile and centralized decision-making were listed as strongly influencing the DI.
In this scenario, there needs to be even more incentive on the part of the organizations and those involved in the program to make the implementation and functioning of the HCP feasible.