Abordagem dos profissionais de saúde frente ao programa de prevenção de perda auditiva no Pólo Industrial de Manaus - AM

Saude nao pode ser vista apenas como ausencia de doenca, ela deve ser entendida a partir de multiplos fatores incluindo entre outros, as condicoes de trabalho. Nos ambientes laborais existem diversas situacoes e condicoes de risco para a saude dos trabalhadores. Entre os riscos ocupacionais, podemos destacar o ruido. A exposicao ocupacional ao ruido e objeto de estudo de pesquisadores da area de saude do trabalhador, por ser um dos riscos mais prevalentes e o que expoe inumeros trabalhadores em todo o mundo. O efeito mais conhecido desta exposicao e a Perda Auditiva Induzida por Ruido (PAIR) ou Perda Auditiva Induzida por Niveis de Pressao Sonora Elevados (PAINPSE), considerada hoje como uma das doencas profissionais mais prevalentes nos ambientes de trabalho e, portanto, foco de atencao de prevencao e promocao da saude. O Programa de Prevencao de Perda Auditiva (PPPA) desempenha um papel fundamental nas atividades destinadas a protecao da saude do trabalhador contra o desencadeamento e agravos provocados pelo ruido ocupacional que levam a consequencias no desempenho profissional, na convivencia familiar e participacao na sociedade. Nesse sentido, pretendeu-se avaliar a abordagem dos profissionais de saude, que atuam na saude do trabalhador em empresas do Polo Industrial de Manaus, frente ao Programa de Prevencao de Perda Auditiva no trabalho. A amostra foi de 20 medicos do trabalho e 20 fonoaudiologos. A tecnica para a coleta de informacoes foi a de entrevista com questoes abertas e fechadas e o metodo de analise foi o de conteudo. Foram identificadas tres categorias que expressam o conhecimento dos profissionais sobre o PPPA: visao pragmatica, visao disciplinar e visao sistemica. Categorias estas que retratam a atuacao profissional e evidenciam limitacoes e avancos de cuidado que as empresas tem em relacao a saude do trabalhador em particular, da audicao. O PPPA como aspecto normativo e processual, busca um conjunto de medidas que exige um trabalho integrado de uma equipe com diversos profissionais de diferentes areas. Este estudo mostra, no entanto, que ainda ha uma distância monumental entre o que e proposto e o que se faz. Os motivos que retratam esse cenario indicam a necessidade de estudos mais aprofundados, de modo a inserir todos os atores sociais e assim evidenciar o contexto nas mais diversas dimensoes.


INTRODUCTION
In work environments, particularly in the industry sector, there are many risk factors for workers' health, one of them being noise. Occupational noise exposure has been an object of study by researchers of several fields, as it is the most prevalent risk for workers worldwide 1 . Its most known effect is Noise-Induced Hearing Loss (NIHL) or Hearing Loss Induced by High Sound Pressure Levels (HLIHSPL). Noise and HLIHSPL do not only cause changes to workers' hearing but also affect their communication ability and life quality 2 . effective measures to preserve and promote workers' health and support public health policies.

METHODS
This qualitative-based study sought to describe how health professionals understand the Hearing Loss Prevention Program and how they proceed having it regulating their work at companies in the Manaus Industrial Pole. In order to obtain that information, the professionals were individually interviewed in the period between August and September 2010 based upon a script of questions, as indicated for semi-structured interviews 16 .
The interviews were conducted with audiologists and occupational health physicians of both sexes who have been working at companies in the Manaus Industrial Pole for more than a year, which was a prerequisite. Then they were selected based upon accessibility or convenience 17 , i.e., they were identified and later contacted by phone or in person so that the study proposal could be presented to them and their availability and willing to participate and sign the Voluntary Informed Consent could be confirmed.
A total of forty health professionals (twenty audiologists and twenty occupational health physicians) who work at companies in the Manaus Industrial Pole took part in the research, twentyseven (67.5%) being females and thirteen (32.5%) being males. They were between 26 and 66 years old, 72.5% being between 26 and 45 years old and the remaining 27.6% being between 46 and 66 years old. They worked for many companies at the same time, which means the amount of time they were present in each company was very short. Among them, 52.5% worked for one to ten companies; 35% worked for 11 to 30 companies; and, surprisingly, 12.5% said they worked for more than 30 companies. On the other hand, they had relatively little experience in the field of occupational medicine. Half of them (50%) said they had worked in the field for 1 to 5 years, 30% had 6 to 10 years of experience, and only 20% had more than 10 years of experience, 5% of which had worked in the field for more than 16 years.
Despite the fact that the interviews were conducted with two groups of professionals (audiologists and occupational health physicians), the analysis was carried out considering a single group, i.e., health professionals, as they are supposed to have the same understanding of the program and the same dedication to implementing actions towards workers' health promotion.
The method used in the analysis of the information collected in the interviews was content Considering that a large number of workers have been exposed to occupational noise and that the effects resulting from NIHL can affect not only their life quality but also their work -both their production and social relationships with their peers -, the importance of individual and collective actions as part of prevention programs becomes clear. The Hearing Loss Prevention Program (HLPP) or Hearing Conservation Program (HCP) is one of such actions, having been proposed by health authorities and consisting of a set of measures to be developed by a multiprofessional team in order to minimize the risks and prevent the emergence or development of work-related hearing loss 11 . The HLPP takes measures to reduce environmental risks by means of collective protection, monitors sound pressure levels, changes or replaces equipment that raises the noise level, provides proper protective equipment, makes workers aware of its use, and monitors their hearing in order to control and assess its efficiency. The activities proposed in the program should include the training of managers and workers on it, highlighting the role to be played by each of them in such an initiative 12 . Nevertheless, a program requires a multisector management in order to achieve effective results, which means it depends upon the cooperation of health professionals, managers and especially workers, all of them being informed of and sensitized to the risks and effects of noise to health.
In Brazil, the Labour Laws (CLT) regulate the relations between employers and employees, as well as work conditions, whilst the Regulatory Norms (NR) define the parameters for applying the laws 13 . The HLPP is provided for by NR-9 -Environmental Risk Prevention Program -and by Attachment 1, Table II Although NIHL has reached an almost endemic proportion in the industry sector, there are still few scientific studies on its natural history in Brazilian workers 15 . In the state of Amazonas, to the best of knowledge, there are no specific data on the actual presence of the HLPP or any systematic monitoring. Only data related to audiometry are reported, as part of a legal requirement of the Department of Labour. In view of that scenario, which demands more efficient actions, this study aimed to assess how health professionals who work for companies in the Manaus Industrial Pole understand the HLPP and apply its practices at work. In addition to that, and most importantly, the results obtained in this research are intended to generate knowledge that can help occupational health professionals and managers to reflect on how to stimulate more

DISCUSSION
The professionals understand the HLPP in different ways. The pragmatic view refers to the definition of the programme as only a set of technical procedures, hearing loss prevention actions being basically restricted to audiometric tests, as these two accounts indicate: The program is done here, all the medical checkups on hiring, all the periodic checkups. Audiometry is performed to monitor the person's hearing loss, and, if we notice something, we refer the person to the otorhinolaryngologist to be examined.
The program is intended to warn and control the worker who is exposed to noise and has hearing loss. I control the number of employees from the audiometry on hiring and then every six months until the worker leaves the company. By doing so, I can detect any damage [to their hearing].
Many professionals believe that they are preventing hearing loss by proceeding thus, but their pragmatic view actually limits the efficiency of the program. It should be noted that an HLPP consists of eight distinguishable elements: training and education; involvement from the supervisor; noise measuring; engineering and administrative control; audiometric monitoring and record maintenance; referrals; ear protection equipment; and management issues 19 . One of the first tasks of an HLPP is the audiometric survey of all workers in risk areas.
The Brazilian legislation determines the use of audiological evaluations as a tool for detecting hearing loss 20 , and nowadays the control of workers' hearing is performed using such evaluations 21 , with the aim of at least meeting the current legislation 22 .
The audiometric evaluation of workers is still the most efficient way to determine the success of an HCP 23 . By comparing annual audiometric results, it is possible to detect changes or reinforcements in the interventions proposed by the program. Based upon the comparison of reference and sequential audiometric tests, the hearing behavior of workers during their permanence in the company and the efficiency of preventive measures adopted by the programme should be assessed.
Some authors state that the review of audiometric data, as an epidemiological surveillance tool, is necessary to confirm the efficiency of the HLPP 24 .
There is no doubt that audiometric tests are essential in an HLPP to monitor workers' hearing. analysis 18 , which consists of comprehending the latent meaning of the answers given by interviewees and establishing categories a posteriori to be discussed in the light of the theoretical references upon which the study is based.
This study followed the ethical procedures recommended by Resolution no. 196/96 of the National Health Council and its protocol was approved by the Ethical Research Committee of the Federal University of Amazonas (no. 0250.0.115.000-10).

RESULTS
The results presented herein are organized in three complementary sections related to: a) the professionals' knowledge of the HLPP; b) the actions taken by the professionals towards hearing loss prevention; c) the professionals' perception of the HLPP for workers' health.

Health professionals' knowledge of the HLPP
By using the content analysis method, it was possible to verify in the information provided by the participants that their understanding of the HLPP varies and is considerably distant from what the program actually proposes. The different sorts of understanding were named as follows: a) pragmatic view, corresponding to 45% of the professionals; b) disciplinary view, corresponding to 40% of the professionals; c) systemic view, corresponding to the remaining 15% of the professionals. Each group expresses a continuous evolution of its understanding of the HLPP.

Hearing loss prevention actions taken by health professionals
In order to investigate hearing loss prevention actions, it is necessary to observe the actions suggested by the HLPP, which are related to the work environment, hearing profile and health conditions of the workers, as well as to their education in the program.

Professionals' perception of the HLPP for workers' health
The professionals who take part in the HLPP should identify hearing risks and their effects on workers, intervening in the workplace. In order to carry out that continuous process of actions, they need to understand the importance of the program for workers' health not as a formality, but as a guidance of actions towards workers' care and citizenship.
such as the importance of audiological monitoring and individual and collective epidemiological surveillance, and especially the involvement from a participative multidisciplinary team and the workers themselves. This perspective is more complete and is in accordance with what is proposed by the National Committee for Noise and Hearing Conservation, which released in Brazil its Boletim no. 6, providing the basic guidelines of an HCP, with elementary recommendations for its formulation. The following stages are included into the guidelines: identification and assessment of risks to hearing; audiometric management; collective protection measures; individual protection measures; education and motivation; data management and assessment of the program.
The three categories or sorts of knowledge presented herein are ways of thinking and acting regarding the HLPP revealed by professionals who work at the Manaus Industrial Pole. Being a set of measures coordinated by a multiprofessional team, the program is a continuous and dynamic process of implementation of routines in companies. The professionals' repertoire of ideas on the HLPP has a direct effect on the implementation of such actions, which are fundamental for the development and, consequently, the efficiency of the program.
At the same time, they are a form of control and assessment of the preventive measures taken by the company. However, it should be pointed out that, even though audiometric tests are important indicators of hearing health, they are useful only when directed towards preventive actions. Furthermore, all elements of an HLPP are essential to prevent hearing loss, which means hearing monitoring is only part of the program.
The second group of professionals, associated with a disciplinary view, focuses on audiometric techniques, ear protection equipment, training and education actions, as indicated by these accounts: I believe the HCP is divided into several parts, stages, including audiometric tests. I believe there are lectures that provide guidance on prevention and also on protection, which is the use of PPEs.
The HCP is provided for by law, by NR-7, whose main purpose is to prevent hearing loss, or, in case there is already some sort of loss, to prevent its progress, when all measures must be taken -collective protection equipment, personal protection equipment -so that the condition of that employee doesn't get worse.
To train and motivate workers with respect to hearing conservation is the most important tool for the correct and most efficient use of ear protectors 23 . Therefore, the success of an HLPP depends upon health education, making workers understand how their behavior and workplace influence both their health and the search for solutions towards their well-being. The aim of education actions at work is to make workers aware of the consequences that aggressive agents present in the workplace can pose to health, and the preventive measures that can be taken with collective participation 11 .
Actions directed towards workers' hearing conservation should be part of an integrated work between the medical team (occupational health physicians and audiologists) and engineering and security. It was noticed that the disciplinary view limits the development of an effective program, because, although it approaches important elements of the HLPP, it provides neither an articulation of the actions nor an effective interaction of the professionals involved. Therefore, taking different measures is not enough to ensure the efficiency of the program.
The third group of professionals showed a systemic view, as they understand the program with all or most of the elements that form an HLPP, Those considerations seem to indicate that some health professionals who work at companies in the Manaus Industrial Pole just comply with the minimum legal requirements. It was also observed that none of the interviewed professionals performs or has any information that the responsible professional performs a speech test during the audiometric tests in the companies. Therefore, audiometry is perceived just as a legal requirement to be complied with, whereupon important information for guaranteeing the quality of the examination is not taken into account.
Management hearing, which includes determining workers' hearing profile and identifying the likely risks to their hearing, is the basis of an HLPP. It is responsible for the longitudinal monitoring of the hearing profile and is an epidemiological surveillance tool. Some studies report that one of One of the actions of the HLPP is to learn about the risks present in the workplace. Once a noise is identified, it is associated with the other agents that pose risk to workers' health 11 . By doing so, it becomes possible to suggest measures to eliminate and/or control those agents either collectively (e.g., intervention in the sound-emitting source) or individually (e.g., reduction of the worker exposure by means of administrative measures). Such actions were in fact reported by some professionals: An HLPP proposal cannot be made without identifying all the risk factors in the environment. It could be noticed that some professionals understand that action as an indispensable tool for the establishment of an HLPP, as its results will support decisions related to many sectors involved in the program.
Another essential action in an HLPP is the investigation of the general condition of workers' health to identify the impact the workplace has on them. The method prescribed by law for hearing change detection and monitoring is audiometry, and the guidelines and minimal parameters for assessing and monitoring the hearing of workers exposed to high sound pressure levels are described in Attachment 1, Table II, NR-7.
In short, the main requirements established by NR-7 concerning the types of audiometric tests and procedures are: reference and sequential audiological tests, including clinical and occupational anamnesis, otological examination, and audiometric examination, which analyses tone air-conduction thresholds from 500 Hz to 8000 Hz. In case any hearing change is detected, tone bone-conduction thresholds and speech recognition thresholds are assessed. Audiometric examination should be conducted after the inspection of the external acoustic meatus in an acoustic cabin and with acoustic rest superior to 14 hours. The procedures carried out in audiometric tests were reported by some professionals as follows: itself, shall: subitem c.: "Participate in the implementation, enhancing and control of programs intended to prevent the progress of the hearing loss of any worker with this condition and others exposed to that risk, considering the provisions of item 9.3.6 of NR-9".
Still in accordance with NR-9, every company must have an Environmental Risk Prevention Program. If sound pressure level is one of the risk agents identified by the program, the company should organize, under its own responsibility, a Hearing Conservation Program.
Educational actions are also fundamental in an HLPP, as shown by the literature. Workers need to be well-informed of the reasons and requirements of the program as a whole, since the success of the program depends to a large extent upon the education of workers. Here are two related accounts: In that company we organize lectures in the first place, we have a very nice relationship with the workers...

I work on this training issue, on PPE regarding clarification and regarding monitoring, which is audiometry.
It becomes clear that some professionals are familiar with hearing loss prevention actions, but they are just concerned with addressing the minimum legal requirements, whereupon they implement actions in a disconnected way. That practice contributes to making such actions inefficient and shows that aspects related to hearing loss prevention are not addressed in their full extension, which means workers' health is far from being fully respected.
In what refers to the professionals' perception of the HLPP for workers' health, they are supposed to identify the risks to hearing and their effects on workers' health, intervening in the workplace. Some professionals showed the value of that tool by indicating improvements in the professional activity and security of workers with the implementation of the HLPP: Its first logical goal is to preserve the worker's health, to have a documentation proving, in any instance, either an internal audit, a quality audit, or a labour claim, that everything is well-monitored, which protects the company, protects the worker, and you have it in your hand to show to anyone who wants to see it, to show that everything is being done. the most important collective stages of an HLPP is the analysis and development of an epidemiological overview, as it defines people's hearing situation and allows the implementation of preventive measures.
The following accounts are testimonies of neglecting, as most of the interviewed professionals said they do not write epidemiological reports. When asked about the importance of such reports, they said: Even among the professionals who claim to write epidemiological reports there is a consensus that the document is secondary or just a means of discussion between peers. Some of them do realize it is a tool with a wide range of possibilities, but they only write it because of their obligations with the companies.
That scenario indicates that many professionals do not follow the technical procedures necessary to guarantee workers' health; somehow they seem to be limited and pressed to address the legal requirements, even if such requirements are vague. That attitude makes clear the gap between the real interest for workers' health and the indices of performance and production of industries. Furthermore, it can be noted that the practice of those professionals and companies lacks information, as hearing loss prevention programs are also described in the Regulatory Norms of the Department of Labour, being as much a legal requirement as audiometric tests.
In Attachment I, Table II, NR-7, item 1.2 reports one of the objectives of Directive no. 19, from April 9, 1998: "To provide assistance for the adoption of programs intended to prevent hearing loss induced by high sound pressure levels and to preserve workers' hearing health". The same directive reports on preventive actions in item 6.1: "In the presence of the worker whose reference audiometric test matches item 4. This study shows that there is still a great gap between what is recommended and what is actually done. Based upon the collected data, it can be concluded that health professionals who work at companies in the Manaus Industrial Pole are familiar with important elements of the aforementioned program and believe to be contributing to it, but their practice is limited to exogenous factors, i.e., it focuses on legal requirements to avoid or reduce labour claims, whereupon the actions related to the program are implemented in a disconnected way, making it inefficient. The reasons that lead professionals to proceed that way is a topic to be studied, as that information will reveal not only their views but also those of the companies where they work. Such social actors can provide more information and context to clarify this reality, which limits not just the worker's health but also their own satisfaction and dedication, as well as the indices of performance and production of the industry sector.
That improvement is not just for the company, it is shared. I think we have a great responsibility because we have to comply with the law and achieve the result expected by the company, and we have to give the result to the employee.
Such improvements come from different perspectives, but they can be the starting point of an increasingly deep transformation of professional practice and a guarantee of workers' health rights, either by the professional's actions or the responsibility and sensitization of the company towards human being, the main point of its economy.

CONCLUSIONS
The present work aimed to assess how health professionals who work at companies in the Manaus Industrial Pole understand the Hearing Loss Prevention Program and apply its practices at work.