Promotion of Worker’s Health in Qualitative Research Approaches: A Scoping Review


 BackgroundIt is known that the investment in promoting health, both at the individual level and at the organizational level can bring benefits to all individuals included in this process. This Scoping Review compares the main results addressed in Brazilian qualitative researches and in other countries that addressed the topic of workers’ health promotion.Methods Thirty-three articles were selected for analysis from the SciELO, BVS - BDENF/Index, PubMed, and LILACS databases. Scientific articles that used a qualitative or quantitative-qualitative approach in Portuguese, English or Spanish, during the period from 2009 to the present moment of our Review (October 2019) were included. This Scoping Review was guided by Arksey and O’Malley’s framework.Results The literature review allowed the discussion on the following related topics: worker’s social participation in health decisions, perceptions/meanings about health promotion, working conditions and worker’s suffering, working conditions and the risk of illness, worker’s awareness, and changes in lifestyles, employers’ stereotypes about their workers and health promotion, the use of technology in health promotion interventions, the importance of communication in promoting workers’ health and social support at work for carrying out health promotion actions.ConclusionThis study showed differences in the research analyzed and provided the mapping of the main results that may support future research and changes in worker’s health policies in general. While in Brazil, studies are still focused on workers’ perceptions about health promotion and the assessment of working conditions risks to their health, in other countries, most qualitative research has been used to assess workers’ perceptions after a given workplace health promotion intervention.

countries, most qualitative research has been used to assess workers' perceptions after a given workplace health promotion intervention.

Background
The 1986 Ottawa Charter represents one of the main documents establishing the conceptual and political foundations for health promotion in the world. This document highlights the multiplicity of factors related to the health-disease process and highlights how health promotion practices deal with this multiplicity by combining the various actors (the State, the community, individuals, the health system, among other sectors of society) and strategies, making it a process based on completeness and equity. 1 In Brazil, the idea of health promotion came through the Federal Constitution of 1988 2 . By ensuring that health was considered a right of all and a duty of the state, the promotion of this right would occur through accessible actions and services, in a universal manner, and through both social and economic policies 2 .

An analysis by Buss and Carvalho 3 on the development of health promotion in Brazil from
1988 to 2008 showed that many advances were made, both in the area of health care services (highlighting the Family Health Program), as well as public policies (such as the Family Grant Program 4 ). However, the authors point out that the promotional strategies, during the period analyzed, faced bureaucratic issues of the State, in a competitive sectoral culture and the biomedical culture, still guiding the health services.
Health Promotion has been discussed in several countries, both as an intervention for changing lifestyles of communities and as a necessary health policy, given the increase in the aging population and the prevalence of chronic noncommunicable diseases 5 . It is known that the investment in promoting health, both at the individual level and at the organizational level can bring benefits to all individuals included in this process because, in addition to causing an improvement, in terms of quality of life for the worker, there is a reduction in work absenteeism 6 . With this, the workplace has become a key player in health policies 7,8 .
The trend is that more workplace health promotion strategies will be planned, as workers have remained in their jobs beyond the age of 60. A study carried out to assess barriers to the implementation of occupational health promotion actions targeting an audience of age higher than 65 in European countries has already pointed to a range of obstacles, such as: lack of flexibility at work, lack of commitment of workers and employers, and absence of worker participation in the preparation of health interventions. 9 As the discussion on worker health promotion in Brazil is still very recent, it is worth questioning which results have been elucidated in the researches carried out here and what differences they present when compared with researches from other countries.
Considering that the identification and understanding of the facilitators and barriers present in the process of consolidating a worker health promotion policy also require indepth analysis, qualitative researches can provide valuable information. In this type of study, the researcher, in general, assumes a critical and implicated position in the process, highlighting the subjectivity and meanings recognized in the researched subjects.
Interpretation by the researcher occurs in a contextualized manner with social, political, economic, cultural and historical issues 10 .
Due to the importance of research with this approach and the lack of research comparing the main results of qualitative studies conducted in Brazil and abroad, on the topic of occupational health promotion, this research aims to make such a comparison. These results may highlight knowledge gaps that deserve further studies, as well as may provide useful results that underpin health policies in the area.

Methods
For the conduction of this study, the Scoping Review methodology was used. This method is used when it aims to: a) identify available evidence types from a given field of study; b) clarify concepts in the literature; c) examine how research has been conducted in a particular field of study; d) identify key features of a concept; e) initiate a precursor study of a systematic review; and f) identify knowledge gaps 11 . Thus, this methodology meets the established objective, since it will allow us to know what has already been produced in the field of worker health promotion, and the results raised here may support future systematic reviews or other studies.
The Scoping Review methodology used was that outlined by Arksey  And editorial studies (letters, comments, brief notes), experience reports, review articles, theses, dissertations and article reflections were excluded from our sample.
Initially, the search for articles was performed in the following databases: Scientific Electronic Library Online (SciELO); Virtual Health Library (BVS), with access to the Nursing Specific Database (BDENF) and the Psychology Index; and Latin American and Caribbean Health Sciences Literature (LILACS). As a strategy for localization of articles we combine the following Health Sciences Descriptors (DeCS) with their Boolean operators: ("Health Promotion", OR "Promoción de la Salud", OR "Health Promotion") AND (workers, OR trabajadores, OR trabalhadores) AND ("pesquisa qualitativa" OR "qualitative research" OR "investigación cualitativa"). Next, a search was performed through the MEDLINE (Medical Literature Analysis and Retrieval System Online) database using the MeSH (Medical Subject Headings) terms: "Qualitative Research" AND "Health Promotion" AND Workplace.
When locating the articles, we initially read the titles and abstracts, excluding those that did not meet the established criteria. Then, the pre-selected papers were read in full and, based on this broader evaluation, they made up or not the final sample. In Figure 1, we describe this process objectively.
The articles that made up this final analysis were thoroughly read by the authors, seeking to adjust the main results brought, as well as meeting the established objective of comparing these results, evaluating possible similarities/differences. To assist in this analysis, two tables were created to facilitate the visualization of characteristics of these studies.

Studies conducted in Brazil
Considering the guiding question, the objective and the inclusion and exclusion criteria, 16 research articles conducted in Brazil were selected and analyzed. The main characteristics of these studies can be better seen in Table 1 (authors/year, audience investigated, objective and categories that emerged from the analysis).

Studies conducted in Brazil
Social participation: an essential principle in the field of Worker's Health One of the selected studies evaluated the Worker's Health Reference Center of Ceará, Brazil (CEREST-CE) based on the beliefs of union representatives and users. The authors identified that there was a lack of dissemination of CEREST-CE activities, and thus, the lack of knowledge of workers to occupy this space, which is an ally in the implementation of important policies in the area 13 .
Another study 14 showed another problem related to social participation. The authors described how the participation of the workers' segments occurred in a Municipal Health Council, however, their results pointed out that besides not being clear among those who were part of the workers' representatives, their performance was mostly technical and minimally politicized.
It is known that social participation is crucial to bring about changes in public policies.
Surveillance, protection, and health promotion practices should occur in a dialogic and participatory manner and should provide the inclusion of workers and their representatives in this process, which requires much more than the mere creation of legal provisions 46 .

Working conditions and workers' suffering
Studies covered by this topic show a diversity of factors, related to working conditions, that cause suffering to the worker. Respondents reported: Lack of identification with the task 23 ; Difficulty in interpersonal relationship with the work team 16,17,23,24 ; Exposure to workplace violence 18,23,24,26 ; Devaluation of the worker 18,23 ; Feeling helpless, given the non-resolution of problems, which require greater State participation 18,24 ; Uninterrupted work 24,26 ; Lack of materials and adequate infrastructure to perform their work 16,17,18,21,24,26 ; Unavailability of adequate food in the workplace 25 ; Exposure to unhealthy conditions 26 ; Alteration of family dynamics by the imposition of new production processes 20 ; Non-participation in decision making processes 20,21 ; Misalignment between new productive activities and ecological characteristics of the territory 20 ; Repetitive work 21 ; And unpredictability of the task 21 .
The relationship between work and mental health has been increasingly studied, given the consequences to the worker and the economic sphere of a country, which loses in terms of workforce 47 . Although only one of the selected studies addresses this topic specifically 23 , the impact that working conditions have on their mental health is implicit in the interviewees' speech.

Perceptions/meanings on health promotion
Understanding the workers' meanings and perceptions about health promotion can bring elements that help in the preparation of health policies in this area, as well as evidence that its concept is not yet clear for this population. In this case, the lack of knowledge can be problematic because it becomes an obstacle to the workers' struggle for a right already provided for in the constitution: health 3 .
In one of the selected studies, the main thematic category of their results concerns the time available to perform health promotion activities 15 . Workers reported that it was necessary to know how to manage time for physical exercises and leisure. Work enters this scenario as a restrictor to health promotion, as it is reported that there is an excessive workload, in addition to the time taken to get to the workplace.
In addition, it is observed that the perception of workers about health promotion is very focused on the individual character of actions, thus disregarding the responsibility of the State in the implementation of this public policy. This more individualistic view of health promotion also appears in other studies 19,27,28 .
The study by Santos and Hennington 22 shows as one of the important elements for health promotion, the meaning that the worker attributes to his work. This perspective allows the worker to avail himself as a subject endowed with desires and needs. In addition, the authors report how the difficulty of access to primary care health services in Brazil has been an obstacle for these workers to participate in health promotion actions. This result shows a failure in the health system, as health promotion and its protection must be made possible through programs and services, at different levels of care, for the entire population 3,48 .

Studies conducted in other countries
Raise awareness to change lifestyles Some selected studies allowed to identify that workers' awareness of aspects of their life and health can motivate them to bring about changes in their lifestyles. This awareness occurred in more personal aspects of women's lives (the double workday -in and out of the house) 29 but was also related to the physical health of workers 32,39,44 .

Employers' stereotypes
An important piece of data identified in this study concerns employers' stereotypes. It was elucidated that the understanding of many about health promotion through incentives for lifestyle changes was considered very personal, and sometimes intrusive 30,34,37 . In addition, for some employers, workers would not be interested in programs that promote health, given the individual characteristics of workers (for example, age) 34 , work intensity 36 , or that their interest would be directed to the purchase of health insurance 30 , or interested in just making money 36,37 .

Working conditions and the risk of illness
Many workers reported difficulties, present or related to work, to effect change in their lifestyle. An intense or irregular workday has been reported as barriers to physical activity 30,33,38,43 . Another very common issue in this category concerns the unavailability of healthy food in the workplace 31,39,40,41 . Considering that the worker spends a third or more of his day at the workplace, it is essential to have options for a balanced diet.
Social support at work An aspect also present in the selected studies concerns the importance of social support at work. This factor was seen as facilitating the adherence of workers to health promotion interventions. The favorable organizational climate for these activities promoted a greater sense of acceptability 35,42,43 .
The importance of communication to promote occupational health When it comes to health promotion, the role of communication in this process is evident.
Information needs to be clear, objective and accessible to all 42 . Therefore, some workers reported preferring to have the information shared personally 32,41,43 .

Technology and its possibilities/difficulties
With the advancement of technology, interventions to promote workers' health gained another ally. The use of applications and/or websites through smartphones, computers, or tablets can be useful tools in this area, especially when the target audience of interventions is not very available given the particularities of their work (transport sector) 45 . Using these resources enables more objective and practical learning and can enable greater interaction between coworkers 44 . A barrier to the use of these technologies in the workplace for health promotion concerns the cost of such equipment, but also the unfamiliarity that some workers may have with the platforms used 45 .

Limitations
The present scoping review is one of the first that proposed to analyze studies with a

Conclusions
This study identified a wide range of discussion categories based on the 33 selected articles. It was possible to realize that while in Brazil, studies are still focused on workers' perceptions about health promotion and the assessment of working conditions risks to their health, in other countries, most qualitative research has been used to assess workers' perceptions after a given workplace health promotion intervention.
Moreover, in Brazil, qualitative research has pointed out the difficulties present in the participatory process of workers in health decisions and the characteristics of the work process potentially causing suffering. In other countries, the discussion has covered the use of technologies in the health promotion process and the employers' perception in the implementation of these strategies, and the stereotypes present have been investigated.
Thus, this Scoping Review allowed us to map the differences/similarities of these researches and it is hoped that the results presented here will serve as a basis for future studies and enable changes in policies to promote worker's health. The success of interventions in the field of worker's health depends on the particularities of each demand and, of course, on the particularities of the workers themselves.

Consent for publication
Not applicable

Availability of data and materials
The datasets supporting the conclusions of this article are included within the article and its additional files.

Competing interests
The authors declare that they have no competing interests.

Funding
This research was funded by the René Rachou Institute -Fiocruz Minas.
The institute was responsible for funding the process of translating this manuscript.  Figure 1 Article selection process