1. Introduction
Chronic noncommunicable diseases (CNCDs) are one of the greatest public health problems today, responsible for 68% of the world’s deaths in 2012 [
1], and for 68.3% of deaths in Brazil in 2011 [
2]. The Global Action Plan for the Prevention and Control of NCDs 2013–2020 [
3] from the World Health Organization (WHO) establishes some priority goals for improving the health status of the population, including reducing the prevalence of smokers, increasing prevalence of physically active persons, reducing the relative coronary risk, periodontal disease, caries, as well as controlling high blood pressure, diabetes, overweight and obesity. The Strategic Action Plan for Coping with CNCDs in Brazil from 2011 to 2022 is based on three main guidelines: (i) Surveillance, information, assessment and monitoring; (ii) health promotion; and (iii) integral care [
4], ratifying the need to develop health strategies that are capable of embracing health complexity. Accordingly, the promotion of global health should be understood as a mechanism that works only with an interdisciplinary and integrated effort, aimed at an aggregating knowledge of several scientific fields that dialogue for holistic health [
5]. In the context of work, CNCDs impact on the reduction of labour force participation, the number of hours worked, greater job rotation and early retirements, as well as the commitment of salaries, gains and achieved position. Estimates for Brazil suggest that the loss of labour productivity and the decrease in family income resulting from only three CNCDs, i.e., diabetes, heart disease and stroke, led to a loss in the Brazilian economy of 4.18 billion US dollars (USD) between 2006 and 2015 [
6,
7].
CNCDs are the main sources of disease burden in Brazil, and important policies for prevention and control have been implemented [
7]. The Brazilian Ministry of Health [
8] organized the surveillance of CNCDs aiming to respond to the scenario of growth of these pathologies in the country. This surveillance consists in a set of actions and processes allowing to know the occurrence, magnitude and distribution of the CNCDs and its main risk factors in Brazil, as well as to identify its economic, social and environmental determinants. In addition, one of the initiatives of the CNCDs surveillance aims to characterize the CNCDs time trend. These actions are essential for the planning, monitoring and evaluation of the activities of integral care and of the public policies of prevention and control of CNCDs in Brazil. The three essential components of CNCDs surveillance are: (a) Monitoring of risk factors; (b) monitoring the morbidity and mortality of CNCDs; and (c) monitoring and evaluation of health assistance and promotion actions to combat CNCDs.
The monitoring of the prevalence of CNCDs risk factors, especially those of a behavioural nature, i.e., diet, sedentary lifestyle, or chemical dependence on tobacco, alcohol and other drugs, whose scientific evidences of association with chronic diseases are proven, is one of the most important actions of surveillance [
9]. The Brazilian Ministry of Health periodically invests in two important national health surveys for this purpose: National Health Survey (NHS) [
10] and Surveillance of Risk Factors and Protection for Chronic Diseases by Telephone Inquiry (Vigitel) [
1]. Numerous health programs and actions in Brazil converge towards the same CNCDs control objective. The Brazilian National Health Promotion Policy (PNPS) sustains that the interdisciplinary effort results in the prevention of acute and chronic diseases situations, as well as in the reduction of possible state health expenditures [
11]. The Brazilian National Food and Nutrition Policy (PNAN) [
12] reports that adequate food consumption and the consequent improvement of the nutritional status of citizens has a direct impact on the prevention and control of CNCDs. The Brazilian National Program to Combat Tobacco (PNCT) [
13,
14] is part of the solid multisectoral tobacco control policy and aims to reduce the prevalence of smokers and the consequent morbidity and mortality related to the consumption of tobacco products in Brazil [
15]. The Brazilian National Oral Health Policy (PNSB) [
16] aims to control oral diseases such as caries and periodontal disease, assuming that the performance of the oral health professionals should not be limited exclusively to the biological field or technical, i.e., dental, work, extending its interdisciplinary practices through education and prevention, distribution of hygiene kits, caries treatment, application of fluoride, extraction and restorations. The National Program for the Promotion of Physical Activity, “Agita Brasil” [
17,
18], is an initiative of the Brazilian Ministry of Health that aims to increase the knowledge of the population about the benefits of physical activity, drawing attention to its importance as a predominant factor of health protection, in order to involve citizens in the practice of such activities. In articulation with the scientific societies, i.e., Cardiology, Diabetes, Hypertension and Nephrology societies, the Brazilian Ministry of Health [
19] presented the Plan for Reorganization of Attention to Hypertension and Diabetes Mellitus with the purpose of linking the patients with these diseases to the health units, guaranteeing follow-up and systematic treatment, through professionals’ training of and services reorganization. In addition to being aligned with the Global Action Plan for the Prevention and Control of NCDs 2013–2020 [
3], the above-mentioned Brazilian programs have in common the character of prevention, health promotion and intersectoral actions.
The challenges for facing CNCDs in Brazil are significant and for that purpose, the articulation of actions is of fundamental importance both in the public and private sectors. Despite its rapid growth, the impact of CNCDs can be reversed through broad and cost-effective health promotion interventions to reduce the risk factors, as well as improved health care, early detection and timely treatment [
20].
The Brazilian public policies have been effective in meeting the goals of the Strategic Action Plan for Coping with CNCDs in Brazil from 2011–2022 [
4,
21,
22,
23]. They comprise policies such as the integration and the articulation of the different sectors, organs and institutions for the construction of guidelines on CNCDs, actions in the scope of regulation of hypercaloric foods and advertisements, encouraging family farming to plant food, creation of conditioning environments for healthy living habits, agility in implementing tobacco-free environments throughout the country, and use of information as a management tool. With respect to achieving the goal of reducing the prevalence of smoking by 30% by 2022, a reduction up to 28% was already reached in 2017 and for the goal of increasing the prevalence of free-time physical activity by 10% in 2017, 23% in 2017 has already been achieved. However, the actions to curb the growth of obesity in adults need to be revised, since there was a growth up to 2017 of 25% in Brazil.
In the current scenario of transformative health care, it is imperative that health professionals focus on care that is centred on the need of each individual in an integrated way [
24]. Thus, the process of interdisciplinary work in health teams, emerging and increasingly urgent, has been supported by innovative policies, practices and care models that bring professionals and patients closer to the limits of traditional disciplinarity [
25]. In this context, interprofessional education is understood as a practice of achieving interdisciplinarity as members of more than one care profession are allowed to learn together and in an interactive way, in order to improve interprofessional collaboration or the health and the well-being of patients [
26]. Interprofessional collaboration has been associated with a number of positive outcomes, including improvements in patient safety and case management, optimized use of the skills of each health care team member, and provision of improved health services, identified as crucial to provision of effective and efficient health care when considering the complexity of individuals’ health needs [
27]. A study conducted in Mexico by Barceló et al. [
28] in 2010 identified, in some cases, improvement in glycaemic control of groups submitted to follow-up by an interdisciplinary team composed of physicians, nurses, nutritionists and psychologists, compared to groups undergoing usual care. The proportion of people with good glycaemic control (A1c < 7%) among those in the intervention group increased from 28%, before the intervention, to 39%, after the intervention. Overall, the proportion of patients achieving three or more quality improvement goals increased more than four-fold between the intervention group, from 16.6% to 69.7% (
p < 0.01), while among the usual care group if decreased from 12.4% to 5.9% (
p = 0.12), although not statistically significant. According to the need of interprofessional collaboration, the field of worker’s health has, since its emergence, a great potential for disciplinary integration in order to try to organize care in a more comprehensive way, translated into factors of influence on the worker’s health, difficult to achieve by the disciplines alone [
29]. Occupational health assessments are essential in the examination of the health conditions of the worker and in the preservation of health by the development of the day to day work. In addition, it is the opportunity to assess the worker’s overall health, including the risk factors for CNCDs. According to the Regulatory Norm (NR) 7 [
30], workers should be examined annually in the periodic assessment. However, this timeframe interval may be long for an adequate monitoring of the risks to the workers’ health. The implementation of a management policy for the risk factors of the CNCDs in a company enables the improvement of health, productivity and quality of life for all workers [
6].
The main objective of this study is to describe the behaviour of epidemiological variables of a population of workers of an oil industry in Bahia, Brazil, before and after implementation of interdisciplinary health practices focusing on health promotion, carried out during annual occupational health assessments.
3. Results
For a reliable assessment and comparison of the results obtained with the health intervention program, it is necessary to have similar characteristics of the participants, although opting for a convenience sample. Accordingly,
Table 1 shows the distribution by sex of the control and the test groups, and it was verified that despite the difference in the absolute value of the number of participants between both groups, they are similar at the percentage level, in both male and female sexes, before and after the health intervention, allowing a real comparison of the data. It should be considered that, because the participants work in the oil industry, the male population (85.0–89.3%) will tend to be larger than the female population (10.7–14.9%), a predominantly male population occupation.
The first stage of this study consisted in calculating the descriptive statistics of the indicators so that an overall analysis of the indicators would be possible, specifically to understand in which stages they were before the health intervention program.
Table 2 shows that the test group had a decline in the performance of all indicators, except for smokers (−0.6%), when compared to the control group.
As mentioned previously, the evaluation of the results of the health intervention in the test group was performed at two levels, inter and intragroup (
Table 3). The three most worrying indicators in the test group are the periodontal disease (10.2 ± 0.01%), high blood pressure (19.8 ± 3.19%) and high glycaemia (22.7 ± 5.31%), which are very high, when compared to the control group, respectively 5.3 ± 0.00, 13.1 ± 0.69 and 17.3 ± 0.77, between 2006 and 2015. These indicators require immediate intervention in global health, since when combined they can lead to the development of several serious chronic diseases.
The results in
Table 4 show that, in the case of the test group smokers and physically active, the indicators follow a similar evolution to the one observed in the Brazilian data (i.e., the smokers decrease and the physically active increase in both cases). On the other hand, a reduction in the obesity and overweight (−0.07%), and also, in the high glycaemia (−0.35%) indicators were identified in the test group. Relating to the same indicators, Brazilian data reveal an increase, respectively, of 1.28% and 0.23%. An increase in the high blood pressure indicator was identified both in test group and in the Brazilian data.
In order to synthesize the results presented in the
Table 3 and
Table 4,
Figure 1 presents the indicators of the test group, corresponding to a statistically significant difference after the health intervention.
Table 5 presents a comparative analysis of the prevalence of smoking, physically active and obesity among Brazilian workers, the control group and the test group, based on the goals of the Strategic Action Plan for Coping with CNCDs in Brazil from 2011 to 2022, planned by the Brazilian Ministry of Health [
4].
The test group stands out in the evolution of the three analysed goals, showing an increase in the prevalence of physical activity in free time by 50% between 2010 and 2017, a percentage well above the proposed target defined in the Strategic Action Plan for Coping with CNCDs in Brazil from 2011 to 2022 [
4] of 10% up to 2022. The same positive result can be observed in the control of obesity growth, where both Brazil and the control group show a significant percentage of growth and the test group reaches the goal of stabilizing this health indicator. Regarding the goal of reducing smoking prevalence by 30%, the overall goal in Brazil (28%) and a significant advance for the test group were observed, reaching a reduction of 56%, also above the control group (53%).
Aiming to summarize the evolution trend of all health indicators,
Table 6 presents the obtained results of the indicators in the test group, after health intervention.
To each indicator a negative or positive polarity was attributed according to the impact on the worker’s health, i.e., smoking has a negative polarity (–) due to its negative impacts on health and physical activity has a positive polarity (+) due to its positive impacts on health. An indicator trend was added to better understand the evolution direction, namely if increasing or decreasing, i.e., coronary risk had increased (↑) and caries had decreased (↓). Finally, an assessment was carried out aiming to identify which indicators had suffered improvement or aggravation since the beginning of the intervention, i.e., periodontal disease has a negative polarity (–) and its trend is to decrease (↓), which represents an improvement (Improvement). On the other hand, coronary risk has a negative polarity (–) and its trend is to increase (↑), representing an aggravation (Aggravation).
Table 6 shows that, in general, interdisciplinary health intervention in the global worker’s health reveals positive results in seven of the nine indicators assessed, namely: decrease of the percentage of smokers, increase of the physically active, decrease of the periodontal disease rate, decrease in the percentage of obese people and overweight, decrease in the number of caries, decrease in the number of workers with high glycaemia and a decrease in the number of days away from work. The remaining indicators where no improvements were observed, namely coronary risk and high blood pressure, should be considered as priorities for subsequent health interventions.
Intending to present the results of the indicators in which no improvement was observed, a logarithmic prediction trend line—to a five year period—was calculated in two different scenarios for each indicator, with and without health intervention,
Figure 2.
The starting values in
Figure 2 are different in the two prediction lines due to the fact they are based in the real baseline values of the two different moments: Before intervention and after intervention. The results show that although no significant differences were found in the two types of indicators, the scenario would be aggravated if interdisciplinary health intervention was not implemented.
4. Discussion
According to the Brazilian health targets to control CNCDs [
4], the difference between the results in the different levels of interventions are accomplished: at a public level, through the public policies of prevention and control of CNCDs in Brazil, at a private level with broad actions of health promotion being carried out, i.e., corresponding to the control group, and at a private level with interdisciplinary interventions directed to the target population, i.e., corresponding to the test group. The positive results obtained in the test group must be emphasised, reinforcing the understanding that the interdisciplinary health practices have positively affected the global health of the studied population.
Table 2 shows that the test group presented a higher prevalence for diseases in the initial study period (2006–2010), except for the indicators of smoking and obesity and overweight, which were slightly aggravated in the control group. After the implementation of the interdisciplinary interventions (2011–2015), an improvement of the profile of the test group for all the health indicators, with exception of the coronary risk and high blood pressure indicators, is observed, which may be justified by sociodemographic aspects such as sex, age and race, as reported by Khera et al. [
36], as well as cultural, whose context is very peculiar in Bahia, Brazil. The results of
Table 3 reinforce the results present in
Table 2 and report the improvements achieved by the test group in relation to the control group for all health indicators except coronary risk and high blood pressure. Regarding smoking, there was an equivalent reduction between both the test and the control groups, ranging from −0.61 to 0.60, without significant differences, this is explained by the fact that the Program to Combat Tobacco is interdisciplinary and applied in a similar way to both test and control groups.
Table 4 and
Table 5 present the advances obtained in the test group in relation to the Brazilian population for all comparable indicators, except for blood pressure. One of the main objectives of the interdisciplinary intervention is not be to seek that the test group presents better results than the control group, but that the results of the test group approach those of the control group, thus representing a global improvement in the overall health profile of the workers test group.
The sedentary lifestyle causes about three million or 8% of all CNCDs due annual deaths in the world [
6]. The benefits of an active lifestyle and the education of workers are essential for the promotion of physical activity and overcoming the barriers commonly reported for this practice, such as the lack of time and access to adequate spaces for the practice of exercise [
37,
38]. In the period under analysis (2006–2015), a growth of the physically active workers in the mean annual variation of 0.51% (
Table 3) per year was observed in the test group, being above the growth variation of the physically active in the control group (0.40%), in accordance with the Brazilian population trend, which was 0.24% per year. These results show that it is possible to change behaviours that meet healthier lifestyles, able to be achieved through structured planning by an interdisciplinary team and centred in the individual. According to Lin (2014), the work context can and should function as an institution that promotes the overall health of the worker.
The obesity epidemic that affects the world, with the consequent increase in the prevalence of diabetes and hypertension, threatens the further reduction of CNCDs [
7]. Obesity and overweight are associated with an increased risk of morbidity and mortality due to hypertension, dyslipidaemia, diabetes mellitus and cardiovascular diseases [
39]. In this study, the test group presented a higher percentage of workers with obesity and overweight, when compared to the control group, and a more intense percentage variation in the level of overweight reduction after implementation of the interdisciplinary health interventions in the oil industry, whereas there was a growth in the variation of 1.28%in the Brazilian population.
According to Brazilian Ministry of Health [
18], cardiovascular diseases are the main cause of morbidity and mortality in the Brazilian population. There is no single cause for these diseases, but several risk factors, which increase the probability of their occurrence. High blood pressure and diabetes mellitus represent two of the main risk factors, contributing decisively to the aggravation of this scenario at the national level [
40]. In this study, it was observed that the test group presented a higher percentage of workers with high blood pressure compared to the control group (
Table 3), as well as an increase in the analysed period of 2006 to 2015, reinforcing the need for more specific health intervention actions for this specific population. With regard to altered glycaemia, a higher prevalence was observed in the test group, in addition to the more marked variation in the reduction of the percentage of workers in this group, in the order of −0.35%, whereas the control group varied in −0.23% and the Brazilian population in 0.23%. Although the results of the study for the high cardiovascular risk were not statistically significant, there was a stagnation of the data variation, which shows a control of cardiovascular risk behaviour, emphasizing the efficiency of the health practices implemented, namely at an interdisciplinary level. The study shows that cardiovascular risk and high blood pressure present better results after the interdisciplinary health intervention, indicating a tendency for improvement in both cases.
As a risk factor for the development of a number of chronic diseases related to cancer, lung diseases and cardiovascular diseases, smoking continues to lead the causes of avoidable global deaths in the world [
41]. Brazil stands out in the implementation of tobacco control measures in the world, along with countries like Australia, Canada, Panama, Turkey and Uruguay [
42] and the success of the Brazilian tobacco control policy between 1986 and 2016 is evidenced by the expressive reduction in the prevalence of smokers over those years [
43]. The PNCT follows a model of interdisciplinary action involving physicians, nurses, psychologists, dentists, among others, in which educational, communication and health care actions [
15], along with support for adoption or compliance with legislative and economic measures, are potentiated to prevent the initiation of smoking, especially among adolescents and young people, to promote smoking cessation and to protect the population from exposure to environmental tobacco smoke, also reducing the individual, social and environmental damage of tobacco products [
9,
44]. The PNCT has excellent results and in the study period of 2006 to 2015, the reduction of smokers in the mean annual variation of −0.60% per year in the test group is observed, above the variation of decrease of the Brazilian population, which was −0.33% per year [
45], ratifying the importance of the targeted actions developed in the studied oil industry, and recommended in this study.
According to the Pan American Health Organization (PAHO) (2016) [
46], in the last decade, scientific evidence of the connection between oral health and systemic disease has continued to grow, making oral health an important component of disease prevention in public health. Behavioural risk factors related to oral diseases are common to other major CNCDs, including an unhealthy diet rich in free sugars, smoking, and harmful alcohol consumption [
47,
48]. Periodontal disease, an infectious pathology with a multifactorial cause, affects the periodontal tissues and is related to diabetes [
49], cardiovascular diseases [
50] and stress [
51]. In 2010, the prevalence of Brazilians with periodontal disease was 22.7%, in the age group of 35–74 years old, which is high when compared to the sample of this study, which presents a reduction of 4% (8% in 2006 for 4.2% in 2015), after the implementation of interdisciplinary health practices. The test group presents a higher percentage of workers with caries (0.9 ± 0.74%) compared to the control group (2.3 ± 2.16%), however it presents an average annual variation of −0.50% years, being more intense in the reduction of the disease in the studied period of 2006 to 2015, while there was an increase in the number of workers with caries in the control group in the range of 0.06% (
Table 3).
The increase in the prevalence of cases of CNCDs in the oil industry can result in a reduction in productivity, absenteeism, disability, early retirement and increased expenses on the health system. The management of risk factors for CNCDs is essential to guarantee workers’ overall health [
52]. It was observed in this study that the test group presented a greater number of days away from work of workers when compared to the control group before the health intervention period of 2006 to 2010. After the health intervention, the test group was the only group that was able to reverse this trend, with a reduction of the number of days away from work in the range of −0.27% per year, oppositely to the control group, which increased by 0.10% per year (
Table 3).
It is clear that a possible scenario without health intervention programs would aggravate performance in all studied health indicators, meaning that interdisciplinary health interventions have and will have very positive and relevant impacts in the short, medium and long term of worker’s health, and it is crucial to continue to invest in actions to assist the main objective, i.e., improving the well-being and the overall health of the worker.
This study is of great epidemiological importance since it deals with the database on workers of an important Brazilian oil industry, thus reflecting two scenes in the studied context universe. First, the national scene of skilled oil workers in the period of 2006 to 2015, typically reported by strata of national surveys, such as Vigitel [
1]. Then, it also reflects the level of intervention of health and work technicians, including all professions or disciplines involved, reporting what changes were introduced in relation to the external universe so that the target public, i.e., the test group, is considered under the intervention of the team, besides the intervention that the population undergo in the same period.
It is important to deepen the research of the variables that did not correspond to significant statistical changes, aiming at a better understanding of the scenario such as race, sex, environmental, labour and cultural determinants under analysis. Another relevant aspect is the analysis of the technical and economic viability of the implementation of interdisciplinary health practices, essential in the socioeconomic context of Brazil. Studies of Mendes [
53], Bielemann [
54] and Djalalov [
55] have demonstrated the importance of investing in health promotion.