Development of the FOREC thesaurus

The French agency for Food, Environmental and Occupational Health and Safety (ANSES) initiated and supervised a multidisciplinary working group to build the FOREC thesaurus. This working group was set up with the representatives of the main occupational and public health actors, such as the ANSES, the French National Health Insurance System (CNAM), Occupational Disease Centers, Occupational Health Services, the French Institute for Public Health Surveillance (InVS), the Interdepartmental Center of Health and Occupational Medicine in Factories (CISME), and the French Institute for Research and Security (INRS). This work was collaborative. The representatives of the main occupational and public health actors who attended the meetings for the creation of the FOREC thesaurus were nationally recognized experts in health, occupational medicine, mental disorders, and work-related stressors (organization, relation, or ethics). Specialized physicians from Occupational Diseases Centers of university hospitals, who undertake mental health consultations in the workplace [17,18], participated in the meetings. For two years, they were asked to list all organizational, relational, ethical and other contributing occupational factors linked with mental and behavioral disorders that were identified during their mental health consultations. Other actors also proposed other putative contributing factors from their own personal experiences. Eleven national meetings were held over three years. Firstly, the occupational exposure factors that could promote mental health and prevent mental and behavioral disorders were listed. All decisions regarding the inclusion of factors within the FOREC thesaurus were approved on a consensus basis. They were then classified, which led to an updated FOREC thesaurus.

Presentation of the FOREC thesaurus

The classification was proposed by members of the multidisciplinary working group on a consensus basis. Occupational factors linked with mental and behavioral disorders were grouped into clinically relevant headings and sections based on ICD-10. The multidisciplinary working group proposed a FOREC thesaurus composed of six chapters: inherent demand of the work, functional organization of the business, relations at work and violence, personal ethics, ethics of the business, and other contributing factors. The first five chapters classify the professional situation inside the enterprise. The sixth chapter concerns the “contributing factors” that are related to the person’s status or are totally external to the enterprise. These six chapters are divided into a total of 34 subchapters. Subchapters are coded with 3 digits and are divided into 186 items in total. Items are coded with 4, 5 or 6 digits. The FOREC thesaurus is presented in Table 1 in its entirety.

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Table 1. Organizational, relational, ethical and other contributing factors–Thesaurus completed to 4, 5 or 6 digits.

https://doi.org/10.1371/journal.pone.0198719.t001

The first chapter, “Inherent demand of the work”, concerns all professional constraints that cannot be dissociated from the activity, but that may be the cause of various disorders. For example, being on call in a hospital can disturb social life or cause insomnia. This chapter is divided into 5 subchapters and consists of 44 items in total.

The second chapter, called “Functional organization of the business”, also concerns strong professional constraints. It classifies occupational exposure factors, such as organizational changes, restructuring, insufficient or excessive workload, and workplace transfers. This chapter is divided into 10 subchapters and consists of 51 items in total.

The third chapter is entitled “Relations at work and violence” (referring to instances such as deleterious relationships experienced with management, verbal aggressions, and sidelining). In this chapter, the notions of individual experiences of a more subjective nature are presented. This chapter is divided into 4 subchapters and consists of 47 items in total.

Chapters four and five are respectively related to “Personal ethics” (e.g. performing an act going against one’s principles) and “Ethics of the business” (e.g. lack of respect in verbal communications). These chapters provide justification of ethical issues based on case studies.

The sixth chapter, “Other contributing factors”, regroups factors that may be viewed as directly related to a person (such as a return after parental leave) or totally external to the enterprise (such as an unfavorable socio-economic context). This chapter is divided into 6 subchapters and consists of 42 items in total.

Multicenter study

To check the exhaustiveness and clinical relevance of the FOREC thesaurus, we aimed to describe organizational, relational, ethical and other contributing occupational factors linked with mental and behavioral disorders identified during consultations for mental health issues at work. A French multicenter study (Clermont-Ferrand, Créteil, Toulouse, Bordeaux, Garches) was therefore implemented. The Occupational Disease Centers at these University Hospitals were chosen because they shared similar characteristics relating to the management of mental health consultations in the workplace. Included workers were addressed to those consultations by their general practitioner or their occupational physician because of a presumed diagnosis of mental health issues at work [17,18]. They were included over a period of twelve consecutive months. There were no exclusion criteria and all patients who attended a consultation for mental health issues at work were included. The protocol was approved by the ethics committee of the University Hospital of Clermont-Ferrand (approval number: n° 2015CE/69). Socio-demographic, occupational and clinical data were retrieved during two interviews, one with a psychologist and a nurse and a second with an occupational physician and a psychiatrist. The final diagnosis of a mental and behavioral disorder was made during this second, specialized, consultation for mental health issues at work, which also established a link between the issues and professional activity. The link was based on the specialist’s judgment, during the medical examination. Mental and behavioral disorder were coded according to the International Classification of Diseases 10th Revision (ICD-10) and all physicians were trained in this coding by the same organization (ANSES). A detailed medical report was systematically written by the occupational physicians and the psychiatrists for each consultation. The medical report mentioned the diagnosis and the socio-demographic, occupational and clinical data, as well as occupational exposure factors linked with the mental health issues of the workers. The medical reports identifiers were coded prior to analysis. One author (CL) reviewed all coded medical reports from all centers. The author identified and retrospectively coded the data and factors contributing to the workers’ health-related issues using the FOREC thesaurus from the perception of the worker.

Statistical analysis

Statistical analyses were performed using Stata software, version 13 (StataCorp, College Station, TX, US). Continuous data were expressed as mean ± standard deviation and categorical parameters as frequencies (associated percentages).

Consequences to mental health following exposure to occupational factors

Mental health issues at work are a public health concern. More interestingly, some factors related to work, such as organizational, relational, ethical and other contributing factors were directly linked with some health-related issues. For example, it has been shown that cardiovascular diseases were associated with job strain [19], low decision latitude [20], low reward [21] and low social support [22,23]. It has also been reported that low social support positively predicts depression [24]. Similarly, changes in organization (10.9% of the 1357 identified factors) and conflict of loyalties resulting from workplace changes may also lead to suicide [25]. Moreover, it has long been recognized that depression and anxiety share similarities in their pathogenesis [26]. Among the mental disorders identified in the present study, anxiety and depression seem to share the same exposure profile, i.e. relational (~40%) [27], whereas burn-out was mainly linked with organizational factors (~60%), as previously reported [28,29,30].

Occupational factors linked with mental and behavioral disorders

In our study, identified factors were mainly relational (42.4%). Relational regulation theory has previously been proposed as a novel way to improve mental and behavioral disorders [31]. On the other hand, inherent work demands were infrequently cited (2%), which consequently may not be a major source of mental health issues at work. In our study, the inherent work demands that cannot be dissociated from the professional activity seem to be accepted and well tolerated by workers, which might appear contradictory to some previous literature [20]. We demonstrated that 1.3% of the factors identified were related to low decision latitude, 7.5% to lack of recognition or reward and 4.9% to perceptions of a deficiency of support. Supervisor support has previously been shown to buffer the impact of excessive work demands [31]. One hundred and sixty-six contributing and contextual factors (12.2%) showed some new insights into particular medical or social status (such as perceived limitations of ability, return after absence) that may be capable of altering relationships or altering work-related self-efficacy. Studying those factors could provide possibilities for changing practices in the workplace.

Recommendation

The FOREC thesaurus has a worldwide application as the use of a standardized and shared terminology is needed to describe at-risk occupational factors that generate mental and behavioral disorders. Identifying those factors is essential for effective prevention in the workplace and must be based on useful evidence-based information in order to help to define priority actions. At-risk workers should receive follow-ups from occupational physician [32,33], and may benefit from a targeted intervention on the occupational factors that have been identified as generating mental and behavioral disorders [34].

Limitations

There are limitations to this study. Some subchapters of the thesaurus may seem less relevant because they were less common. However, a detailed thesaurus is required for exhaustively encoding exposures. This thesaurus can be improved, as are other thesauruses which are continuously enriched by the French National Occupational Diseases Monitoring and Prevention Network (RNV3P) [35,36,37], which also guarantees that they will remain current. The sample size used for describing results from the FOREC thesaurus may seem low, however workers were recruited at the Occupational Diseases Centers of the University Hospitals’ during specialized consultations for mental health issues at work [17,18]. Moreover, a relevant number of occupational factors linked with mental and behavioral disorders were identified (over one thousand), providing substantial data. Variability between independent coders also needs to be assessed. Comparing encoding between a physician and an administrative employee would be of interest. Furthermore, personality traits of the coder may influence data encoding and should be evaluated. Further studies are needed to assess the profile of occupational exposure factors with regard to socio-professional occupations and workers’ demographic characteristics.