Musculoskeletal symptoms in Primary Health Care professionals

Sintomas osteomusculares em profissionais da Atenção Primária à Saúde

Síntomas musculoesqueléticos en profesionales de Atención Primaria de Salud

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

The Brazilian National Primary Care Policy (PNAB - Política Nacional de Atenção Básica) establishes that Primary Health Care (PHC) or Primary Care (PC) is considered the first level of care, and encompasses individual and collective health actions, focused on the “promotion and protection of health, disease prevention, diagnosis, treatment, rehabilitation and health maintenance”.¹

In PHC services, the overload of worker activities to guarantee assistance based on care that is more articulated to the context of people’s lives adds to the traditional occupational risks in the health field (chemical, physical, ergonomic and biological).² In this context, healthcare professionals’ routine, which is normally tiring, becomes even more intense, leading workers to experience situations of pain, distress, illnesses and deaths in their work routine. Therefore, professionals can develop Burnout syndrome, characterized by physical and emotional signs and symptoms, which have implications for their health and can trigger mental illness and physical musculoskeletal problems.^2,3

Musculoskeletal disorders are injuries that affect healthcare professionals, in the performance of their duties, as a consequence of movements and efforts to which they are subjected during the performance of their duties, especially those that require repetitiveness or continued efforts. Above all, they occur due to the imposition of positions that are not recommended on the body and that require spinal torsion, taking it away from the center of balance of the muscular system and causing strong pressure and twisting in its fibers. As a result of these efforts, more than one symptom may appear, characterizing musculoskeletal disorders.^2-4

These disorders involve disorders of tendons, nerves, synovium (joint linings), ligaments, muscles and fascia (muscle envelope), in isolation or in combination, with tissue degeneration possible, and are associated with pain and paresthesia. These morbidities can also be defined as repetitive strain injuries (RSI), musculoskeletal disorders (MSD) and cumulative trauma injuries (CTI), generally affecting the upper limbs, the scapular region around the shoulder and the cervical region, causing tendinitis, low back pain, neck pain and back pain. They can also affect the lower limbs and are often responsible for temporary or permanent work disabilities.^2,5

Musculoskeletal morbidities are among the main occupational diseases arising from the industrialization process. It is believed that this condition is among the main public health problems, causing several negative impacts on the social and economic environment of a country. In general, the symptoms gradually develop and, when they are noticed, they are already systematically installed, leading to loss of productivity and compromising workers’ production capacity, who begin to present high rates of absenteeism.^2,6-7

Healthcare professionals are very vulnerable and subject to musculoskeletal disorders, due to the high workload and lack of effort that goes beyond the work activity itself. Added to this is the lack of specific training to perform the role, incorrect physical postures, inappropriate lifting, repetitive movements and other issues related to body postures.^2,7-8

Therefore, the work process and the work environment have a strong influence on the process of musculoskeletal illness in healthcare professionals, who perform repetitive activities and under overload conditions, capable of causing irreversible physical injuries.^2-3,9 In this context, this study aimed to analyze the occurrence of musculoskeletal symptoms in PHC professionals.

This is a cross-sectional study, carried out in two municipalities in the state of São Paulo, with a non-probabilistic, convenience sample, which included 429 professionals from the Basic Health Units teams.

The first municipality (municipality A) is located in western state, 596 km from the capital, São Paulo. It is a small municipality, with a population of 33,707 inhabitants. The municipality is a reference center in health for municipalities in the Nova Alta Paulista region. When structuring the local health model, during the study period, PHC was carried out by four Basic Health Units, with ten Family Health teams and coverage of 100% of the municipality’s population.¹⁰

The second municipality (municipality B) is in northwestern São Paulo, 452 km from the capital. It is a large municipality, with an estimated population of 438,354 inhabitants. The municipality is the headquarters of Regional Health Division XV, the largest in the state of São Paulo, in addition to being a reference in healthcare.¹¹

During the study period, the municipality had a restructuring of its geographic division and began to be organized into ten health regions (previously there were five health regions), according to Decree 18,073 of June 29, 2018. PHC was responsible for 27 municipal services, three of which were Basic Health Units with teams from the Community Health Workers Strategy (EACS) and 24 Basic Health Units that comprised 58 Family Health teams and 21 Oral Health teams, responsible for covering 61.2% of the municipality’s population.¹²

The study population was made up of all professionals who made up the minimum team of the Family Health Strategy (doctors, nurses, nursing assistants/technicians, community health workers), including professionals from oral health teams (dentists and dental assistants), from all Basic Health Units in both municipalities. This choice aimed to equate the professionals assessed in both municipalities. Professionals who were on vacation during the data collection period and/or away from professional activities for any other reason were excluded.

Data were collected in the first half of 2018 using two self-administered instruments: the first was a questionnaire containing closed questions about training, age, sex, marital status, income, education, type of employment (Consolidation of Labor Laws (CLT - Consolidação das Leis do Trabalho), statutory), type of care unit/service, if has other employment relationships, practice physical activity, smoke/drink, if is satisfied and/or if has thought about giving up the profession/function, if has been away in the last year (reasons and number of times); the second was the Nordic Musculoskeletal Questionnaire (NMQ), translated and adapted into Portuguese, which allowed assessing symptoms of work-related musculoskeletal disorders (WMSD) and their relationship with musculoskeletal morbidity, demographic and occupational variables and personal habits. This questionnaire is simple to apply, and the Portuguese version was validated in Brazil.¹³ The NMQ contains two parts. The first has a human figure divided into nine anatomical regions, such as cervical, shoulders, arms, elbows, forearm, wrists/hands/fingers, dorsal region, lumbar region, hips/lower limbs. Participants identify, on this body map, the presence of pain, discomfort or numbness in the indicated regions, during the last 12 months. For symptomatic regions, participants indicate whether or not the symptoms are related to the work they perform.

Data collection was previously scheduled with nurses and managers of health units and carried out, preferably, during team meeting. After presenting the study to professionals from the team(s) and collecting signature on the Informed Consent Form, the researchers delivered the questionnaires to professionals, who were able to answer them immediately or within a week. After answering, the professionals delivered the questionnaires to the unit managers in sealed, unmarked envelopes. After receiving the completed instruments, managers contacted the researchers to collect the questionnaires.

The data obtained was stored in a database, using a Microsoft Excel^® spreadsheet. Analysis was performed with Statistical Package for the Social Sciences (SPSS) version 23.0.

Sociodemographic and professional variables were used to characterize the study population. To assess the symptoms of musculoskeletal disorders, initially, the NMQ answers were categorized into occurrence and non-occurrence of musculoskeletal symptoms in the last 12 months. Different body parts were considered (neck/cervical, shoulders, dorsal/thoracic, lumbar, elbows, forearms, wrists/hands/fingers, hips/thighs, knees and ankles/feet). Then, the answers were grouped by body regions, considering the upper trunk (neck/cervical and dorsal/thoracic), lower trunk (lumbar region), upper limbs (shoulders, elbows, forearms, wrists/hands/ fingers) and lower limbs (hips/thighs, knees, ankles/feet). Finally, the answers were grouped considering body parts (neck/cervical, shoulders, back/thoracic, lumbar, elbows, forearms, wrists/hands/fingers, hips/thighs, knees and ankles/feet) to assess whether, during the last 12 months, professionals had to avoid daily activities (work, domestic service or leisure/hobby) due to musculoskeletal problems/symptoms. Comparisons were made using the chi-square test, considering a significance level of 5% (p≤0.05).

This study is part of a matrix project entitled “Qualidade de vida, engagement, comprometimento e entrincheiramento com a carreira, estresse, estratégias de enfrentamento e queixas de distúrbios osteomusculares entre trabalhadores da Atenção Básica”. In compliance with current ethical aspects regarding research involving human beings (Resolutions 466/2012 and 510/2016 of the Ministry of Health), the project was approved by the Faculdade de Medicina de São José do Rio Preto (FAMERP) Research Ethics Committee on December 4, 2017, under Opinion 2,412,726 and Certificate of Presentation for Ethical Consideration (CAAE - Certificado de Apresentação para Apreciação Ética) 59604116.0.0000.5415.

The sample was defined by convenience and consisted of 429 professionals who answered the instruments, 85 (19.8.2%) from municipality A and 344 (80.2%) from municipality B. Among the professionals assessed, 41 (9.6%) were doctors, 92 (21.4%), nurses, 25 (5.8%), dentists, 83 (19.3%), nursing assistants/technicians, 177 (41.3%), community health workers, and 11 (2.6%), oral care assistants. Figure 1 shows the distribution of study professionals according to municipality and professional category. Professionals’ mean age was 42.6 years, ranging from 20.9 to 75.4 years.

Figure 1
Study sample distribution

As shown in Table 1, there was a predominance of female professionals (79.7%), married (63.4%), aged between 36 and 50 years (42.9%), with a 40-hour working day weekly (87.6%) and family income of two to five minimum wages (59.9%). It was observed that 34.7% of professionals were overweight; 60.4% did not practice physical activity; 60.1% had leisure activities; 80.7% had no other paid activity; and 79.7% slept six to eight hours a night. In relation to the length of professional experience, it is noteworthy that 40.3% of professionals had worked for five years or more in PHC services.

Table 1
Distribution of sociodemographic and professional characteristics of Primary Health Care workers assessed in the study

*Minimum wage value: R$937.00; BMI – Body Mass Index; PHC – Primary Health Care.

The results did not show statistically significant differences in the percentages of professionals with musculoskeletal symptoms between the municipalities (Table 2). It was observed that the main complaints of pain, in the last 12 months, involved the lumbar region (56.2%), neck/cervical (48.4%), shoulders (44.7%), dorsal/thoracic region (35.3%) and ankles/feet (31.7%). The lowest rates of pain complaints were for elbows (10.5%) and forearms (14.6%).

Table 2
Percentage of complaints of musculoskeletal symptoms by body parts among Primary Health Care professionals

* Chi-square test.

In municipality A, there was a slightly higher percentage of professionals complaining of musculoskeletal pain than in municipality B, but without statistical significance (Figure 2).

Figure 2
Distribution of percentages of complaints of musculoskeletal symptoms by body regions among Primary Health Care professionals (chi-square test)

Table 3 shows that 203 (48.7%) professionals reported that, in the last 12 months, they had to avoid daily work, domestic service or leisure/hobby activities due to musculoskeletal problems/symptoms.

Table 3
Distribution of professionals who, in the last 12 months, reported having avoided daily activities due to musculoskeletal symptoms

* Chi-square test.

The profile of the participants in this study is consistent with other studies carried out with PHC workers,2-3,14-16 and the professional structure of the teams complies with PNAB regulations in relation to the composition of the Family Health Strategy minimum teams.¹

The percentage of PHC professionals with complaints of musculoskeletal symptoms found in this study is much higher than that reported in the Brazilian population, whose prevalence of musculoskeletal diseases is approximately 2.5%.¹⁶ The appearance of these symptoms in healthcare professionals is due to several factors and is generally related to work characteristics, such as strenuous working hours, double employment, inadequate furniture and posture.^2,3

In the case of community health workers, long distances covered, often with excessive weight, in strong heat or inadequate postures, are risk factors for the emergence of injuries and musculoskeletal symptoms.³ Among nursing professionals, doctors and oral healthcare professionals, risk factors for the appearance of musculoskeletal symptoms can be considered: double shift work or night work, common among these professionals; performing repetitive movements; the adoption of inappropriate postures; lack of breaks, due to high demand or demands for productivity; exposure to work stressors, such as lack of training and professional autonomy; and insufficient time to carry out work activities.^17-19

In addition to work overload and inadequate professional sizing, emotional involvement also leads to dissatisfaction that can cause health problems for team professionals,²⁰ showing that social and psychological factors can contribute to worsening the clinical condition of workers affected by musculoskeletal injuries/symptoms.²¹ A study with Family Health Strategy professionals showed that workers with high levels of perceived stress were more likely to develop musculoskeletal diseases.²²

The predominance of complaints of musculoskeletal symptoms in the lumbar region, neck/cervical region, shoulders, dorsal/thoracic region and ankles/feet, observed among the PHC professionals studied, is reported in other studies^2-3,19, showing that the work process in PHC services can cause illness among professionals, compromising the physical conditions of workers, who begin to present musculoskeletal symptoms.

A study with nursing professionals from a Basic Health Unit pointed out heavy loads, postural problems and uncomfortable chairs as the main ergonomic risks for these workers. Lack of foot support and work overload were also indicated as factors associated with the prevalence of musculoskeletal symptoms. The authors associated work overload with a reduction in the quality of care, considering that overworked professionals are not able to offer care in accordance with the time and quality required expected by users.²³

Another important consequence related to musculoskeletal symptoms is absenteeism or absence from work, which causes discontinuity in care processes and the relationship with the patient, in addition to staff being absent due to frequent leaves of absence. Furthermore, pain makes it difficult to carry out work efficiently, directly affecting the quality of care provided to patients.²⁰

The high rates of professionals complaining of musculoskeletal symptoms in the thoracic region support the literature, which indicates the existence of a high role and work overload among healthcare professionals, the consequences of which are the high prevalence of back pain and ergonomic problems.²⁴ Given this scenario, it is necessary to implement regular training, with programs aimed at worker health and safety and that seek to prevent complications caused by work overload, such as workplace gymnastics, training courses on ergonomic issues at work, implementation of pre-established breaks and weight control programs.²⁰

Regular physical activity is seen as a great ally in improving or maintaining professionals’ health conditions and quality of life. The inclusion of physical activity practices, such as workplace gymnastics, in the workplace has contributed significantly to improving physical health and the perception of quality of life. Therefore, simple and low-cost measures, such as assessing the level of physical activity and monitoring workers, can contribute to preventing musculoskeletal problems and reducing absenteeism, favoring an increase in work performance and the quality of service provided to the population.²⁵

In this context, it is essential that managers monitor and to know their teams, understand their needs and encourage actions to prevent damage (physical and/or mental) professionals, i.e., it is important that they identify factors that lead to imbalances in workers’ health and act on them.²⁰Encouraging physical activity by PHC workers is an important prevention and health promotion strategy, seeking to minimize or avoid the illness of these healthcare professionals.

This study has limitations related to convenience sampling, which reduces the potential for generalizing the results and restricts the representativeness of the population, and data analysis, which does not allow inferring the existence of a direct relationship between musculoskeletal symptoms and the current work activity of assessed professionals. However, the results contribute important information for planning and implementing actions to promote health and prevent musculoskeletal injuries in PHC workers.

As demonstrated, PHC professionals in the municipalities studied reported complaints of musculoskeletal symptoms, mainly in the lumbar region, neck/cervical region, shoulders, dorsal/thoracic region and ankles/feet in the last 12 months. The regions with the lowest rates of complaints were the elbows and forearms. There was no significant difference in the number of professionals complaining of musculoskeletal symptoms between the municipalities. However, there was a slightly higher percentage of professionals with complaints of musculoskeletal symptoms in the small municipality (municipality A) compared to the large municipality (municipality B). These results show that musculoskeletal symptoms are an important problem for PHC workers’ health, since almost half of the professionals studied reported having avoided daily work, domestic service or leisure/hobby activities in the last 12 months, due to musculoskeletal problems/symptoms. For this reason, it is necessary to implement actions to promote PHC workers’ health, especially the prevention of work-related injuries and treatment/rehabilitation of professionals suffering from musculoskeletal injuries/complaints.