Orientador: Heleno Rodrigues Corrêa Filho / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T02:50:44Z (GMT). No. of bitstreams: 1 Stenger_Eunice_D.pdf: 85030272 bytes, checksum: a69c9a0f209ac8b7f2341213f4f8a023 (MD5) Previous issue date: 2014 / Resumo: O presente trabalho partiu do questionamento sobre a tendência temporal e ecológica das morbidades mentais entre metalúrgicos e trabalhadores da educação. Investigamos o possível relacionamento dessas tendências com as mudanças que intensificaram o processo de trabalho em dois setores de atividade econômica muito diferentes. Esta tese combinou método de estudo de caso do setor metalúrgico com estudo ecológico nacional sobre trabalhadores da metalurgia e da educação. Realizamos o estudo de caso com observação direta e entrevistas no ambiente de trabalho sucedida por estudo documental histórico sobre empresa metalúrgica transnacional utilizando fontes públicas oficiais: _ Ministério do Trabalho e Emprego ¿ MTe, Ministério Público do Estado de São Paulo ¿ MP e o Ministério Público do Trabalho ¿ MPT. Numa segunda etapa os trabalhadores da educação foram comparados com metalúrgicos em estudo ecológico que usou bases nacionais brasileiras de dados sobre benefícios do Instituto Nacional de Seguridade Social ¿ INSS. Os desfechos epidemiológicos foram diagnósticos concedidos no Brasil aos trabalhadores para Licenças do Trabalho para tratamento de Saúde ¿ LTS e as exposições estudadas foram as categorias econômicas classificadas na Classificação Nacional de Atividades Econômicas ¿ CNAE, versão 2.0, para período de doze anos entre 2000-2011. O primeiro artigo abordou riscos psicossociais decorrentes da introdução de um novo modelo de gestão, o Lean Production, em uma indústria metalúrgica. O Lean passou a ser objeto de observação do trabalho de campo realizado no ano de 1996, quando a empresa passava por processo de fusão e internacionalização. Foram feitas entrevistas chave de trabalhadores e gerentes, complementadas posteriormente com análise documental. Anos depois, entre 2004 e 2009 voltamos a estudar a empresa, refazendo entrevistas a sindicatos e analisando processo judicial no MPT que lhe atribuía más condições trabalhistas, riscos à saúde e ao xx ambiente do trabalho. Essa metodologia criou oportunidade inédita de confrontar observação direta com resultantes posteriores sobre o trabalho e a saúde dos trabalhadores. O questionamento fundamental foi sobre relações entre o modelo de gestão - lean-production - e sua possível associação com riscos psicossociais à saúde dos trabalhadores. Constatamos nos processos judiciais que aquela multinacional de autopeças foi questionada pelo uso de jornadas excessivas com horas extras de trabalho, trabalho sem descanso semanal e jornadas com duração acima de dez horas. Essas condições de trabalho foram consideradas pelo MTe, MP e MPT como fontes de riscos psicossociais associados com afastamentos relacionados a adoecimento pelo trabalho. Os artigos Dois e Três analisamos adoecimentos de trabalhadores no setor da metalurgia no Brasil no período de 2000 a 2011. Nestes artigos descrevemos as doenças às quais foram atribuídas as LTS analisando fontes brasileiras de dados para todo o mercado formal de trabalho (celetista) no país. Os numeradores foram extraídos dos diagnósticos que motivaram as LTS classificados pela Classificação Internacional de Doenças (CID10) no Sistema Único de Benefícios (SUB) do INSS. Os denominadores foram retirados da GFIP ¿ Guia de Recolhimento do Fundo de Garantia por tempo de Serviço (FGTS) e de Informações à Previdência Social cobrindo doze anos no período 2000 a 2011. Estes artigos apresentam estudo ecológico descritivo sobre uma coorte nacional dinâmica não concorrente dos trabalhadores de cada setor da economia formal e traçaram as tendências das doenças mais prevalentes (artigo 2), detalhando posteriormente a comparação entre as incidências de LTS por doenças mentais e cardiovasculares entre os trabalhadores das duas categorias de atividades econômicas (artigo 3). O artigo 2 descreve as causas principais de LTS. As lesões externas foram a principal causa de afastamentos entre trabalhadores da metalurgia ¿ variando de 125,4 a 221,6 por 10.000 trabalhadores com vínculo celetista. A segunda causa foram os distúrbios musculoesqueléticos com 85,5 a 207.1 benefícios por 10.000 xxi trabalhadores. Seguiram-se os transtornos mentais com 19,8 a 58,8 / 10.000 na metalurgia e 11,5 a 38,9 / 10.000 entre os trabalhadores da educação. O câncer apareceu como a única categoria de doenças com incidência mais alta de LTS entre os trabalhadores da educação comparados aos da metalurgia. Os transtornos mentais atingiram mais os metalúrgicos que aos trabalhadores do ensino. Esse foi o achado mais importante e reforçou a hipótese de que o `Lean Production¿ trouxe estressores aos ambientes de trabalho e contribuiu para aumentar os adoecimentos e trazer os metalúrgicos a um nível de adoecimento psíquico mais elevado que o dos trabalhadores da educação. Estudamos no artigo 3 os adoecimentos mentais e cardiovasculares entre trabalhadores da educação e metalúrgicos. A força de trabalho média anual da metalurgia variou entre 268.759 e 468.613 no período de 2000 a 2011. Um total de 19.722 trabalhadores sofreram afastamento por transtornos mentais e 10.787 tiraram LTS por doenças do aparelho circulatório. Entre os transtornos mentais predominaram os transtornos do humor com curvas de afastamento superiores para os trabalhadores da metalurgia com pico de 29,2 comparados a 25,7 / 10.000 entre trabalhadores da educação em 2006. Os transtornos mentais por abuso de substâncias psicoativas apresentam tendência de elevação mais importante entre os trabalhadores da metalurgia (15,9 v.g. 2,4 / 10.000 em 2011). Também os transtornos neuróticos relacionados com o stress predominam entre os metalúrgicos até 2008 (11,0 v.g. 9,2 / 10.000). Entre as doenças do aparelho circulatório predominaram as doenças das veias e linfáticos principalmente entre trabalhadores da metalurgia (19,1 v.g. 8,7 / 10.000). As doenças hipertensivas predominaram entre trabalhadores do ensino com picos de 6,5 / 10.000 em 2002 e 2004 comparados a 4,5 / 10.000 entre metalúrgicos em 2005 com tendência decrescente até 1,4 e 1,0 respectivamente em 2011. As doenças isquêmicas do coração flutuam entre valores próximos de 2,5 e 4,1 por 10.000 trabalhadores, sendo que a curva em geral é mais elevada para os trabalhadores da metalurgia e ambas categorias apresentaram tendências de queda a partir de 2008 / Abstract: The present research departed from questioning the time trends and the ecology of mental morbidities amongst workers in metallurgy and education. We investigated the possible relationships of those trends with the increased work process intensity, which changed these two sectors of the economy with so different settings. This thesis combined the method of a case study in the metallurgy sector with a national ecologic study on workers of metallurgy and education. We conducted the case study with direct observation and interviews at the work environment followed by a historic and documental study on a transnational metallurgical company using official public records from the: _ National Department of Labor and Employment ¿ MTe, São Paulo State Department of Public Attorneys ¿ MP and the Federal Department of Labor Public Attorneys ¿ MPT. In a second step, we compared education workers with metallurgists in an ecologic design that used Brazilian national databases of workers¿ compensations from the National Institute of Social Security ¿ INSS. The epidemiologic outcome was the diagnosed morbidity recorded in Brazil when workers claimed sick leaves ¿ LTS and the exposure studied was presumed to working in the economic sectors classified according the National Classification of Economic Activities ¿ CNAE, version 2.0, for the twelve years period of 2000-2011. The first article addressed psychosocial risks arising from the introduction of the de Lean Production method in a metallurgic industry. This method combined a field observation conducted in the year 1996 with key interviews of workers and managers. It was complementary added to a historical documental analysis long afterwards the moment of the field observation when the company was undergoing the merging and internationalization process. Years later, from 2000 through 2009, we analyzed the litigation process put by the MPT that attributed to the company the responsibility for bad working conditions, with risks to workers¿ health and work xxvi environment. This methodology created the unprecedented opportunity of confronting results from direct observation with late results on workers¿ health and work environment inspection. Our fundamental question was on the relationships between the managing model of - lean-production and its possible association with psychosocial risks at work. We found that the multinational auto parts company was sued after using excessive journeys with long extra working hours, the lack of weekly days of resting, and work journeys longer than then hours a day. The MTe, MP and the MPT considered these working conditions as a source of psychosocial risks associated with sick leaves and working related morbidity. Articles 2 and 3 described the diseases to which sick leaves (LTS) were attributed after analyzing the Brazilian database sources for the total of the national formal labor market in the country. Numerators were taken from the diagnosed morbidity classified according to the International Classification of Diseases - (ICD10 /CID10) that were considered the reasons for the LTS at the National Unified Compensations¿ System (SUB) of the INSS. Denominators came from the GFIP ¿ a database that combined the Tax Report Form of the Worker¿s Savings Fund of Working Time (FGTS) together with the Labor Force Reports to the Department of National Social Security that covered a twelve years period from 2000 to 2011. These two articles reported a descriptive ecologic study on a national dynamic and non-concurrent cohort of workers in each sector of the formal economy. They traced the twelve years trend of the most prevalent diseases (article 2), detailing at last the comparison between the LTS incidences due to mental and cardiovascular diseases among workers of the two categories of economic activity (article 3). Article 2 describes main causes for LTS. External causes were the most incident reasons for sick leaves among metalworkers ¿ varying from 125.4 to 221.6 by 10,000 formally registered jobs. The second group were musculoskeletal disorders with 85.5 to 207.1 LTS for 10,000 workers. Mental disorders followed in both sectors with 19.8 to 58.8 / 10,000 in metallurgy and 11.5 to 38.9 / 10,000 among xxvii education workers. Cancer appeared as the only disease group¿s category with high LTS incidence among educators compared to metalworkers. Mental disorders affected more metalworkers than those in education. This was the most important finding that reinforced the hypothesis that the `Lean Production¿ method brought more stressors to the work environment and contributed to increase morbidity of metalworkers to levels of mental disorders above those in the educational economic sector. Article 3 studied the LTS due to mental and cardiovascular diseases comparing educational and metalworkers. The yearly mean employed work force in metallurgy varied from 268,759 to 468,613 job places in the period 2000 through 2011. About 19,722 metalworkers took LTS due to mental disorders and 10,787 were affected by circulatory disorders. Mental disorders were mostly specified as affective and mood disorders with sick leaves¿ trends of metallurgy well above with peaks of 29.2 compared to 25.7 / 10,000 among education workers in 2006. Mental disorders due to psychoactive drugs¿ abuse (F10- F19) showed an increasing trend more important among metalworkers (15.9 vs. 2.4 / 10,000 in 2011). Stress related neurotic disorders were also predominant among metalworkers until 2008 (11.0 vs. 9.2 / 10,000). Diseases of lymphatic vessels and veins were the main causes of LTS in the cardiovascular diseases¿ group especially among metalworkers (19.1 vs. 8.7 / 10,000). Hypertensive diseases predominate among education workers with peaks of 6.5 / 10,000 in 2002 and 2004 compared to 4.5 / 10,000 among metalworkers in 2005 both with a decreasing trend until 1.4 and 1.0 respectively in 2011. Ischemic heart diseases drifted among figures close to 2.5 and 4.1 / 10,000 workers with the metalworkers running always above despite both economic sectors showed a noticeable decrease from 2008 on. Our conclusions were discrepant from the preliminary hypothesis that supposed to find greater psychic risks among education workers once metalworkers would expose themselves mostly to physical workloads with a consequence of higher xxviii incidence of musculoskeletal diseases in LTS. The analysis of both ecologic studies turned this forecast down. The main finding of this research was that metalworkers showed increasing trends of LTS incidence by prevalent morbidity above those found among education workers of the education economic sector due to affective and mood disorders, as well as mental disorders due to psychoactive drugs¿ abuse, the somatoform and stress related neurotic disorders. The twelve years period under analysis showed a trend of increasing the incidence of LTS in both groups of economic activity with the exception of cardiovascular diseases. Keywords: Government Regulation; Work Schedule Tolerance; Working Conditions; Psychosocial Impact; Working Environment - analysis ¿ adverse effects - policies / Doutorado / Política, Planejamento e Gestão em Saúde / Doutora em Saúde Coletiva

Contexte - Considérées comme un progrès thérapeutique notable en cancérologie, les thérapies ciblées ne sont pas sans effet secondaire, en particulier sur le plan dermatologique. Très peu de données sont actuellement disponibles quant à leurs retentissements sur la qualité de vie des patients. Le service de dermatologie de Gustave Roussy a développé un protocole de recherche prospectif (SKINTARGET) consacré à cette thématique afin de pouvoir proposer des mesures préventives et/ou curatives adaptées. Inscrite dans ces travaux, notre thèse avait pour objectif principal de décrire les changements observés du point de vue de l’état émotionnel, de l’image corporelle et des interactions sociales avec l’apparition des atteintes cutanées, en s’intéressant à la place des représentations associées au traitement dans le processus d’ajustement des patients à ces symptômes.<p>Méthode - Il s’agissait d’une étude comprenant quatre temps d’évaluation (initiation du traitement, un, deux et trois mois après), qui associait de façon concomitante deux modes d’évaluation :quantitatif (questionnaires :IPQ-R, DLQI, POMS, BDI-II, QIC) et qualitatif (entretiens semi-directifs). L’inclusion était proposée par les oncologues aux patients allant débuter un traitement par thérapie ciblée. Les analyses statistiques ont été menées à partir du logiciel SPSS version 14.0 ;les analyses des entretiens ont combiné méthode thématique et méthode par questionnement analytique, en s’appuyant sur le modèle théorique de Pedinielli. <p>Résultats - Quatre-vingt-deux patients ont donné leur accord pour la recherche biomédicale, 62 d’entre eux ont accepté de participer à l’étude psychologique. La partie quantitative a été complétée par 33 patients, pour moitié hommes (âge moyen 56 ans), soignés pour un cancer métastatique cutané, pulmonaire, rénal ou thyroïdien. L’échantillon comptait une majorité de personnes en couple, avec enfants, soit à la retraite soit en arrêt de travail. Quatre-vingt-quatorze pour cent a développé au moins un des principaux symptômes suivants :rash cutané, syndrome main-pied, alopécie ou photosensibilité. Les changements observés ont été un inconfort physique et une gêne à la réalisation des activités du quotidien. Aucun signe de perturbation de la sphère émotionnelle, de l’image du corps et des relations sociales n’a été mis en évidence au cours des trois premiers mois de traitement. Les symptômes dermatologiques ont majoritairement été rattachés par les patients à l’action du traitement, sans être interprétés comme signes de son efficacité. La représentation d’un médicament contrôlant la maladie a émergé comme un des facteurs significativement associés aux variations de l’impact des toxicités cutanées sur la qualité de vie. <p>La partie qualitative a concerné 41 patients, dont les caractéristiques médicales et socio-démographiques étaient très similaires à celles de l’échantillon quantitatif. Pour une majorité les effets secondaires dermatologiques ont été « embêtants », « gênants », quelquefois « impressionnants », voire « perturbants » lorsqu’ils entraînaient douleurs, difficultés à la mobilité ou troubles du sommeil, mais sont restés « gérables, supportables ». Les représentations associées au traitement, très positives, sont apparues comme un élément soutenant dans l’ajustement des patients. Du discours des patients en souffrance psychologique sont ressorties une défiance vis-à-vis du regard d’autrui et une impossibilité d’amorcer le travail de renoncement nécessaire à l’intégration des transformations liées au cancer et à ses traitements. L’origine de cette souffrance serait un débordement des défenses psychiques par une angoisse de mort :la difficulté pour restaurer l’état d’équilibre psychique antérieur provenant de l’activation concurrentielle de deux dynamiques, l’une surnommée « substantielle », l’autre « identitaire ».<p>Discussion - Ces résultats rejoignent les données de la littérature en concluant à un impact d’intensité faible à modérée des toxicités cutanées sur la qualité de vie pour une majorité de patients. Contrairement à ce qui était attendu, il n’a pas été observé de changement sur le plan de l’état émotionnel, de l’image corporelle et des interactions sociales. L’investissement positif du traitement, la réappréciation des valeurs, le très bon état général des patients et l’optimisme ont été évoqués pour expliquer non seulement l’absence de perturbation, mais aussi les très bas niveaux d’anxiété, de tristesse et de fatigue globalement rapportés. L’importance de l’encadrement soignant et médical a également été soulignée parce qu’il sécurise les patients en anticipant les difficultés, en informant et en proposant une prise en charge suivie.<p>Conclusion - Le développement croissant des thérapies ciblées devrait s’accompagner d’un renforcement des mesures de prévention et de prise en charge des effets secondaires dermatologiques, qui requiert formation et sensibilisation des acteurs de soin à cette problématique, en rappelant la dimension singulière du vécu de chaque patient et l’impossibilité de le réduire à l’observable médical.<p>Background - Considered as a significant therapeutic progress in cancer, targeted agents are not without side effects, particularly dermatological ones. Very little information is presently available about their consequences on patients’ quality of life. The dermatological team of Gustave Roussy has developed a prospective research (SKINTARGET) in order to provide preventive and curative adapted care. Integrated into this work, our thesis aimed to describe the psychosocial changes occurring with cutaneous toxicities and to explore the implication of treatment representations in the patient’s adjustment process.<p>Methods - The study included four phases of evaluation (treatment initiation, one, two and three months after) and used simultaneously two methods: a quantitative one (questionnaires: IPQ-R, DLQI, POMS, BDI-II, BIQ) and a qualitative one (semi-structured interviews). The inclusion was proposed by oncologists to patients who were about to start a targeted therapy. Statistical analyzes were conducted with SPSS 14.0 software; analyzes interviews combined thematic approach and analytical questioning methods and referred to the Pedinielli’s theoretical model.<p>Results - Eighty- two patients gave their consent for biomedical research, 62 of them agreed to participate to the psychological study. The quantitative part was completed by 33 patients (50% men, mean age 56 years) treated for metastatic skin, pulmonary, renal or thyroid cancer, who were mostly in a relationship with children, either retired or stopped working. Eighty- four percent developed at least one of the following main symptoms: skin rash, hand-foot syndrome, alopecia or photosensitivity. The observed changes were characterized by a physical discomfort and difficulties in the activities of daily life. No sign of disturbance was noted in emotional domain, body image or social relations during the first three months of treatment. Dermatological symptoms were mainly related by patients to treatment action, without being interpreted as an evidence of its effectiveness. The representation of a drug controlling the disease was significantly associated with a lower impact of skin problems on the quality of life.<p>The qualitative part included 41 patients. Medical and sociodemographic characteristics were very similar to those of the quantitative sample. For most people, dermatological side effects were "boring", "uncomfortable", sometimes "impressive" or "disturbing" when they were associated with pain, mobility difficulties or sleeping troubles, but remained "manageable, bearable". The very positive treatment representations appeared as a supporting element in patients’ adjustment. Psychological distress seemed appear when patients feared being stared by others and failed to engage themselves in the renouncement work which is needed to adjust oneself to the transformations related to cancer and its treatments. In such situation psychological distress was supposed to come from an overflow of the psychic defences by a fear of death; the difficulty to restore mental balance would be explained by the activation of two competitive dynamics, which struggle for the organism and the identity survival.<p>Discussion - These results are consistent with the literature data. The skin toxicities impact on quality of life is mild to moderate for a majority of patients. Contrary to our expectations, there was no evidence of change in the domains of emotions, body image and social interactions. The positive investment of treatment, a reassessment of values, the very good physical state of patients and the influence of optimism in patients state of mind have been cited to explain not only the absence of disturbance, but also the very low levels of anxiety, sadness and fatigue generally reported. The importance of the caregiving provided by health professionals was also highlighted: anticipating difficulties, giving information about side effects and effectively managing problems secure patients.<p>Conclusions - The growing development of targeted therapies implies strengthening prevention and management of dermatological side effects. Moreover, it requires to aware and to train more health professionals to this problem, recalling the singular dimension of each patient which can not being reduced to the medical observable.<p> / Doctorat en Sciences Psychologiques et de l'éducation / info:eu-repo/semantics/nonPublished

This exploratory study investigated the psychosocial impact on rural grandmothers of Gutu, Zimbabwe, caring for their grandchildren orphaned by HIV/AIDS. The participants included 12 paternal and maternal grandmother-caregivers from four districts of Gutu, whose ages ranged from 56 to 76 years with orphans in their care ranging from infants to 18 years. The present study made use of Erikson's psychosocial theory of development on late adulthood. Data were gathered using semi-structured open-ended interviews in the participants' homes. Interpretive analysis was used to analyse the audio-taped data. Findings reveal that most grandmothers are experiencing a personal toll in dealing with the late adult crisis of integrity versus despair, including finding it difficult to resolve the grief of losing children while engaging in full time grandparenting in a stigmatising society. Participants reported a need for support and interventions tailored to their unique needs. Counselling, social support, financial assistance, and skills and knowledge about HIV/AIDS are therefore recommended. / Psychology / M.Sc. (Psychology)

This exploratory study investigated the psychosocial impact on rural grandmothers of Gutu, Zimbabwe, caring for their grandchildren orphaned by HIV/AIDS. The participants included 12 paternal and maternal grandmother-caregivers from four districts of Gutu, whose ages ranged from 56 to 76 years with orphans in their care ranging from infants to 18 years. The present study made use of Erikson's psychosocial theory of development on late adulthood. Data were gathered using semi-structured open-ended interviews in the participants' homes. Interpretive analysis was used to analyse the audio-taped data. Findings reveal that most grandmothers are experiencing a personal toll in dealing with the late adult crisis of integrity versus despair, including finding it difficult to resolve the grief of losing children while engaging in full time grandparenting in a stigmatising society. Participants reported a need for support and interventions tailored to their unique needs. Counselling, social support, financial assistance, and skills and knowledge about HIV/AIDS are therefore recommended. / Psychology / M.Sc. (Psychology)