Objetivos. Este estudo teve como objetivos avaliar a capacidade para o trabalho, a estrutura temporal do sono, da 6-sulfatoximelatonina e do cortisol em trabalhadores em turnos da área de enfermagem. Métodos. Foram realizados dois estudos. Um estudo transversal para analisar a capacidade para o trabalho e o envelhecimento funcional precoce, através de questionários de condições de vida e trabalho e sintomas de saúde, da qual participaram 696 profissionais da área de enfermagem. E um cronobiológico com 19 trabalhadores do sexo feminino. Neste foram avaliados: o ciclo vigília-sono, através de actígrafos e protocolos diários de atividades; as concentrações da 6-sulfatoximelatonina e do cortisol; e a ritmicidade circadiana (avaliada utilizando a metodologia do ajuste dos parâmetros ritmométricos pela curva cosseno, método cosinor). Foi realizada coleta de urina em dois períodos de 4 dias consecutivos (com dias de trabalho e de folga,) para os trabalhadores noturnos, submetidos a turnos de 12 horas seguidas de 36 horas de descanso; e em um período de 8 dias consecutivos para os trabalhadores diurnos (6 dias de trabalho e 2 de folga). O grupo de 19 pessoas também foi analisado segundo a maior e menor tolerância ao trabalho em turnos. A tolerância ao trabalho em turnos foi avaliada utilizando 9 indicadores de saúde (escore de sonolência e fadiga, escore de concentração e atenção, escore da fadiga projetada sobre o corpo, escore geral da fadiga, SRQ20, escore de insônia, sonolência no trabalho, escore de problemas de sono) e disponibilidade do tempo livre. Resultados. A idade média da população era de 34,9 anos (dp + 9,5 anos), e esta era predominantemente feminina (87,8%), sendo que 40,6% começou a trabalhar antes dos 18 anos. As variáveis ligadas à capacidade para o trabalho inadequada foram: 1) sócio-demográficas: ter a responsabilidade pela renda familiar sozinho (OR=1,922), ter filhos ou menores sob a guarda (OR=1,558) e ter menos de 40 anos (OR=1,400). 2) ligadas ao trabalho: referir desconforto térmico (OR=1,548), referir ter sofrido abuso verbal pelo menos duas vezes no último ano (OR=1,670). 3) variáveis ligadas à saúde foram referir obesidade (OR=2,714), doenças de sono (OR=1,681), e fadiga (OR>3,771). No segundo estudo, as trabalhadoras noturnas apresentaram maior duração, e também melhor qualidade de sono noturno. Estas também referiram níveis de alerta significantemente mais elevados quando puderam cochilar durante o turno de trabalho. Foi encontrada uma grande variabilidade nos parâmetros rítmicos ao longo dos dias de trabalho e de folga. As concentrações médias de 6-sulfatoximelatonina e cortisol das trabalhadoras noturnas foram estatisticamente menores do que as encontradas em trabalhadores diurnos (p<0,001). Quando as trabalhadoras foram classificadas como mais e menos tolerantes ao trabalho em turnos, as trabalhadoras noturnas menos tolerantes referiram menor qualidade de sono e menores níveis de alerta. As concentrações médias de 6-sulfatoximelatonina e cortisol ao longo dos dias de trabalho e de folga variaram de modo distinto nos grupos de trabalhadoras mais e menos tolerantes ao trabalho em turnos. Conclusões. A capacidade de trabalho inadequada é resultado da associação de variáveis de múltiplas naturezas, tais como condições de vida e trabalho, hábitos e estilos de vida e à organização do trabalho. O cochilo durante o turno noturno de trabalho mostrou ser efetivo na manutenção dos níveis de alerta durante o trabalho noturno. As trabalhadoras noturnas apresentaram menores concentrações médias de 6-sulfatoximelatonina quando comparadas as trabalhadoras diurnas, o que pode estar relacionado à exposição à luz durante o turno noturno de trabalho. As trabalhadoras noturnas apresentaram menores concentrações de cortisol quando comparadas as trabalhadoras diurnas, o que pode estar relacionado à maior fadiga referida por estas trabalhadoras. Os ritmos de 6-sulfatoximelatonina e cortisol têm comportamentos diferentes nos grupos de trabalhadoras mais e menos tolerantes ao trabalho em turnos, mas nenhum padrão pode ser definido, uma vez que existe uma grande variabilidade individual. / Objectives. The aim of this study was to evaluate work ability and biological rhythms of health care shiftworkers. Methods. To evaluate the work ability it was designed an epidemiological approach using a comprehensive questionnaire which included working and living conditions and health symptoms. 696 health care shiftworkers participated in this study. A sub sample of 19 female registered nurses and nurse aides/technicians were invited and agreed to participate in the chronobiological evaluation. Workers answered daily logs and wore actigraphs (Ambulatory Monitoring) to monitor activity and evaluate rest and waking periods along data collection. Urine samples were collected and voided volumes were measured during two periods of four consecutive days (working days and days off) of night workers, submitted to 12 hour night shifts followed by 36 hour off, and during one period of 8 consecutive days (six working days and two days off). It was also evaluated the 6-sulphatoxymelatonin and cortisol concentration, and their circadian rhythmicity using the Cosinor method. These 19 nurses were evaluated as more or less tolerant to shiftwork. The tolerance to shiftwork was evaluated by 9 health scores(dull and sleepy score, decline of working motivation, projection of fatigue to some parts of the body, general fatigue score, Self-Report Questionnaire (SRQ-20 score), insomnia score, sleepiness score, sleep disturbances score) and availability of free time. Results. Mean age of the respondents was 34.9 years, most of them female (87.8%) and 40.6% entered labor force before 18 years old. The socio-demographic factors associated to inadequate work ability were: income responsibility - sole breadwinner (OR=1.922), raising kids (OR=1.558), age group (under 40 years old) (OR=1,400). Factors associated with working conditions were: thermal discomfort (OR=1.548), and verbal abuse (OR=1.670). Obesity (OR=2.14), sleep problems (OR=1.681) and fatigue (OR>3.771) were health outcomes associated to inadequate work ability. Night workers showed longer mean sleep duration and referred better sleep quality to nocturnal sleep. These workers also reported higher alertness level when they nap during the night shift. Mean concentration of 6-sulphatoxymelatonin and cortisol among night workers were significantly lower than the day workers concentrations (p<0,001). When workers were classified into more and less tolerant to shiftwork, the less tolerant night workers referred worst sleep quality and lower alertness levels. The mean concentration of 6-sulphatoxymelatonin and cortisol, during working days and days off, showed distinct behavior in the two groups. It was found a great variability of the rhythmic parameters during working days and days off. Conclusions. Inadequate work ability was associated with a number of variables present at work and living conditions. Strategy of taking naps during night work was effective to maintain the alertness levels during work. Night workers 6-sulphatoxymelatonin mean concentrations were lower than day workers concentration. This might be related to light exposure during the night shift. The higher reported fatigue by these workers might explain the lower cortisol mean concentration presented by night workers when compared to day workers. The rhythms of 6-sulphatoxymelatonin and cortisol showed different behaviors when compared more and less tolerant workers, but any standard behavior could be observed since there is a great individual variability.

Σκοπός της διατριβής ήταν η διερεύνηση του φαινομένου της απουσίας (για λόγους υγείας) από την εργασία στον ιδιωτικό τομέα και ιδίως στη βαριά βιομηχανία, και τη πιθανή επίδραση στην ικανότητα εργασίας. Η παρούσα διδακτορική διατριβή στηρίχτηκε κυρίως στη μελέτη του αρχείου αναρρωτικών αδειών (μιας κοόρτης) εργαζομένων σε ένα από τα μεγαλύτερα ναυπηγεία της χώρας, καθώς και στις ετήσιες στατιστικές αναφορές του Ιδρύματος Κοινωνικών Ασφαλίσεων (ΙΚΑ) της τελευταίας 20ετίας. Τα χαμηλά επίπεδα απουσιασμού ασθενείας στον ιδιωτικό τομέα στην Ελλάδα επιβεβαιώθηκαν από τη μελέτη που έγινε στα πλαίσια αυτής της διατριβής, αν και τα αποτελέσματα υποδεικνύουν ότι ο απουσιασμός ασθενείας στην Ελλάδα είναι ελαφρώς μεγαλύτερος από ότι υποδείκνυαν οι πρόσφατες διεθνείς συγκριτικές μελέτες. Το ποσοστό απουσιασμού (Absenteeism rate) βρέθηκε περίπου 2.5%, από τα χαμηλότερα στην Ευρώπη. Παρόλα αυτά, επειδή περιλαμβάνει τον εργάσιμο χρόνο που διαφέρει από χώρα σε χώρα, δεν χρησιμοποιείται συχνά στις μελέτες αν και ίσως είναι ο πιο έγκυρος δείκτης απουσιασμού. Η μέση διάρκεια απουσίας για κάθε εργαζόμενο ανά έτος ήταν 5.8 ημέρες( μέγιστη τιμή 8 ημέρες προς το τέλος της περιόδου μελέτης) με ένα αντίστοιχο μέσο όρο που ξεπερνούσε κατά πολύ τις 10 ημέρες στην υπόλοιπη Ευρώπη. Ενδιαφέρον εύρημα αποτελεί το γεγονός ότι οι μικρής διάρκειας απουσίες (<4 ημέρες) αντιστοιχούσαν στο 25% της συνολικής διάρκειας των απουσιών, κάτι που μέχρι τώρα δεν μπορούσε να υπολογιστεί από τα εθνικά στατιστικά δεδομένα του ΙΚΑ. Κατά τη μελέτη των δεδομένων του ΙΚΑ τις δυο τελευταίες δεκαετίες, βρέθηκε μια κυματοειδής πορεία του απουσιασμού, επιδεικνύοντας πτωτική πορεία μέχρι τα τέλη τις δεκαετίας του 1990, σε συμφωνία με τις προηγούμενες μελέτες και εν συνεχεία μια ανοδική πορεία, αν και μέχρι το τέλος της περιόδου μελέτης τα επίπεδα παρέμειναν χαμηλότερα από τα αρχικά. Σίγουρα οι παρατηρήσεις αυτής της μελέτης χρήζουν περαιτέρω διερεύνησης, καθώς ο χαμηλός απουσιασμός μόνο μερικώς μπορεί να αποδοθεί στα χαμηλά επίπεδα αποζημίωσης μισθού σε περίπτωση αναρρωτικής άδειας ή τα υψηλά ποσοστά ανεργίας. Βασικός σκοπός πρέπει πάντα να είναι η διατήρηση και προώθηση της καλής υγείας των εργαζομένων, μέσω όσο το δυνατόν καλύτερων εργασιακών συνθηκών. Καθώς τόσο οι εργασιακές συνθήκες όσο και η υγεία των εργαζομένων είναι σε μια δυναμική κατάσταση, χρειάζονται εργαλεία παρακολούθησης. Η μέτρηση του απουσιασμού ασθενείας είναι ένας παράγοντας που πάντα θα πρέπει να εκτιμάται από τον ιατρό εργασίας και τον εργοδότη, χρησιμοποιώντας τους διάφορους δείκτες που έχουν καθιερωθεί. Σαν συμπληρωματικό εργαλείο παρακολούθησης προτείνεται η χρήση του Δείκτη Ικανότητας Εργασίας (Work Ability Index), που είναι ένα ερωτηματολόγιο, το οποίο σταθμίστηκε στα Ελληνικά και εκτιμά γενικά τη λειτουργική ικανότητα των εργαζομένων, όντας άμεσα συνδεδεμένο με τον απουσιασμό ασθενείας. Η ελληνική έκδοση του Δείκτη Ικανότητας Εργασίας έδειξε ικανοποιητικές ψυχομετρικές ιδιότητες και συνοχή, και μπορεί να αποτελέσει μια αξιόπιστη εναλλακτική επιλογή στα εργαλεία αξιολόγησης της ικανότητας εργασίας σε ατομικό και ομαδικό επίπεδο. Ο παράγοντας Bradford είναι ένας ακόμα δείκτης που η προγνωστική του δύναμη όσον άφορα το βραχυπρόθεσμο απουσιασμό φάνηκε σε αυτή τη μελέτη. Προτείνεται επίσης η χρήση και των δυο αυτών δεικτών με την μορφή ενός νέου δείκτη (Δείκτης Πρόβλεψης Πιθανής Απουσίας), για την ανίχνευση εργαζομένων και τομέων εργασίας με αυξημένη πιθανότητα απουσίας για λογούς υγείας τα αμέσως επόμενα χρόνια. Στα πλαίσια της στάθμισης έγινε επίσης φανερό το πρότυπο νοσηρότητας του πληθυσμού των ναυπηγείων, όπου κυριαρχούν οι μυοσκελετικές και αναπνευστικές παθήσεις μαζί με το τραύμα, ενώ τη μεγαλύτερη επίδραση στην ικανότητα εργασίας φαίνεται να έχουν οι καρδιαγγειακές και ψυχικές παθήσεις. Αναδείχτηκε επίσης η υποδιάγνωση των ψυχικών παθήσεων, που είναι ένα γενικότερο πρόβλημα στην Ελλάδα. Οι ραδιοτεχνίτες και οι φλογοχειριστές φαίνονται να εμφανίζουν τα μεγαλύτερα επίπεδα απουσιασμού. Οι παράγοντες που βρέθηκαν να συσχετίζονται θετικά με αυξημένα επίπεδα απουσιασμού είναι η μικρή ηλικία, οι χειρωνακτικές εργασίες, το χαμηλό επίπεδο εκπαίδευσης και η εργασιακή εμπειρία άνω των 3 ετών. Συμπερασματικά, χρειάζονται περαιτέρω μελέτες για να κατανοηθεί πλήρως ο απουσιασμός ασθενείας, σε όλους τους εργασιακούς τομείς και βεβαίως εκπαίδευση του ιατρικού προσωπικού στο θέμα της χορήγησης αναρρωτικών αδειών, όπου θα βοηθούσε η χρήση εργαλείων όπως αυτά που μελετήθηκαν σε αυτή τη διατριβή(πχ Disability Guidelines), και ήδη βρίσκουν εφαρμογή σε άλλες χώρες. / The aim of this study was to estimate the levels and analyse sickness absence in the private sector in Greece, using shipyard and national insurance data. Field data were collected in a cohort of shipyard employees in the period between 1999 and 2006. In addition, national sickness absenteeism data (compensated days) of employees insured at the Social Insurance Institute (IKA, the largest insurance scheme in Greece) were retrieved from the Institute’s annual statistical reports for the period 1987-2006. Low levels of sickness absence in the private sector in Greece have been confirmed by this study, although the findings show that sickness absence in Greece is slightly higher than what the recent international comparative studies indicate. The absenteeism rate was 2.5%, which is one of the lowest in Europe. Nevertheless, due to the fact that it involves working hours which differ from one country to another, it is not often used in the studies despite being the most valid indicator of absence. The average duration of absence for every employee per year was 5.8 days (maximum number was 8 days towards the end of the study). In Europe, the average number of days of sickness absence exceeded 10 days. An interesting finding is the fact that short period absences (<4 days) constituted 25% of the total duration of absences, which could not be calculated until now by the national statistical data of the Social Insurance Institute (IKA). While studying the data of IKA of the last two decades, a sinusoidal-like trend was recorded regarding absenteeism. Declining trend by the end of the 1990s was observed, in accordance with previous studies and then an increasing trend, although at the end of the study period the levels remained lower than those at the beginning. Further research is needed concerning the observations of this study since the low absenteeism levels can only be partially attributed to the low compensation rate in case of sick-leave or to the high levels of unemployment. The primary objective should always be health preservation and promotion of the employees by means of the best possible working conditions. As both working conditions and employees’ health are dynamic situations, monitoring tools are required. Sickness absence should always be monitored by the occupational health physician as well as the employer, using the various established tools. The use of Work Ability Index is recommended as an additional monitoring tool. It is a questionnaire, directly linked to sickness absence, which generally evaluates the employees’ functional ability. The Greek version of Work Ability Index displayed satisfactory psychometric properties and consistency thus constituting an appropriate option for evaluating work ability in both individual and population-based settings. The Bradford factor is another index whose prognostic strength concerning short-term absenteeism was evident in this study. The use of both these tools in the form of one new index (Sickness Absence Probability Factor) is also recommended in order to identify employees and work areas with an increased tendency for sickness absence. During the validation process, the morbidity pattern of the shipyard population also became obvious. Musculoskeletal, respiratory diseases as well as trauma are most prevalent, whereas cardiovascular and mental diseases seem to have the biggest impact on work ability. The underdiagnosis of mental diseases was also revealed, which is a general problem in Greece. Radiomen and flame-cutters seem to have the highest levels of absence, while the factors which were found to be positively linked to high levels of absenteeism are young age, manual labor, low educational level and working experience over 3 years. In conclusion, further research is necessary to fully describe and understand the phenomenon of sickness absence in various work fields. Medical staff training in the area of issuing sick-leave is essential and has already been implemented in other countries. Tools, like the ones studied in this dissertation should be utilized.

Made available in DSpace on 2016-06-02T20:18:18Z (GMT). No. of bitstreams: 1 TeseIAPW.pdf: 1512962 bytes, checksum: fa65d9db2288861ce39f29eb99b3533c (MD5) Previous issue date: 2004-12-02 / Work-related musculoskeletal disorders (WRMDs) are diseases that result in persistent pain, loss of functional capacity and associated work disability. This diagnostic is important because it is used to guide clinical and legal decisions. Their initial diagnosis is difficult because such diagnoses are based on complaints of pain and they often involve conflicting social and economic interests. Because of the complexity of such diagnoses, further studies are needed in order to analyze the association between subjective descriptions and objective findings. Therefore was made two research. The objective of the first research was to evaluate the impact of personal, clinical and occupational aspects on work ability of workers with and without WRMDs using an approved version of the Work Ability Index (WAI) and pain scale. This evaluated 127 workers of industrial production lines. A descriptive analysis was carried out using the Chi-square test and it was also performed a logistic regression analysis. A significant association was identified between the WAI and all personal, clinical and occupational aspects. Regression analysis showed that pain and sick leave together accounted for 59% of poor work ability. The objective of the second research was to evaluate the clinical and functional aspects of WRMDs, in relation to physical evaluation, perception of pain, self-reporting of symptoms and functional ability, among active workers at a single company with and without symptoms or evidence of this disorders. 134 female workers were physically evaluated by two trained physiotherapists. They filled out a questionnaire on discomfort due to pain, a pain scale, the Oswestry Disability Questionnaire (ODQ) and the Work Ability Index (WAI). The results were correlated and logistic regressions were run. According to the results symptom reports were explained by the results from the pain scale and the clinical findings and clinical findings by symptom reports and WAI. In two research the relationship between pain, symptom reports and clinical findings demonstrates that the patient s current state can be assessed not only by means of objective examinations, but also by means of instruments that take into account the patient s perception of his or her state. / Os distúrbios ostemusculares relacionados ao trabalho (DORT) podem resultar em dor crônica, diminuição da capacidade funcional e associada incapacidade para o trabalho.Seu diagnóstico é importante pois direciona as decisões clínicas e legais. No entanto, essas lesões apresentam desafios para seu diagnóstico e prognóstico, uma vez que envolvem indicadores subjetivos, porque há fatores de interesses sociais e econômicos envolvidos. Em função desta complexidade, mais estudos são necessários para analisar a associação entre relatos subjetivos e achados objetivos. Desta forma foram realizados dois estudos. O objetivo do primeiro foi avaliar o impacto de fatores pessoais, do trabalho e da lesão na capacidade funcional dos trabalhadores com e sem história de acometimento de lesões músculo-esqueléticas relacionadas ao trabalho, utilizando a aplicação autorizada do Índice de Capacidade para o Trabalho (WAI) e escala de dor. Este avaliou 127 trabalhadores de linhas de produção industrial. Os resultados foram analisados descritivamente, por meio do teste Qui-quadrado e pela análise de regressão logística. Todos os fatores pessoais, ocupacionais e clínicos analisados apresentaram relação significativa com a capacidade para o trabalho. A análise de regressão mostrou que dor e afastamento do trabalho explicaram juntas 59% da baixa capacidade para o trabalho. O objetivo do segundo estudo foi avaliar os aspectos clínicos e funcionais dos DORT, em relação a avaliação clínica, percepção da dor, auto-relato de sintomas e capacidade funcional através da avaliação de trabalhadores de uma mesma empresa, com sem sintomas de DORT. 134 mulheres foram fisicamente avaliadas por dois fisioterapeutas treinados e responderam a um questionário relacionado a sensação de dor ou desconforto, escala de dor, questionário de incapacidade de Oswestry (ODQ) e índice de capacidade para o trabalho (WAI). Os resultados foram correlacionados e a análise de logística foi aplicada. Os resultados indicaram que relatos de sintomas foram explicados pela escala de dor e exame clínico e o exame clínico foi explicado pelos relatos de sintomas e WAI. As associações entre dor, relatos de sintomas e exame clínico, demonstraram que o estado atual do paciente pode ser avaliado não somente por exames objetivos mas também por meio de instrumentos que levem em conta a percepção do próprio paciente sobre seu estado.