Introdução: Câncer de mama é o mais comum em mulheres. Embora sua incidência ainda esteja em ascensão, as taxas de recorrência e mortalidade têm diminuído, em especial nos países desenvolvidos. Assim o câncer pode ser considerado um choque transitório que não impede que os sobreviventes retomem a normalidade em suas vidas, incluindo atividades laborais. Na América do Norte e Europa, as taxas de RT entre as pacientes com câncer de mama variam de 24-66% após 6 meses e 53-82% após 36 meses de diagnóstico. Os fatores mais associados ao RT são: idade, quimioterapia, sequelas da terapia do câncer e apoio do empregador e colegas de trabalho. Esses achados, no entanto, variam sugerindo que outros fatores e até aspectos de diferentes legislações podem interferir no RT. Na América Latina há escassez de dados sobre RT após o diagnóstico de câncer de mama. Objetivos: Avaliar as taxas de retorno ao trabalho nos meses 12 e 24 após o diagnóstico de câncer de mama e verificar a correlação de fatores à retomada ao trabalho aos 24 meses. Métodos: Estudo prospectivo observacional avaliando taxas de RT em mulheres com câncer de mama tratadas no Instituto do Câncer do estado de São Paulo, com idade > 18 e < 57 anos e que trabalhavam de forma remunerada por pelo menos 03 meses ao diagnóstico. Pacientes com doença inoperável ou metastática foram excluídas. Nos meses 06, 12 e 24 do seguimento responderam à questionários do estudo e de qualidade de vida (FACT-B), por telefone. Resultados: Entre julho/2012 e setembro/2014, 125 pacientes assinaram o TCLE. Quatro foram excluídas da análise (02 óbitos e 02 sem contato por telefone). A idade média foi de 45.1 anos (± 8,1). A maioria (94%) gostava do trabalho, 73% receberam apoio do empregador, mas apenas 29% relataram ter recebido oferta de ajuste no trabalho. Metade apresentava doença no estádio II e 93% fizeram quimioterapia como parte de seu tratamento. As taxas de RT foram 21,5%, 30,3% e 60,4% aos 06, 12 e 24 meses, após o diagnóstico de câncer de mama. Na análise multivariada os fatores que afetaram de forma positiva as taxas de RT foram: renda familiar mensal >= 02 salários mínimos (OR 17,76, IC95% 3,33-94,75, p 0,001), cirurgia conservadora da mama (OR 9,77, IC 95% 2,03-47,05, p 0,004) e oferta de ajuste no trabalho pelo empregador (OR 37,62, IC95% 2,03-47,05, p 0,004). Fatores que se associaram de forma negativa ao RT foram: terapia endócrina (OR 0,11, IC95%0,02-0,74, p 0,023) e diagnóstico de depressão após o câncer (OR 0,07, IC95% 0,01-0,63, p 0,017). Conclusões: As taxas de RT aos 12 e 24 meses após diagnóstico de câncer de mama são inferiores a maioria dos estudos conduzidos na América do Norte e Europa. Oferta de ajuste no trabalho, maior renda familiar, cirurgia conservadora da mama, terapia endócrina adjuvante e diagnóstico de depressão após o câncer de mama desempenharam importante papel no RT / Background: Breast cancer is the most common cancer in women. While its incidence has been increasing, recurrence and mortality rates have been decreasing, mainly because of better treatment options. Because of that cancer can be regarded as a transient shock that does not prevent survivors resume normality in their lives including return to their workplace. In North America and Europe return to work (RTW) rates vary among breast cancer patients from 24- 66% after 06 months and 53-82% after 36 months of diagnosis. Factors most associated with the decision to return to work are: age, chemotherapy, sequelae related to cancer therapy and support from the employer and coworkers. However, these findings vary among the different populations evaluated, suggesting that other factors and even variations in countries laws may interfere with the decision to return to work. So far there is a lack of data on RTW after breast cancer diagnosis in Latin America. Endpoints: To evaluate return to work rates on months 12 and 24 after breast cancer diagnosis, and check the correlation of some factors with the decision to return to work at 24 months. Methods: A prospective, observational study evaluating RTW rates in patients with breast cancer diagnosis, > 18 and < 57 years old and a paid work for at least 03 months at the time of dianosis. Patients with inoperable or metastatic disease were excluded. On months 6, 12 and 24 they answered a telephone interview and the quality of life questionnaire (FACT-B). Results: Between july/2012 and september/2014, 125 patients were enrolled. Two of them died and two other could not be reached by telephone, and were excluded from the analysis. Mean age was 45,1 years (± 8,1). Most of them reported that they liked their job (94%) and received support from employer (73%), but only 29,1% reported having been offered work adjustment. Half of patients had stage II disease and 93% received chemotherapy as part of their treatment. Overall, 21,5%, 30,3% and 60,4% of patients returned to work 06, 12 and 24 months after breast cancer diagnosis, respectively. In the multivariate analysis, factors associated with positive RTW outcomes included higher income (OR: 17,76, CI95% 3,33-94,75; p = 0,001), breast conserving surgery (OR: 9,77, CI95% 2,03-47,05; p = 0,004) and work adjustment (OR: 37,62, CI95% 2,03-47,05; p= 0,004). Factors associated with negative RTW outcomes included adjuvant endocrine therapy (OR: 0,11, IC95% 0,02-0,74; p = 0,023) and depression diagnosis after breast cancer diagnosis (OR: 0,07, IC95% 0,01-0,63; p = 0,017). Conclusion: RTW rates after 12 and 24 months of breast cancer diagnosis are lower than reported in North America (with exception for low income americans) and Europe. Workplace adjustments, higher income, breast conserving surgery, endocrine therapy and depression after breast cancer played an important role in the RTW decision

The background to this thesis is the dramatic increase of the long-term sickness absence that took place in Sweden from the late 1990s. There was also a shift in the diagnostic pattern with rising mental diagnoses. The overall purpose was to describe and try to understand the process leading to long-term sickness absence from the perspective of the sickness absentees, in order to get a better knowledge base for preventive and rehabilitative actions. The thesis comprises four studies (I-IV). Research methods have been both qualitative and quantitative. In study I data from individual interviews with 32 persons on long-term sick leave due to burnout was analyzed using a grounded theory approach. In study II the study population comprised of 2064 employed sick-listed persons, a sub sample derived from the 2002 national Swedish survey on health, working conditions, life situation and sick-listing. It was analyzed if persons with burnout had higher probability of having experienced the steps in the burnout staircase compared to other diagnostic groups in accordance with the previously suggested hypothesis of "the burnout staircase". Study III comprised of 2521 employed persons, a sub sample derived from the same national survey as in study II. It was analyzed if psychosocial work environment and conflicts and losses in private life independently or in combination were more strongly associated to sickness absence with mental diagnoses as compared to a healthy population. In study IV individual interviews with 25 professional rehabilitation actors and 14 unemployed sick-listed persons were conducted. Data were analyzed according to grounded theory method. The process that led to sicknes absence can be described as an emotional deprivation process, illustrated as a flight of stairs (the burnout staircase) describing a sequence of steps toward sickness absence (I). In accordance with the tested hypothesis persons with burnout to a noticeable higher extent reported expereince of being in the different steps in the burnout staircase compared to sickness absentees with other diagnoses. The model seemed to be valid also for persons with other mental diagnoses (II). Reorganization and conflicts at work as well as adding adverse private life events were associated with increased risk for sickness absence with mental diagnosis (III). Three significant factors behind the weak co-operation between local social insurance and employment agencies were identified: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies (IV). In this thesis it has been suggested that the course of events preceding sickness absence might be understood as a process of emotional deprivation, where the individual is gradually emptied of the life-giving emotional energy revealed in joy, commitment, and empathy. This life-giving force finds its nourishment in safe and secure social relations with others and in a social structure that promotes this type of social relations. The profound changes in the Swedish labour market during the 1990s influenced not just the psychosocial work climate but also the rehabilitation efforts for unemployed sick-listed persons. When the political goal of reducing the unemployment level came to the forefront the indistinct regulation and the conflicting goals in addition were factors that impaired co-ordinated rehabilitation. In this process also the physicians were involved. A labour market problem was turned into a medical problem.

Introdução: Câncer de mama é o mais comum em mulheres. Embora sua incidência ainda esteja em ascensão, as taxas de recorrência e mortalidade têm diminuído, em especial nos países desenvolvidos. Assim o câncer pode ser considerado um choque transitório que não impede que os sobreviventes retomem a normalidade em suas vidas, incluindo atividades laborais. Na América do Norte e Europa, as taxas de RT entre as pacientes com câncer de mama variam de 24-66% após 6 meses e 53-82% após 36 meses de diagnóstico. Os fatores mais associados ao RT são: idade, quimioterapia, sequelas da terapia do câncer e apoio do empregador e colegas de trabalho. Esses achados, no entanto, variam sugerindo que outros fatores e até aspectos de diferentes legislações podem interferir no RT. Na América Latina há escassez de dados sobre RT após o diagnóstico de câncer de mama. Objetivos: Avaliar as taxas de retorno ao trabalho nos meses 12 e 24 após o diagnóstico de câncer de mama e verificar a correlação de fatores à retomada ao trabalho aos 24 meses. Métodos: Estudo prospectivo observacional avaliando taxas de RT em mulheres com câncer de mama tratadas no Instituto do Câncer do estado de São Paulo, com idade > 18 e < 57 anos e que trabalhavam de forma remunerada por pelo menos 03 meses ao diagnóstico. Pacientes com doença inoperável ou metastática foram excluídas. Nos meses 06, 12 e 24 do seguimento responderam à questionários do estudo e de qualidade de vida (FACT-B), por telefone. Resultados: Entre julho/2012 e setembro/2014, 125 pacientes assinaram o TCLE. Quatro foram excluídas da análise (02 óbitos e 02 sem contato por telefone). A idade média foi de 45.1 anos (± 8,1). A maioria (94%) gostava do trabalho, 73% receberam apoio do empregador, mas apenas 29% relataram ter recebido oferta de ajuste no trabalho. Metade apresentava doença no estádio II e 93% fizeram quimioterapia como parte de seu tratamento. As taxas de RT foram 21,5%, 30,3% e 60,4% aos 06, 12 e 24 meses, após o diagnóstico de câncer de mama. Na análise multivariada os fatores que afetaram de forma positiva as taxas de RT foram: renda familiar mensal >= 02 salários mínimos (OR 17,76, IC95% 3,33-94,75, p 0,001), cirurgia conservadora da mama (OR 9,77, IC 95% 2,03-47,05, p 0,004) e oferta de ajuste no trabalho pelo empregador (OR 37,62, IC95% 2,03-47,05, p 0,004). Fatores que se associaram de forma negativa ao RT foram: terapia endócrina (OR 0,11, IC95%0,02-0,74, p 0,023) e diagnóstico de depressão após o câncer (OR 0,07, IC95% 0,01-0,63, p 0,017). Conclusões: As taxas de RT aos 12 e 24 meses após diagnóstico de câncer de mama são inferiores a maioria dos estudos conduzidos na América do Norte e Europa. Oferta de ajuste no trabalho, maior renda familiar, cirurgia conservadora da mama, terapia endócrina adjuvante e diagnóstico de depressão após o câncer de mama desempenharam importante papel no RT / Background: Breast cancer is the most common cancer in women. While its incidence has been increasing, recurrence and mortality rates have been decreasing, mainly because of better treatment options. Because of that cancer can be regarded as a transient shock that does not prevent survivors resume normality in their lives including return to their workplace. In North America and Europe return to work (RTW) rates vary among breast cancer patients from 24- 66% after 06 months and 53-82% after 36 months of diagnosis. Factors most associated with the decision to return to work are: age, chemotherapy, sequelae related to cancer therapy and support from the employer and coworkers. However, these findings vary among the different populations evaluated, suggesting that other factors and even variations in countries laws may interfere with the decision to return to work. So far there is a lack of data on RTW after breast cancer diagnosis in Latin America. Endpoints: To evaluate return to work rates on months 12 and 24 after breast cancer diagnosis, and check the correlation of some factors with the decision to return to work at 24 months. Methods: A prospective, observational study evaluating RTW rates in patients with breast cancer diagnosis, > 18 and < 57 years old and a paid work for at least 03 months at the time of dianosis. Patients with inoperable or metastatic disease were excluded. On months 6, 12 and 24 they answered a telephone interview and the quality of life questionnaire (FACT-B). Results: Between july/2012 and september/2014, 125 patients were enrolled. Two of them died and two other could not be reached by telephone, and were excluded from the analysis. Mean age was 45,1 years (± 8,1). Most of them reported that they liked their job (94%) and received support from employer (73%), but only 29,1% reported having been offered work adjustment. Half of patients had stage II disease and 93% received chemotherapy as part of their treatment. Overall, 21,5%, 30,3% and 60,4% of patients returned to work 06, 12 and 24 months after breast cancer diagnosis, respectively. In the multivariate analysis, factors associated with positive RTW outcomes included higher income (OR: 17,76, CI95% 3,33-94,75; p = 0,001), breast conserving surgery (OR: 9,77, CI95% 2,03-47,05; p = 0,004) and work adjustment (OR: 37,62, CI95% 2,03-47,05; p= 0,004). Factors associated with negative RTW outcomes included adjuvant endocrine therapy (OR: 0,11, IC95% 0,02-0,74; p = 0,023) and depression diagnosis after breast cancer diagnosis (OR: 0,07, IC95% 0,01-0,63; p = 0,017). Conclusion: RTW rates after 12 and 24 months of breast cancer diagnosis are lower than reported in North America (with exception for low income americans) and Europe. Workplace adjustments, higher income, breast conserving surgery, endocrine therapy and depression after breast cancer played an important role in the RTW decision

Cette thèse doctorale poursuit l’objectif de mieux comprendre le rôle joué par la profession réglementée en tant que déterminant de la détresse psychologique de la population en emploi au Québec et au Canada. Ceci, dans un contexte où plusieurs ordres professionnels représentant des professions réglementées, s’inquiètent de la santé mentale de leurs membres et de la pression considérable exercée sur eux dans une économie caractérisée par des pénuries de main-d’oeuvre importantes. Cette thèse fut également inspirée par les nombreuses limites constatées à la suite d’une revue de la littérature sur la santé mentale au travail, alors que les risques différenciés auxquels seraient soumis ces professionnels, comparativement à l’ensemble de la population en emploi, demeurent largement à documenter. La profession réglementée s’associe-t-elle directement à l’expérience de détresse psychologique? Quelles sont les conditions de travail susceptibles de conduire au développement ou à l’aggravation de la détresse psychologique pour ces professions? Dans le but de mieux comprendre le rôle joué par la profession réglementée en matière de détresse psychologique, nous avons eu recours à un modèle théorique multidimensionnel qui postule que les contraintes et les ressources découlent d’un ensemble de structures sociales incluant la profession, le travail, la famille, le réseau social hors-travail et les caractéristiques personnelles. Ce modèle découle des théories micro et macro en sociologie (Alexander et al., 1987; Ritzer, 1996), de l’approche agent-structure(Archer, 1995; Giddens, 1987) ainsi que de la théorie du stress social (Pearlin,1999). Trois hypothèses sont soumises à l’étude à travers ce modèle. La première hypothèse, est à l’effet que la profession réglementée, les conditions de travail, la famille ainsi que le réseau social hors-travail et les caractéristiques individuelles, contribuent directement et conjointement à l’explication du niveau de détresse psychologique. La seconde hypothèse induite par le modèle proposé, pose que le milieu de travail médiatise la relation entre la profession réglementée et le niveau de détresse psychologique. La troisième et dernière hypothèse de recherche, postule enfin que la relation entre le milieu de travail et le niveau de détresse psychologique est modérée par les caractéristiques individuelles ainsi que par la famille et le réseau social hors-travail. Ces hypothèses de recherche furent testées à partir des données longitudinales de l’Enquête nationale sur la santé de la population (ENSP) (cycles 1 à 7). Les résultats obtenus sont présentés sous forme de 3 articles, soumis pour publication, lesquels constituent les chapitres 5 à 7 de cette thèse. Dans l’ensemble, le modèle théorique proposé obtient un soutien empirique important et tend à démontrer que la profession réglementée influence directement les chances de vivre de la détresse psychologique au fil du temps, ainsi que le niveau de détresse psychologique lui-même. Les résultats indiquent que les professions réglementées sont soumises à des risques différenciés en termes de conditions de travail susceptibles de susciter de la détresse psychologique. Notons également que la contribution du milieu de travail et de la profession réglementée s’exerce indépendamment des autres dimensions du modèle (famille, réseau social hors-travail, caractéristiques personnelles). Les résultats corroborent l’importance de considérer plusieurs dimensions de la vie d’un individu dans l’étude de la détresse psychologique et mettent à l’ordre du jour l’importance de développer de nouveaux modèles théoriques, mieux adaptés aux contextes de travail au sein desquels oeuvrent les travailleurs du savoir. Cette thèse conclue sur les implications de ces résultats pour la recherche, et sur les retombées qui en découlent pour le marché du travail ainsi que pour le développement futur du système professionnel québécois et canadien. / This doctoral thesis aims to understand the role played by the regulated occupations as a determinant of psychological distress of the working population in Quebec and Canada. This, in a context where several professional organizations, representing regulated occupations, are concerned about the mental health of their members and the pressure exerted on them in an economy characterized by important shortages of labor. This thesis was also inspired by the many limitations observed after a literature review on work and mental health, whereas the differentiated risks which would be subjected to these professionals, compared to the total working population, remains largely undocumented. Is there a direct link between the regulated occupation and the experience of psychological distress? What working conditions contribute to the development or accentuate psychological distress for these regulated occupations? In order to better understand the role played by the regulated occupations in psychological distress, this thesis proposes a multidimensional theoretical model which postulates that the constraints and resources are generated by a set of social structures including the regulated occupation, the working conditions, family, social network outside of work and personal characteristics. This model stems from the micro and macro theories in sociology (Alexander et al., 1987; Ritzer, 1996), the agent-structure approach (Archer, 1995; Giddens, 1987) as well as the social stress theory (Pearlin, 1999). Three hypotheses are subject to analysis through the model. The first hypothesis assumes that regulated occupations, work conditions, family, social network outside the workplace, and individual characteristics contribute directly and jointly to explaining the level of psychological distress. The second hypothesis induced by the proposed model postulates that the workplace mediates the relationship between regulated occupations and psychological distress levels. The third and final research hypothesis postulates that the relationship between the workplace and psychological distress levels is moderated by individual characteristics, as well as by family and the social network outside the workplace.These hypotheses have been validated using longitudinal data from the National population health survey (NPHS) (cycles 1 to 7). The results of these analyses are presented in three articles submitted for publication, which are the chapters 5-7 of this thesis. Overall, the theoretical model gets an important empirical support and suggests that the regulated occupations directly influence the chances of living psychological distress over time as well as the level of psychological distress itself. The results also suggest that the regulated occupations are exposed to differentiated risks in terms of working conditions likely to generate psychological distress. The contribution of the workplace and regulated occupations is exercised independently of other dimensions of the model (family, social network outside of work, personal characteristics). The results also corroborate the importance in considering many dimensions of the life of an individual in the psychological distress and to put on the agenda the importance of developing new theoretical models, better suited to the realities characterizing today’s working environments in which knowledge workers work. This thesis concludes on the implications of these findings for research, and the benefits it brings to the labor market and for the future development of the professional system in Quebec and Canada.

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