The influence of medical work leaves in the perception of health and quality of life of adult individuals

98 The influence of medical work leaves in the perception of health and quality of life of adult individuals A influência do afastamento do trabalho na percepção de saúde e qualidade de vida de indivíduos adultos La influencia del alejamiento del trabajo en la percepción de salud y calidad de vida de individuos adultos Fabiana Caetano Martins Silva e Dutra1, Letícia Cardoso Costa2, Rosana Ferreira Sampaio3


INTRODUCTION
Work is an essentially human activity that dignifies life in its personal and social aspects, and intermediates the relationship between man and society.It is through the action of work that human kind transforms the environment so that it meets its needs 1 .Such transformation carries considerable influence on workers, their health, satisfaction, and productivity, and generates significance with central role in the buildup of the individual identity and the various forms of social inclusion [1][2][3] .
However, inadequacies of work are responsible for illness processes and may temporarily or permanently limit the life of the worker, restricting their social participation, and consequently their quality of life.Studies show that health is influenced by socioeconomic status, and is related to quality of life and the different work conditions [4][5][6] .There is consensus that working in unfavorable conditions causes damage, exposing the worker to occupational diseases, dissatisfaction at work, and restrictions on quality of life 7 .
Nonetheless, non-insertion in the labor market also results in many losses for the individuals, their family, and the community.The absence of work leads the worker to rely on third parties for their livelihood, in addition to feelings of failure and low productivity 8 .A qualitative study with workers in rehabilitation process showed that leaves, unemployment, or retirement can cause suffering associated with the loss of the social role as a worker 9 .Thus, the restriction of labor activities influences the quality of life, with the individual outside the labor market being also excluded from other social networks, and inserted into a vulnerabilization path 4 .
In this context, it becomes essential, to promote and maintain the quality of life of the individuals, to adopt preventive measures and effective access to jobs; and interventions that minimize the occurrence of accidents and diseases arising from labor activity, benefiting the worker's capacity and decreasing unemployment and medical leaves.Currently, Brazil bases the worker's health actions at all levels of the Brazilian Unified Health System (SUS) service through the National Network of Integral Attention to the Health of the Worker (RENAST), integrating a network of assistance services, surveillance, and development of actions related to the worker's health 10 .RENAST becomes effective through the Reference Centers of Occupational Health (CEREST), whose objective is to change the morbidity and mortality profile, using an epidemiological approach with actions for health surveillance, outpatient care, and health-related educational activities.
Therefore, analyzing the quality of life empirically allows identifying different aspects of the worker's life, in addition to indicating possible strategic areas of intervention that help maintain health, provide security, direct investments in employment policies, and improve the functionality and productivity of the worker.On the above, the objective of this study was to investigate and compare the perception of health and quality of life of active workers and workers on leave attended by the public health services in the city of Uberaba, Minas Gerais, Brazil.

METHODOLOGY
This study was carried out in a cross-sectional observational perspective, using a quantitative approach, approved by the Research Ethics Committee of the Triângulo Mineiro Federal University (opinion no.2394).All participants were informed about the goals and procedures of data collection, and those who agreed to participate voluntarily in the study signed an informed consent form.
The estimation of sample size considered a confidence level of 95%; a maximum desired error of three points; and an average standard deviation estimated in a pilot study equal to 15.5 points, totaling a minimum sample of 103 individuals.Inclusion criteria were adults of both sexes between 18 and 60 years old.Participants should be workers, regardless of the current situation in the labor market (active, on leave or unemployed) and the type of contract (formal or informal), and they should be attended by one of the health units of the city.Those who showed no willingness to participate in the study, presented conditions that prevented understanding or trustworthiness of their answers, and according to self-reports never developed formal or informal work activities were excluded.
Thus, for convenience, the sample was composed by 111 workers being attended in the public health network in the city of Uberaba, Minas Gerais, Brazil, between March and October 2014.The territorial health system map in Uberaba is divided into three Health Districts, and the basic network is organized into 17 Family Health Units, 2 Basic Units, and 9 Matrix Health Units 11 .This research was undertaken in 9 health units (basic and family units) chosen at random, respecting the minimum of three units per health district and the participants' evaluation occurred at the time of their appointments.
To characterize the participants, social, demographic and occupational information were collected in a questionnaire developed for this study, comprised by issues such as sex, age, marital status, education, current occupation and time on that occupation, income, number of depending people in the house, main diagnosis, current work situation, and for those who were on leave, the time on leave.
The sample was divided into two groups: one consisting of active workers and another composed of workers away from the labor market.The workers on leave by the National Social Security Institute, unemployed or retired were considered out of laboring activities.
The self-assessment of health was measured by the question: "How would you rate your overall health in the last 30 days?"A likert-type scale of five points was used as a response option, with categories ranging from very good to very bad.Subsequently, very good and good categories were added, as well as regular, bad, and really bad categories.
In the evaluation of quality of life the questionnaire "Medical Outcomes Study 36 items" (SF-36) was used, a generic assessment of health translated and validated to Portuguese by Ciconelli et al. 12 The SF-36 is composed of 36 questions that measure eight areas related to quality of life, namely: functional capacity, physical appearance, pain, general health, vitality, social, emotional, and mental health aspects.The functional capacity domain relates to difficulties in performing daily activities and the physical aspect refers to physical activities.The pain domain relates to the perception of pain, and general health refers to the general health conditions of the individual.The vitality domain refers to the stamina, energy, exhaustion, and tiredness, and the social aspect relates to social activities.Now, the emotional aspect is related to the emotional problems, as well as to mental health, depression, and nervousness domains 12 .Each domain has a score ranging from 0 (zero) to 100 (one hundred), and the closest to 0, the worse the quality of life, and the closer to 100, the better the quality of life 12 .
Data collected was subjected to a descriptive analysis and normality test.For the comparison of perception on health between active and inactive workers, the Chisquare test was used, and the Mann-Whitney U test was used to compare the quality of life.In all statistical tests a significance level of 5% was considered, and the analyses were performed using the SPSS software version 20.0.

RESULTS
The sample was composed of 111 workers averagely aged 36 years (SD=13.40),and 63.1% were female.The majority of respondents had completed high school (33.3%), and was single (48.6%).Seventy-seven workers were active in the labor market and 34 were on leave.The time in occupation ranged from 1 to 480 months, while the workers who were on leave showed an average of 2.85 months on leave (SD=11.27).The family income of workers obtained a median of BRL 2,500.00(minimum of BRL 550.00 and maximum of BRL 12,000.00).Table 1 presents all the social demographic information in detail.In general, respondents worked in activities related to the economic sectors of trade and services.Most of the respondents worked as salesmen (16), receptionists (9), and health professionals (9), followed by teachers (7), administrative assistants (6), general services clerks (6), and concierges (5). Figure 1 presents the complete distribution of occupations of the interviewed workers.
Of the total respondents, 85 (76.6%) rated their health as very good or good, while 26 (23.4%) self assessed their health as regular, bad, or very bad.When analyzing only the active workers group, 68 had a positive perception of their health, and 9 self-evaluated their healths as regular, bad, or very bad.Now, among the workers on leave, 17 assessed their health as very good or good, while 17 showed a negative health perception.When comparing the self health assessment between groups of workers, there was a statistical difference (c 2 = 19.3;p=0.000) indicating that participants who were active at work had a better health perception than workers on leave.Concerning the quality of life outcome, the functional capacity domain presented average scores of 85.49 (SD=17.08),this being the best rated domain among workers, followed by the social domain, averaging 76.01 points (SD=27.08).The general state of health presented an average score of 74.16 (SD=18.58),while the results of the pain domain were 71.05 (SD=24.38).For mental health and physical appearance, the average final score was 70.19 (SD=15.36),and 69.14 (SD=38.72),respectively.Finally, the vitality domain presented an average of 65.94 (SD=17.16)and the emotional aspect an average of 61.56 points (SD=41.97),this being the worst score among the quality of life domains.
When comparing the quality of life of active and on leave workers, the latter presented a significantly worse quality of life than active workers for the following domains: functional capacity (p=0.000),physical aspect (p = 0.000), pain (p = 0.002), general state of health (p = 0.011), social aspect (p = 0.000), emotional aspect (p = 0.000), and mental health (p = 0.023).Table 2 presents mean values and standard deviations in the quality of life separately for active and on leave workers, as well as the results of the comparison between the quality of life of the two groups of workers.

DISCUSSION
The findings point to an association between working and a better quality of life and health perception.The ability to evaluate and compare the quality of life for active workers and workers who are out of the labor market allows to demonstrate how the involvement and participation in laboring activities can have a positive influence on the perception of health and quality of life of the adult population.
In this study, we observed a predominance of women among participants that can be associated to the locations where the data was collected, such as basic health units.The pattern of demand and use of health services by the Brazilian population is determined by different factors when comparing men and women, and the predominant use by women is attributed to factors such as reproducibility, age, worse health perception, as well as to a higher incidence of non-fatal chronic diseases 13 .
Respondents had higher family income and level of education when compared to the rest of the Brazilian population.The median family income found in this sample (BRL 2,500.00)was greater than the individual income pointed by the Brazilian Institute of Geography and Statistics (IBGE) 13 (BRL 1,441.00)for the average monthly income of Brazilians residing in the Southeast region and living in urban areas.The 2010 Census 14 indicates that 40.52% of the economically active population in Uberaba, Minas Gerais, Brazil, has a wage income above three minimum wages.A possible explanation of the use of public services by workers with this income is the way the provision of these services is organized in the city.In Uberaba, most health establishments that offer primary and tertiary attention belong to the public service, and thus, are the only health care options for all income ranges of the population 14 .
As noted, most of the participants work in labor activities of the service and trade sectors.The city of Uberaba is a well-known university and service offering pole serving 27 cities in the Macro Region of the South Triangle, and its economically active population is divided according to the regional trend of providing more vacancies just in these sectors 15 , with the services segment being responsible for the greater portion of the financial activities in the city (58.03%), followed by industry (32.8%), and agriculture (9.17%) 15 .
Similarly, health conditions reported by workers who participated in this study follow the trend found in the literature, showing the most prevalent chronic diseases in the adult Brazilian population 16 .
In this sample, 30% of the workers were on leave from the labor market.In Brazil, in 2011, the number of workers away from their labor activities due to illnesses or accidents arising from work activities was 611,576 for temporary absences, and 14,811 for permanent incapacity, causing large consequences on public health with approximate expenses of BRL 63.6 billion 16 .Regarding unemployment, Moretto and Proni 17 stressed that after the global financial crisis in September 2008 the number of unemployed workers nearly doubled, causing negative impacts on the national economy.
According to the results, the perception of health and quality of life of workers on leave from labor activity was significantly worse when compared to the one from the active workers.Several studies have investigated the quality of life for workers in the labor market and in specific occupational groups, such as bank clerks 18 , fire figthers 19 , dentists 20 , motorcycle taxi drivers 21 , public service workers 22 , teachers 23 , and health care professionals 24 , among others.However, in national literature, few investigations analyze the perception of health from workers and the impact of being out of work on the quality of life of the individual.
Hultman 25 found similar results, showing that active workers presented best aspects of health when compared to individuals outside the labor market that shpwed a poorer quality of life.Other studies confirm the results, providing evidence that being away from the labor market, as well as long periods of leaves are stress factors that are detrimental to the well-being of individuals, negatively influencing their quality of life 26 .Alavinia and Burdorf 27 comparing the health status between employed and unemployed workers have shown that a negative health perception was strongly associated with the non-participation of respondents in the workforce.In this study still, chronic illnesses such as depression, stroke, diabetes, chronic lung disease, and musculoskeletal diseases were significantly more common among the workers on leave 27 .Regarding long-term unemployment, it is associated with high mortality, worse general health state, and high health care costs 26,28 .
To Waddell and Burton 28 , working is usually the most important means of achieving well-being and full participation in society, taking into account the important psychosocial needs for individual identity, social roles, and social status.On the other hand, there is strong association between the lack of work and health problems, showing that unemployment is harmful, if binding to higher mortality; worse overall health; increased prevalence of chronic diseases; the presence of functional limitations; worst mental health and increased distress 9,28 .In this sense, adults should remain or be reassigned at work to minimize the physical, mental, and social effects of work absence, reducing not only the incapacity risk and of developing chronic diseases, but promoting an improvement in life quality and well-being.
Some factors can represent limitations present in this study, and need to be discussed.The cross-sectional outlining points to association between perception of health, quality of life and work, however it is not possible to establish a causal relationship between the variables investigated.The sample presents education and aboveaverage income of Brazilian population served by public health services, so generalizations to other populations should be made with caution.However, this study gains relevance when it explores the influence of not working on health care, and incorporates different workers occupations and diagnostics.Traditionally, the various researches in the area of worker's health feature analysis towards the work-related illness generated in specific occupations.

CONCLUSION
This study points to the importance of the work for the quality of life and the perception of health of adults in productive age.The findings presented show a decreased quality of life and of the health perception of workers on leave.The comparison of health perception and quality of life among active and on leave workers reiterates the need to promote full inclusion of adults in laboring activities, once the worst health perception and quality of life in the general population is a strong predictor of morbidity and mortality.The results described have direct implications on the economic and social policies that should encourage employment and provide assistance in terms of returning to work to fight the negative effects of the exclusion from the labor market.

Table 1 .
Social demographic and occupational data of the workers interviewed (n=111).Uberaba-Minas Gerais state, 2015

Table 2 .
Comparison of quality of life by the SF-36 among the groups of active and on leave workers (n=111).Uberaba, Minas Gerais, Brazil, 2015 continues...