Daniela Bulcão Santi; Ana Rita Barbieri; Maria de Fátima Meinberg Cheade
BACKGROUND: Sickness absenteeism involving civil servants impairs the delivery of essential services to citizens and burdens the public coffers as a function of the interruption of services or of the expenses posed by the rehabilitation of employees.
OBJECTIVE: To analyze Brazilian studies on sickness absenteeism within the public service, as well as strategies suggested for prevention and for rehabilitation of civil servants.
METHOD: Integrative review of studies located in electronic databases LILACS and SciELO.
RESULTS: Eight articles met the inclusion criteria. Musculoskeletal and mental and behavioral disorders predominated, affecting health and education workers, with the following main characteristics: female sex and age above 40; the duration of sick leaves increased together with longer length of work.
DISCUSSION: As their job involves provision of assistance, involving direct contact with service users, civil servants tend to exhibit high levels of musculoskeletal and mental wear. High demands and the precariousness of public service work contribute to the employees' vulnerability. The suggested strategies stress the relevance of the workers' agency for the development of their health process.
CONCLUSION: Sickness absenteeism represents a potential indicator of illness and work conditions. Prevention and rehabilitation strategies are needed in policies on workers' health targeting civil servants.
Keywords: absenteeism; public sector; sick leave.
INTRODUÇÃO: O absenteísmo-doença no serviço público afeta a entrega de serviços essenciais aos cidadãos e onera os cofres públicos devido à interrupção da prestação do serviço ou às despesas para a reabilitação do servidor.
OBJETIVO: Analisar estudos nacionais sobre o absenteísmo-doença no serviço público e as estratégias propostas para prevenção contra doenças e reabilitação do servidor público.
MÉTODO: revisão integrativa, nas bases de dados eletrônicas LILACS e SciELO.
RESULTADOS: Oito artigos atenderam aos critérios de inclusão. Houve predomínio de doenças osteomusculares (DOM) e transtornos mentais e comportamentais (TMC), evidenciados em servidores das áreas da saúde e da educação, com as características principais: sexo feminino, acima dos 40 anos de idade, com tempo de duração da licença aumentando proporcionalmente ao tempo de carreira.
DISCUSSÃO: Por trabalharem em ocupações assistenciais, que envolvem contato direto com usuários, esses profissionais tendem a apresentar elevado nível de desgastes osteomusculares e psíquicos. A alta demanda e precariedade no setor público colabora para a vulnerabilidade do servidor. As estratégias ressaltam a importância do protagonismo do trabalhador para a evolução do seu processo de saúde.
CONCLUSÃO: Evidenciou-se o absenteísmo-doença como potencial indicador das condições de adoecimento e de trabalho, além da necessidade de estratégias de prevenção e reabilitação em políticas de saúde do trabalhador voltadas ao servidor público.
Palavras-chave: absenteísmo; setor público; licença médica.
Ubiquitous in each and every country, no matter whether their political organization is autocratic or democratic, civil servants represent the link between government and population, and play a crucial role in public policies.
Public service became stronger after World War II, when democracy enabled workers and the middle class increase their demands for social services both gratis and equal for all. In Brazil, a management reform was implemented in the 1990s to administrate such services1. However, such management-centered administration adopted the private management model, which thus influenced the policies, structures and culture of governmental organizations2. As a result, the model of state in force might result in different work conditions within the public service.
While the number of public servants in Brazil increased in the past decade, mainly at the municipal level, their total number is lower than the one at the onset of the 1990s3. Civil servants represent 10% of the total workforce of the country, corresponding to half the proportion in France and one third compared to Denmark4. The challenge to increase the government's ability to manage public policies demands duly qualified civil servants. Proper attention to the health and quality of life of this population of workers tends to progressively improve public services.
Absence of employees from work is called absenteeism, an indicator corresponding to the ratio of number of days absent to number of scheduled workdays5. Term absenteeism began to be used at the time of the Industrial Revolution, and its main types were later on defined as a function of its motives:
Voluntary: due to personal reasons other than disease;
For illness: including all, but occupational diseases;
For occupational disease: due to work-related accidents or diseases;
Legal: due to reasons established in legislation, such as pregnancy leave, bereavement, wedding, blood donation and military service;
Compulsory: for being arrested or any other reason that hinders workers from arriving in the workplace6.
Sickness absenteeism is defined by the International Labor Organization (ILO) as "non-attendance to work by some employee attribuchart to an individual's incapacity, except for pregnancy or imprisonment," namely, a disease or accidental injury7, as a measure to avoid the propagation of communicable diseases, or even from a simple ill-being to a severe condition8.
Indiscriminate occurrence of sickness absenteeism reveals the health and work conditions within the world of work. In the particular case of public service, it hinders the continuous provision of services considered to the essential or relevant to citizens, in addition to representing a burden to the public coffers as a function of the loss in productivity and the expenses associated with the rehabilitation of employees9.
Therefore, the main aim of the present integrative review was to compile Brazilian studies on sickness absenteeism within the public service published as articles in order to analyze its causes and consequences, as well as prevention strategies targeting civil servants on leave.
The present study consisted in an integrative review of the literature. The review involved several steps: the research questions were formulated first; then we selected the articles that composed the database, followed by analysis, criticism and interpretation of the results. Finally, we organized the findings to synthesize the obtained information.
The present study sought to answer the following questions: "What is the knowledge on the causes of sickness absenteeism within the Brazilian public service?" and "Which strategies for prevention and rehabilitation of civil servants' health such studies point out?"
The search was conducted on electronic databases Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO) based on keywords: "workers' health" and "absenteeism". Although the focus of the study was on the occurrence of sickness absenteeism among civil servants, we did not include keyword "public service" not to limit the search results. To verify whether the articles met this criterion, we performed a judicious analysis of their abstracts.
Data collection was performed in May and June 2016. We located 196 articles published along the past 10 years and exclusively in the Portuguese language, as our subject of interest was occurrence of sickness absenteeism within the Brazilian public service. The following types of publications were excluded: dissertations, newsletters, systematic and integrative reviews, duplicates, articles without their full text available, articles unrelated to the subject of interest, or addressing specific illnesses or professional categories.
For the purpose of selection we employed the search filters available in the databases. Titles and abstracts were then analyzed. An ad hoc form was used for data extraction to ensure a judicious selection of articles, depicted in Figure 1, which describes the steps that led to the selection of eight articles. In regard to ethical issues, we respected the ideas and data described by the authors of the selected articles in a trustworthy manner.
We selected eight articles, which information is summarized in Chart 1. All were descriptive and epidemiological studies; seven performed retrospective (secondary) data collection and one was a survey (article #2).
CHARACTERIZATION OF CIVIL SERVANTS ON LEAVE
According to the reviewed articles, sickness absenteeism predominated among women10,11,13,14,16. However, whereas the overall number of leaves was larger among the women, the number of long leaves was larger among the males11,16. One study found that the leave rates for women increased 100% at a Secretariat of Management and 48% at a Secretariat of Health from 1995 to 200514.
Women are the majority of civil servants at state and municipal agencies; these are the organizations responsible to meet health, social work and education demands, to wit, fields traditionally associated with the female gender. While the majority of employees at the federal level are male, women occupy most of the leading positions18. Globally, there is a difference of 20% unfavorable to women in the representation of genders within the workforce19 .
The French feminist movement promoted a discussion in the 1970s on the notion of sexual division of labor, criticizing the "invisible" work of women derived from a sense of maternal duty, nature or love20. Higher exposure to risk factors at work (repetitive strain, ergonomically poor equipment) and at home (less opportunity to relax and exercise outside work) might account for the higher rates of sickness absenteeism among women21. Paradoxically, some studies indicate that women exhibit higher rates of presenteeism, defined as going to work while ill, a circumstance that might end in absenteeism, being both phenomena unfavorable in terms of productivity22,23. Among women, the number of work accidents is higher compared to typical or commuting accidents24.
Some studies analyzed the age of civil servants on leave10,11,13,16; sickness absenteeism was found to increase from age 40 up10,13,16. In turn, in the study that analyzed primary data, the occurrence of sickness absenteeism was higher for range 30 to 39 years old11. Relative to the relationship between sick leave and age, short- and medium-term leaves involved younger workers, while the long-term leaves the older ones. According to some authors25, this fact might more related to motivational issues than to health problems.
According to some estimates, by 2040 57% of the Brazilian population of economically active age will correspond to individuals older than 4526. In association with the work conditions, this demographic effect favors functional aging, which impairs work ability and manifests before chronological aging27.
In regard to variable length of work in the public service, the highest prevalence of sickness absenteeism was found among the employees who had worked more than 11 years10,11,16. Civil servants at the top of their careers might have feelings of frustration (and a need to redefine the meaning of their activities) for having had to follow established patterns for many years, as well due to difficulties in coping with new techniques and tools, especially the ones related with information technology28. On the other hand, a study conducted with civil servants from Tocantins found that when these servants reach job stability they have more affective commitment to the instituition29.
Analysis of variables salary and educational level showed that sickness absenteeism stood out among the employees with low salary and low educational level10. While these variables were not considered in all the analyzed studies, they were evident in the case of employees with middle and technical level and occupying operative positions11,14,13. In other studies, sickness absenteeism exhibited greater association with low educational level than with occupational category, income or other factors30,31. One study conducted with airline employees found association between absenteeism and low educational level32.
The Whitehall II study, led by the epidemiologist Marmot, sought to investigate the influence of social and occupational factors on health. For this purpose, more than 10,000 British civil servants were followed up for about 15 years. The results showed that the mortality rate was three times higher among the employees at the lower hierarchical level compared to the ones at higher hierarchical levels33.
Relative to variable job position, sickness absenteeism was relevant and the employees at Secretariats of Education10,11,15,16 and Health13,14; also Secretariats of Sports15 and Management14 and Inspection and Surveillance Services12 were mentioned. In 2014, the National Council of State Secretaries for Management prepared a report on sickness absenteeism among tenured state civil servants from the Federal District, Rio Grande do Sul, Santa Catarina and Espírito Santo, which showed that 75% of the cases of absenteeism corresponded to the Secretariats of Education and Health34. The same was the result of an analysis of sickness absenteeism at Vitória municipal secretariats performed in 201235. Differently, the Secretariats of Social Defense and Public Works stood out in terms of percent absenteeism in Curitiba36. These areas involve employees engaged in the provision of assistance, who therefore tend to exhibit high levels of musculoskeletal and mental wear. A report by the World Health Organization (WHO) indicates that in the European Union stress was prevalent among health and education workers, and that it could be associated with violence and harassment37.
The analyzed articles unanimously emphasized the difficulty to collect data; seven studies employed secondary data (such as medical records, school reports and health statements) and one primary data collected by means of an electronic survey11. The authors also made mention of the lack of electronic records,10,11,17 as well as of the poor quality of records, which lacked data relevant for the characterization of employees (such as sex, age and length of work) and leaves (records of leaves lasting more than 312-14 or 15 days15). Some studies did not provide any characterization of civil servants on leave12,15,17.
CAUSES OF SICKNESS ABSENTEEISM: MENTAL AND BEHAVIORAL DISORDERS
Diagnosis "mental and behavioral disorders" (MBD) was the first cause of sickness absenteeism in five of the analyzed studies10-15, the second cause in three13,14,17, and was not mentioned among the most frequent causes in one16. One study assessed two groups of civil servants; MBD was the first cause of sickness absenteeism for workers at a Secretariat of Health, and the second for the ones at a Secretariat of Management14.
The lowest and highest rates of sickness absenteeism due to MBD were 15.3817 and 39.45%15, respectively. In the studies conducted with state public servants, MBD represented 20.2 and 40.1% of instances in Alagoas38 and Santa Catarina39, respectively. For federal civil servants MBD was the cause 29.2% of sick leaves in Tocantins40 and of 9.6% in Rondônia41.
Facing the variability in the frequency of MBD among the analyzed studies, the attempts at relating its etiology to work pose a true challenge, when one considers that one in four people will have some mental or neurologic disorder at some point in life42. Nevertheless, work is a core factor in the promotion of mental development and for identity construction, while organizational hindrances or constraints might cause mental suffering and illness43.
When there is a technical-epidemiological link between work and disease, the latter is considered is to have accidental nature44. For the period from 2004 to 2013, BMD was not listed among the 20 main accidental diseases resulting in sick pay within the private sector. In turn, relative to non-accidental diseases, MBD and musculoskeletal disorders (MSD) together represented 55% of the causes of sick pay45. Thus, one might conclude that the system is inadequate to assess the impacts of negative psychosocial factors at work46.
Codes F (in which MBD are included) in International Statistical Classification of Diseases and Related Health Problems (IDC-10) chapter V comprise a total of 99 diagnoses47. The Guidelines for Support to Medical Legal Decision Making were published in 2008, and include technical parameters to ground the assessment of work disability. However, this document might not be comprehensive as concerns the determination of the relationship between work and disease, and thus contributes to accentuate the technical rigor, with consequent reduction of the granting of social security benefits48.
Perception of work as stressful and presence of people who disturb the environment stood out among the predictors of burnout syndrome among civil servants from Tocantins49. The burnout syndrome is a psychosocial phenomenon that develops in response to chronic psychosocial stressors at work50. Its mental and behavioral manifestations are variable, eventually collective and severe, to culminate in violence and suicide. In São Paulo, the risk of suicide was found to be higher among workers compared to the unemployed51.
In one of the analyzed studies, MBD did not appear among the first three causes of sickness absenteeism, with a relative frequency of 16.39% — the main cause was respiratory diseases, corresponding to 35.79%16. Authors suggest a relationship between respiratory diseases and the local climate and air pollution, based on other ones from the same location35. The precarious building of the public service construction and maintenance may develop the called sick building syndrome, since the most of closed spaces, as well as companies, schools, movie theaters, houses and even hospitals, has inadequate ventilation and air-conditioning cleanse52. These might further reflect precarious building construction, and also precarious maintenance of public services as determinants for the development of diseases.
It is worth noticing than in some of the analyzed studies, the proportion of leaves due to MBD and MSD was similar10-13. MBD might have a relevant relationship of causality with development of MSD, and thus subjective manifestations should be taken into account, the diagnostic accuracy should be weighted and one should bear in mind possible underreporting of such diseases53.
CAUSES OF SICKNESS ABSENTEEISM: MUSCULOSKELETAL DISEASES
MSD were mentioned as the first cause of sickness absenteeism in three articles13,14,17, as the second in four10,11,12,14, and as the third in three15,16. The lowest and highest frequency of MSD as cause of leaves was 9.9315 and 29.53%15, respectively. The studies in which MSD was the most frequent cause analyzed civil servants from Secretariats of Health13 and Management14 and the banking sector17. These results reinforce the interest in conducting studies on ergonomic influences on the development of diseases.
Among municipal civil servants in Goiânia (GO), 5.38% of the total number of leaves along a 2-year period were due to lumbar pain and lasted 16 days, on average54. An analysis of French workers along a 5-year period showed that acute lumbar pain was associated with occupational factors, whereas the chronic form could depend on individual factors, such as depression55. Occupational vulnerability, such as work at the operative level and health care, might have a relationship with musculoskeletal pain21.
The multicenter study Cultural and Psychosocial Influences on Disability — CUPID — analyzed the variation in rates of leaves due to musculoskeletal pain across 47 occupational groups (mainly nurses and office workers) from 18 countries. The results showed that the investigated condition was more frequent in groups with greater time pressure at work, lower job control and more adverse beliefs about the relationship between work and MSD56. A prospective study conducted in Denmark concluded that low muscle strength was not a good predictor for MSD and long-term sickness absence57. These studies reinforce the influence of subjective issues on the occurrence of MSD, such as social organization at work, management model and interprofessional relations.
In Norway, where 40% of leaves are due to MSD and 20% to MBD, various stakeholders involved in the sick leave process, including workers, physicians and insurers, reported divergent assessments of state of health, work ability and leave duration. The authors concluded that workers with subjective comorbid complaints might be a marginalized group which does not receive the due care58.
Within the social security system, workers on leave depend on the conclusions of the medical legal assessment. An analysis of disability retirement among civil servants from São Luiz, Maranhão, called the attention to iniquities vis-à-vis employees affected by MSD; the authors concluded that the employees who performed ergonomically poor activities were the most vulnerable ones, falling prey to the system's inertia59.
STRATEGIES FOR PREVENTION AND REHABILITATION OF WORKERS' HEALTH
Relative to strategies to deal with sickness absenteeism, the analyzed studies converged on several aspects. The common denominator among them was the relevance given to the agency of workers in the evolution of policies on workers' health. As concerns research, the authors suggest supporting and improving records, as well as the creation of a System of Workers' Health15 to detect similarities and differences between definite occupational groups10. In regard to care delivery, proposals include making medical and dental outpatient clinics available to civil servants15, and rehabilitation and return to work measures which consider intersubjective relations, rhythms, the fragmentation of work and professional humanization13.
Launched in Brazil in 2008, the Longitudinal Study of Adults' Health (Estudo Longitudinal de Saúde do Adulto — ELSA) is the largest epidemiological study developed in Latin America. Within its context, 15,000 civil servants from six Brazilian higher education and research institutions are investigated and followed up. Relevant aspects, such as living conditions, social differences, relationship to work, gender and dietary particularities, are assessed in order to establish the incidence of and risk factors for chronic diseases, particularly cardiovascular conditions and diabetes60. ELSA results might come to promote research on occupational health and absenteeism.
The National Policy on Workers' Safety and Health (Política Nacional de Segurança e de Saúde do Trabalhador — PNSST) and National Policy on Male and Female Workers' Health (Política Nacional de Saúde do Trabalhador e da Trabalhadora — PNSTT)61,62 are the response to the need to implement and operationalize care delivery for workers in Brazil, which was previously granted by the Federal Constitution and the Organic Law on Health via the Unified Health System (Sistema Único de Saúde — SUS)63,64. The National Network of Workers' Integrated Health Care (Rede Nacional de Atenção Integral à Saúde do Trabalhador — RENAST) is responsible, via Reference Centers on Workers' Health (Centros de Referência em Saúde do Trabalhador — CEREST), for preventive actions against diseases, health promotion and rehabilitation of Brazilian workers.
Some studies include pertinent and focal proposals, such as adjusting the Position and Career Plan to favor a perception of organizational justice among employees29. It was also suggested to establish a model of medical legal examination and professional rehabilitation involving greater interaction between medical experts and multiprofessional staff aiming at reinsert public servants at work65. To reduce workplace-related stress, the OMS suggests having workers' associations and unions participate in the divulgation of information, as well as in sensitization campaigns37. One study conducted with civil servants from Rio de Janeiro found that although attaining job stability and labor rights was significant, lack of solidarity and cooperation in the everyday routine was a source of distress for the analyzed employees66. The better the interpersonal relations, the higher the odds for shorter treatment leaves among hospital workers67.
The lack of a general law for the public administration has impacts on management, as well as on the development of the workforce at the municipal, state and federal levels, which thus address problems differently68, resulting in variable strategies for the management of workers' health.
The analyzed studies stress the scarcity of information on civil servants on leave. The factors associated with sickness absenteeism were female sex, age over 40, more than 11 years of work, low educational level and work in education and health. This profile might vary as a function of the employment relationship, as particular specific historical and socioeconomic contexts might lead to different work conditions within the public sector.
The studies included in the present review call the attention to MBD and MSD as causes of sickness absenteeism among civil servants independently from the area to which they are allocated, which reflects their vulnerability to these conditions. Within their conclusions, the analyzed studies suggested possible, albeit generic strategies for prevention and control of sickness absenteeism, as e.g. intersectoral actions, promotion of humanization, investment on research and implantation of electronic databases.
The limitations of the present study derive from the heterogeneity among the analyzed studies, which employed different research methods, had different access to data records and included different populations of civil servants in terms of demographic characteristics, management model and employment relationship.
To the collective imagination, a reflection on civil servants might sound an exaggeration and superficial, as a function of the legal protection this category of employees enjoy. However, they are a vulnerable group, subjected to political and public pressure, and which must perform their work often under inadequate conditions and against the bureaucratic inertia. Then, the source of these workers' payment is the taxpayers' contributions, and thus they must exhibit a productive capacity compatible with their position and function. Finally, sick leaves, in this case, impair the delivery of services to the population.
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28 de Agosto de 2017.
Aceito em 1 de Dezembro de 2017.
Trabalho realizado na Universidade Federal de Mato Grosso do Sul (UFMS) – Campo Grande (MS), Brasil.
Fonte de financiamento: nenhuma