Abstract
BACKGROUND:
The implementation of the electronic judicial process (PJe) in recent years is associated with an increase in workload and stricter control through productivity targets in the Brazilian labor judiciary.
OBJECTIVES:
To evaluate the relations between musculoskeletal symptoms, psychosocial factors and work ability in civil servants of a labor justice body in the context of the PJe.
METHODS:
A cross-sectional exploratory study with a quantitative approach involving 449 workers. Sociodemographic, occupational and related data were collected through questionnaires validated in the Brazilian context. Data analysis was conducted by descriptive and inferential statistics: Mann-Whitney test, Spearman’s correlation coefficient and multiple linear regression.
RESULTS:
There was a correlation between musculoskeletal symptoms and psychosocial factors (p < 0.05), as well as between both musculoskeletal symptoms and psychosocial factors with reduced work ability (p < 0.05). The multiple linear regression model pointed to the female gender and the dimensions “demands”, “control” and “peer support” as related to the musculoskeletal symptoms.
CONCLUSION:
We highlight the importance of a broader approach, involving psychosocial factors in preventive actions related to musculoskeletal disorders considering the important relationship with work ability.
Introduction
The transformations undergone by the Brazilian labor judiciary in recent years have involved not only the computerization of labor suits, but also an increase in demand and stricter control through productivity targets. After the implementation of the electronic judicial process (PJe), tasks related to procedural acts started to be done exclusively by means of the computer, which allowed the acceleration of procedural progress and the performance of teleworking. However, the intensification of computer use at work may be related to a number of physical symptoms such as headache, visual fatigue, joint pain, shoulder stiffness, low back pain and general fatigue [1], but it is especially related to musculoskeletal symptoms and disorders in the neck and upper limbs [2–9].
Work-related musculoskeletal disorders (WRMDs) refer to insidious injuries resulting from work activity when there is exposure to repetitive movements that require excessive force, with inadequate postures or when there is vibration, i.e. when the physical work load exceeds the adaptive and repair capacity of the exposed structures [10, 11]. However, although they are more commonly related to the physical factors of work, WRMDs are better understood by taking into account their multifactorial etiology, which also involves individual characteristics and psychosocial factors at work [12, 13].
Current evidence suggests that the promotion of improvements by focusing only on the physical conditions of work is not enough to prevent the genesis and aggravation of WRMDs, and preventive interventions must be developed with the participation of workers, also taking into account psychosocial risk factors to be more effective [14–16].
Often, musculoskeletal disorders and mental disorders are associated in the work environment and, particularly, work-related stress seems to be associated with the presence of chronic musculoskeletal pain [17]. This association can indicate occupational stressors as predictors for the occurrence of musculoskeletal symptoms, especially when monotony at work and lack of social support are involved [18], as well as musculoskeletal symptomatology as a trigger for increased stress, since pain and functional limitations make individuals less tolerant to the psychological demands of work [19]. High occupational stressors levels are associated with psychological tension, which, in turn, relates to higher levels of musculoskeletal symptoms in wrists and hands, shoulder and lumbar spine, even when controlling for the physical demands of the job [20]. High labor demand, low autonomy, low social support and negative social interaction are associated with occupational stress, while this variable positively relates to the occurrence of musculoskeletal symptoms [21–25].
Although musculoskeletal symptoms have not led to absence from work, they may represent the initial stage of WRMDs and lead to a loss of productivity of individuals with complaints [26]. As symptoms relate to the work activity, whether due to repetitive movements or static postures for prolonged periods associated with the psychosocial factors at work, the permanence in the function without proper clinical and/or occupational health follow-up may lead to an aggravation of this situation with progressive loss of work ability [27]. Work ability can be understood as how well a worker is or will be at this time or in the near future and how able he/she is to perform his/her work according to the requirements of their health status and physical and mental abilities [28].
The connection between the occurrence of musculoskeletal symptoms and disorders with reduction of work ability and productivity is well-known [29–31]. However, high levels of occupational stress associated with musculoskeletal pain may be related to even greater injuries [32]. Among the organizational determinants, besides demand with physical overload, high mental demand and low autonomy are also associated with reduced work ability [33].
In this context, this study was designed to evaluate the association and correlation between demographic and occupational variables, musculoskeletal symptoms, psychosocial factors and work ability in civil servants of a Brazilian labor judicial body after the implementation of the PJe.
Method
Exploratory and cross-sectional study, with a quantitative approach, among civil servants of a Regional Labor Court (TRT) that had 164 first instance units distributed over more than 100 cities in the state of São Paulo.
Subjects
We included servants allocated to 148 first-instance TRT units that worked exclusively in administrative offices of regional labor courts, in outposts of the labor judiciary, and in itinerant labor courts, in addition to the assistants of judges. Regional labor courts comprise the first instance of lawsuits under the jurisdiction of the Labor Court, being competent to judge individual conflicts arising in labor relations. We did not include judicial officers from regional labor courts, as they carry out external activity (diligences), and employees in units that were participating in supervised regular program of labor gymnastics, whose offer was circumstantially restricted to two labor forums (16 regional labor courts) of this organ.
We excluded servants with less than one year of work in their units and servants that carried out their main function in court hearings. Participants who, after agreeing to participate in the study, did not fully complete the data collection instruments did not have their data analyzed.
Sample size calculation was performed considering the methodology for estimating a sample size for a proportion. In the sample calculation, a p-ratio equal to 0.50 was considered, whose value represents the maximum variability of the binomial distribution, thus generating an estimate with the largest possible sample size. We assumed a sampling error of 5%and a significance level of 5%, and the sample size obtained from a population of 1564 civil servants was 309, reaching at least 371 servants taking into account a 20%loss rate.
Data collection
Data collection was performed in October and November of 2017 through self-administered tools available through the Internet using the online Survey Monkey® questionnaires and surveys platform. Servants were invited to participate in the survey by means of an institutional e-mail (with link to access the questionnaires) and telephone contact with a servant of each unit.
Data collection instruments
Demographic and occupational characterization questionnaire
A questionnaire developed specifically for this work was applied, with questions related to age, gender, working time in the institution, working time in the first instance, average hourly workload per day, average daily workload using PJe, and presence of disease-causing musculoskeletal symptoms.
Nordic musculoskeletal questionnaire (NMQ)
The occurrence of musculoskeletal symptoms was assessed using the Brazilian version of the Nordic Musculoskeletal Questionnaire (NMQ), created by Finnish researchers to standardize the evaluation of musculoskeletal symptoms in the occupational context [34] and validated and adapted to Brazilian Portuguese [35, 36].
The NMQ consists of questions about the presence of symptoms in the neck, shoulder, elbow, wrist and hand, dorsal, cervical and lumbar spine, hips, thighs and buttocks, knees, ankles and feet in the last 12 months and in the last seven days. It also assesses the repercussion of this symptomatology on performance at work and in domestic and leisure activities and on the need to visit a health professional because of this condition. NMQ results provide a measure of the frequency with which the nine assessed body regions are identified as related to musculoskeletal symptoms and may also provide a measure of the number of body regions with complaints by summing the regions in which problems were identified in each individual.
Brazilian version of the health and safety executive - indicator tool (HSE-IT)
Psychosocial risk factors at work were assessed through the quantitative step of the Brazilian version of the Health and Safety Executive - Indicator Tool (HSE-IT). The HSE-IT is a tool that allows to identify at the organizational level the causes of occupational stress related to the main dimensions indicated by workers [37–39], whose validation for the English language was prepared by Edwards et al. [40] and translation and validation for Portuguese Brazil was performed by Lucca et al. [41].
The HSE-IT consists of 35 items distributed over seven dimensions: demands, control, managers’ support, peer support, relationships, role and change. The result, which is obtained for each dimension separately, can range from 1 to 5 and, for composing the final result of the dimensions of “demands” and “relationships”, the results were inverted so that for all seven dimensions better results were representative of better psychosocial conditions at work, i.e., represent a lower risk of occupational stress [42].
Work ability index (WAI)
Work ability was assessed by applying the Brazilian version of the Work Ability Index (WAI) [28], which demonstrated satisfactory measurement properties regarding construct validity, criterion and reliability for assessing work ability in both individual approaches and population surveys in the Brazilian population [43]. The WAI is an instrument that allows to assess work ability from the worker’s own perception, through ten questions synthesized in seven dimensions: “current work ability compared with lifetime best”; “work ability in relation to the demands of the job “; “number of diagnosed illnesses or limiting conditions from which one suffers”, obtained from a list of 51 diseases; “estimated impairment owing to diseases/illnesses; “amount of sick leave during the last year”; “own prognosis of work ability in 2 years’ time”, and “mental resources”. The answers to item two, referring to the demands of the job, were weighted considering the job with fundamentally mental requirements, as recommended by Tuomi et al. [28] for administrative work.
The results of the seven dimensions of WAI provide a measure of work ability ranging from 7 to 49 points. The scores obtained in each question are summed, resulting in a final score that can vary from 7 to 49 points, classified as follows: from 7 to 27 points: poor; from 28 to 36 points: moderate; from 37 to 43: good; and from 44 to 49: excellent [43]. The first two categories (poor and moderate) can still be classified as “inadequate” (score < 37), while the last two (good and excellent) can be classified as “adequate” (score≥37) [44].
Data analysis
Descriptive analyses were performed using frequency tables with absolute values (n) and percentages (%), position measurements (mean, median, minimum and maximum) and dispersion (standard deviation and interquartile range –IQR) for all variables.
The non-parametric Mann-Whitney test was ap-plied to make comparisons between quantitative variables according to WAI category (< 37; ≥37). Quantitative variables were correlated using Spearman’s correlation coefficient. Correlations between 0.10 and 0.29 were considered as satisfactory but weak; between 0.30 and 0.49 as moderate, and equal or greater than 0.50 as strong.
A multiple linear regression model was constructed to verify the relationship between demographic and occupational characteristics and psychosocial factors with the occurrence of musculoskeletal symptoms. P values < 0.05 were considered statistically significant and the SAS software version 9.4 was used for the analyses. Data analysis was performed with the assistance of the Statistical Service of the Nursing School of Unicamp.
Ethical aspects
This study was conducted in accordance with CNS Resolution 466/12 and complementary resolutions. The research project was authorized by TRT’s management and obtained consent from the union representing public servants. It was submitted to the Research Ethics Committee (CEP) of the University of Campinas (Unicamp) and approved under opinion 2.021.746/2017. Participants were only able to join the study and had their data used in accordance with a free and informed consent form presented on the research homepage, without which access to the data collection instruments would not have been possible.
Results
Public servants of 148 units of first instance courts were contacted about the survey, and 543 followed the link sent by e-mail and answered the Free and Informed Consent Form. Of these, 11 servants did not agree to participate. Of the 532 servants that accepted to take part in the study, 55 were excluded due to incomplete filling out of the data collection instruments, 22 that worked mainly in office of hearings, and six that had less than one year in the first instance. Therefore, data of 449 participants distributed over 138 first instance units were analyzed, resulting in a 28.7%response rate that involved the participation of servants of 93.2%of the units surveyed.
The mean age of the sample was 45.0 (8.4) years, with a mean of 15.1 (8.6) years of working time in the TRT and 14.8 (8.5) years in the first instance. The majority of the participants were female (58.8%), held the position of judicial technician (67.3%), had no specific role in the regional labor court (54.1%), and had no diagnosed illness in the last 12 months causing musculoskeletal symptoms (82.0%). The average workload was 7.6 (0.9) hours, 6.3 (1.4) hours of which involved the use of PJe (Table 1).
Descriptive analysis of demographic and occupational variables (n = 449)
Descriptive analysis of demographic and occupational variables (n = 449)
*SD = Standard Deviation; **IQR = Inter-Quartile Range.
Participants presented 4.0 (2.3) body regions with problems in the last 12 months and 1.9 (2.0) in the last seven days. The HSE-IT dimensions that presented the best results were “role”, with a score of 4.3 (0.6), and “relationships”, with a score of 4.1 (0.7), and dimensions with the worst results were “demands”, with a score of 3.3 (0.7) and “control”, with a score of 3.6 (0.7) (Table 2).
Descriptive analysis of results of musculoskeletal symptoms, psychosocial factors and work ability (n = 449)
Regarding the correlation analyses between NMQ, HSE-IT and WAI variables, only the dimensions “managers’ support” and “role” did not present a significant result when analyzed together with the total number of medical visits in the last 12 months, while the latter was not correlated either with the total number of impairments in this period. The WAI result showed a moderate positive correlation with NMQ results and HSE-IT dimensions, with the exception of “managers’ support”, “relationships” and “change”, in which the correlation was weak, though satisfactory and statistically significant (Table 3).
Spearman’s correlation coefficient between musculoskeletal symptoms and psychosocial factors at work (n = 449)
*p < 0.05; **p < 0.01; ***p < 0.001.
The WAI was categorized into one group with results below 37, comprising low and moderate results (inadequate work ability) and another group with results above or equal to 37, including good and excellent results (adequate work ability). When comparing these two WAI categories, all HSE-IT dimensions presented a statistically significant difference, with better results observed in the second category for all variables (Table 4).
Association between psychosocial factors results according to WAI category (n = 449)
*Mann-Whitney test.
The multiple linear regression model, having as dependent variables the number of body regions with complaints from the four NMQ questions, showed that gender was directly related to all of them, and working time in the TRT was related to medical visits in the last 12 months. Regarding HSE-IT dimensions, “demands” and “peer support” were inversely related to problems in the last 12 months and in the last seven days, while “control” was indirectly related to impairments and medical visits in the last 12 months (Table 5).
Coefficients of multiple linear regression relating demographic and occupational variables and psychosocial dimensions to musculoskeletal symptoms (dependent variables) (n = 449)
The present study aimed at evaluating the association and correlation between demographic and occupational variables, musculoskeletal symptoms, psychosocial factors and work ability in civil servants of a federal labor justice body in the context of the electronic judicial process (PJe). Considering that the impacts of computerization of work processes are not restricted to physical risk factors [12, 13], and taking into account the multifactorial etiology of musculoskeletal symptoms in the workplace, we investigated the psychosocial risk factors at work. The WAI was evaluated as a measure of the behavior of the other variables of study regarding work ability.
Among individual characteristics, the highest oc-currence of musculoskeletal complaints in the female subjects observed in this study is reported in most of the studies that perform this analysis in comparison to males in the occupational context [45, 46]. In administrative workers, Maakip et al. [12] observed that being female was the main predictive individual characteristic for the occurrence of musculoskeletal symptoms, adding to physical work risk factors and psychosocial risk factors. Blatter and Bongers [5] observed that gender-based analysis of the relationship between working time with the computer and the occurrence of musculoskeletal symptoms pointed to a stronger relationship in women.
Regarding the evaluation of psychosocial factors at work, the application of the quantitative HSE-IT step was performed considering the ease of obtaining the results for each dimension of the occupational stress risk and for being an instrument that allows acting on the primary level of intervention. The HSE-IT “demands” and “control” dimensions presented the worst results of the seven dimensions of the instrument. The working context of the labor judiciary, with computerization of processes and setting of productivity goals amidst the increasing demand for work, may explain these findings. The “demands” dimension is directly related to work overload, while “control” is related to autonomy in the way of performing work [26].
According to Griffiths et al. [47], from the computerization of work processes, there is a change in work organization that impacts not only biomechanical conditions but also workers’ psychological demands. New psychosocial stressors are introduced into the work environment, which may involve increased demand, reduction of control over tasks, pressure for deadlines and goals controlled by the computerized system, the need to maintain concentration for long periods with reduced social interaction, a sense of urgency and a tendency to increase supervision control combined with reduction of autonomy. In response to these factors, many workers are encouraged to work for many hours with the computer under high mental demand, resulting in high levels of muscular effort and tension with insufficient recovery pauses. In fact, a significant negative correlation was observed between the average daily workload and the “demands” dimension of HSE-IT in the present study.
Significant positive correlations were observed between the number of body regions with complaints of the four NMQ questions and almost all HSE-IT dimensions. The dimensions of “peer support”, “demands” and “control” presented the highest correlations with the occurrence of musculoskeletal symptoms, both in the last 12 months and in the last seven days. In the multiple linear regression model, “demands” and “peer support” were related to problems in the last 12 months and in the last seven days, while “control” was related to impairments and medical visits in the last 12 months.
Some authors suggest that the relationship between psychosocial factors at work with the occurrence of musculoskeletal symptoms is underestimated in the level of preventive health interventions in companies, although this relationship has been well documented in the literature [14, 48]. Indeed, studies that reviewed this relationship point out that observational research provides consistent evidence for the association between musculoskeletal symptoms and psychosocial factors at work [11, 49], especially when psychic overload overlaps with physical overload [50]. According to the systematic review carried out by Costa and Vieira [51], low levels of social support and control over work, as well as high levels of psychological demands, have been related to symptoms in the neck, lumbar spine and upper limbs.
Workers submitted to working conditions assessed as having a high psychological demand and low control over work can be observed in a greater proportion in individuals with musculoskeletal symptoms [52]. When the demand for work is high and the worker has no freedom to control the working pace, especially if breaks are not taken during continuous work with the computer (pauses every two hours at least), complaints of pain in shoulders, wrists and hands are more frequent [53]. Alavi et al. [4] observed that subjects who reported working long hours (more than five hours) without resting pauses reported more complaints of shoulder pain, while Kaliniene et al. [54] found a higher incidence of painful neck complaints during periods of high cognitive demand for work without the possibility of taking rest breaks at least every two hours.
Ortiz-Hernández et al. [55] point out that, under certain ergonomic conditions, psychosocial factors at work can modify the risk of the occurrence of musculoskeletal disorders. These authors observed that workers with lower psychological demand and greater control over tasks had a reduced risk of developing these disorders due to the greater number of rest breaks taken, while among workers with low social support, the adoption of inappropriate postures was associated with a substantial increase of this risk.
The WAI outcome of the sample, even including participants who reported a diagnosis of diseases related to musculoskeletal symptoms, presented a mean score of 38.7 (6.4), within the spectrum where it can be considered as good work ability [56]. Significant moderate correlations were observed between the number of body regions with complaints and the WAI score, with results close to 0.50. This correlation can be understood insofar as the musculoskeletal functioning is among the aspects with the greatest impact on functional capacity and this is considered as the basis for work ability, influencing the worker’s fatigue and job performance [51].
The WAI results also showed significant correlations with all HSE-IT dimensions, with higher correlations observed with the dimensions of “control”, “peer support” and “demands”. Other studies investigating the correlation between the variables of these two instruments also found a correlation between the psychosocial risk dimensions and the results of for work ability [57, 58]. Cordeiro and Araújo [59] observed that psychosocial factors were predictors of reduced work ability in their review of studies with Brazilian workers, pointing to factors such as stress, fatigue, work dissatisfaction and low autonomy as determinants of psychic overload with consequent reduction of work ability.
These relationships between WAI results and those of psychosocial factors are reinforced as we compare groups with inadequate work ability (< 37 points) with those with adequate work ability (≥37 points). All HSE-IT dimensions presented a statistically significant difference when these two groups were compared, with better results for the group with better work ability.
Taking into account that this is a cross-sectio-nal study, although important relationships were ob-served between the variables studied, it was not possible to establish any cause-effect relationships, especially between psychosocial factors and musculoskeletal symptoms, which represents a limitation of this study. To this end, new longitudinal studies should be performed with this population for a more adequate analysis of these relationships. On the other hand, the strengths of this study are especially related to the researched population and to the sample size obtained for data analysis. There are few publications about the health of federal labor justice workers, especially at a time when structural changes impose a new way of working.
Conclusion
Occupational psychosocial factors assessed thro-ugh HSE-IT, especially the dimensions of “de-mands”, “control” and “peer support”, were related to the occurrence of musculoskeletal symptoms. The number of body regions with complaints, as well as all psychosocial dimensions, were significantly related to servants’ level of work ability.
The results of this study point to the importance of a broader approach, involving psychosocial factors, besides the physical risk factors of work, in the preventive actions related to musculoskeletal disorders, considering the important relation of the latter with work ability.
Conflict of interest
None to report.