Abstract

This study was conducted in an artisanal fishing community. The main health complaints included musculoskeletal disorders (MSD) attributable to working conditions. The present work found a prevalence of neck and distal upper limb MSD among the artisan fisherwomen/shellfish gatherers in Saubara, Bahia, Brazil. This was a cross-sectional cohort epidemiological study involving 209 artisanal fisherwomen/shellfish gatherers. The Brazilian version of the Job Content Questionnaire (JCQ), the Nordic Musculoskeletal Questionnaire (NMQ) and a survey listing physical demands adapted to shellfish gathering were used for the study. The MSD values obtained in some part of the body, neck or shoulder, and distal upper limb were 94.7%, 71.3% and 70.3%, respectively. The shellfish gatherers were found to work long shifts despite the high prevalence of MSD. The factors that cause these women to keep performing such activities include the need to make a living and provide food for their families through the sale and consumption of seafood.

Key words
Artisanal fisherwomen; Shellfish gatherers; Musculoskeletal disorders

Introduction

Few epidemiological studies assessing musculoskeletal disorders (MSDs) in artisan fishermen/ shellfish gatherers have been published in the literature. Those workers mostly live in traditional communities and develop informal seafood trade and processing practices¹1. Pena PGL, Martins V, Rego RF. Por uma política para a saúde do trabalhador não assalariado: o caso dos pescadores artesanais e das marisqueiras. Rev. bras. saúde ocup 2013; 38(127):57-68.,²2. Bandeira FPSF, Brito RRC. Comunidades pesqueiras na Baía de Todos os Santos: aspectos históricos e etnoecológicos. In: Cardoso C, Tavares F, Pereira C, organizadores. Bahia de Todos os Santos: aspectos humanos. Salvador: EDUFBA; 2011. p. 291-326.. Work-related MSDs were identified among the main demands of a community of artisan fisherwomen/shellfish gatherers in the course of a research study conducted in Saubara in the municipality of Baía de Todos os Santos (BTS), whose population lives almost exclusively on artisan fishing.

As BTS fishing communities are considered traditional communities, they are culturally differentiated groups who recognize themselves as such. They have their own forms of social organizational and occupy and use territories and natural resources as a condition for their cultural, social, religious, ancestral and economic reproduction, using knowledge, innovations and practices generated and transmitted by tradition³3. Brasil. Decreto n° 6040, de 7 de fevereiro de 2007. Política Nacional de Desenvolvimento Sustentável dos Povos e Comunidades Tradicionais. Diário Oficial da União 2007; 8 fev..

Data reported in the Statistical Bulletin of Sea and Estuarine Fisheries of the State of Bahia (Boletim Estatístico da Pesca Marítima e Estuarina do Estado da Bahia)⁴4. Bahia Pesca. Boletim Estatístico da Pesca Marítima e Estuarina do Estado da Bahia: ano 2003. Bahia Pesca: Salvador: 2004. indicate that the total annual production estimated in 2003 for the group of 14 municipalities of Baía de Todos os Santos was 14,413.45 tons of fish, which corresponded to 33.22% of the production estimated for the State in the same year. In 2010, the Brazilian production of fish in Brazil was approximately 1,265,000 tons of fish, reaching 19^th in the world rankings of fish production for this year⁵5. Brasil. Ministério da Pesca e Aquicultura (MPA). Boletim estatístico da pesca e aquicultura. 2011. [acessado 2014 abr 09]. Disponível em: http://www.mpa.gov.br/index.php/informacoes-e-estatisticas/estatistica-da-pesca-e-aquicultura
http://www.mpa.gov.br/index.php/informac... . Approximately 45% of the annual production comes from artisan fishing⁶6. Brasil. Ministério da Pesca e Aquicultura (MPA). Pesca Artesanal. 29 de Ago de 2011. 2011b. [acessado 2012 maio 13]. Disponível em: http://www.mpa.gov.br/pescampa/artesanal
http://www.mpa.gov.br/pescampa/artesanal... . The vast majority (75%) of the fish produced in the Northeast comes from artisan fishing, according to the diagnosis of fishing in Brazil⁷7. Brasil. Ministério da Pesca e Aquicultura (MPA). O diagnóstico da Pesca Extrativa no Brasil. 22 de Fevereiro 2012. [acessado 2012 maio 13]. Disponível em: http://www.mpa.gov.br/index.php/component/content/article/101-apresentacao/250-o-diagnostico-da-pesca-extrativa-no-brasil
http://www.mpa.gov.br/index.php/componen... .

Despite their large contribution to Brazilian fishing, artisanal fishing communities are generally among the poorest segments of the population, which may be explained by their dependence on exploiting a limited natural resource and the inherent uncertainty of the fishing profession⁸8. Committee on Fisheries (COFI). 2011. Good Practices in the Governance of Small-Scale Fisheries: Sharing of Experiences and Lessons Learned in Responsible Fisheries fos Social and Economic Development. 29° Sessão, Roma, 31 Jan – 4 Fev, 2011..

The shellfish gatherers of BTS may be characterized as artisan fisherwomen because they perform their work as a method of subsistence or for commercial purposes, simply and individually (autonomously) or as a type of family business (as opposed to an industrial company), with family support⁹9. Garcia SM. 2009. Glossary. In: Cochrane K, Garcia SM, editors. A fishery managers’ handbook. FAO and Wiley -Blackwell: 473-505. [acessado 2012 ago 14]. Disponível em: http://www.fao.org/fi/glossary/
http://www.fao.org/fi/glossary/... , and are responsible for their work tools and all stages of the production process¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392.. The work of shellfish gatherers ranges from the preparation of materials for shellfish gathering to the final product for sale and is performed in dwellings, outbuildings and outside environments.

Shellfish gatherer shave no vacations, weekly rest or paid holidays, according to Pena et al.¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392.. Their illness may cause losses at work, compromising their food security.

The activities performed by shellfish gatherers, including the gathering of crustaceans and mollusks by hand, along the Brazilian coast may cause health problems to these workers, according to Rios et al.¹¹11. Rios AO, Rego RCF, Pena PGL. Doenças em trabalhadores da pesca. Rev Baiana de Saúde Pública 2011; 35(1):175-188.. They are subjected to muscle strain in the neck, shoulders, back, upper limbs and lower back and repetitive strain injury of the wrist. Thus, the activities performed by shellfish gatherers are an ergonomic risk for these work-ers¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392..

MSDs are found worldwide, in both industrial and non-industrial groups¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84., and there is growing concern about their social and economic consequences, especially in the workplace¹³13. Stock SR, Fernandes R, Delisle A, Vézina N. Reproducibility and validity of workers’ self-reports of physical work demands. Scand J Work Environ Health 2005; 31(6):409-437.. Although their cause does not exclusively result from occupations or working conditions¹⁴14. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004; 14(1):13-23.,¹⁵15. World Health Organization (WHO). Identifcation and control of work-related diseases. Report of a WHO Expert Committee. Genebra: WHO; 1985., MSDs comprise a key part of all work-related diseases recorded in many countries¹⁴14. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004; 14(1):13-23.. The National Research Council/Institute of Medicine¹⁶16. National Research Council and the Institute of Medicine (NRC/IOM). Commission on Behavioral and Social Sciences and Education. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. W a shington: National Academy Press; 2001. reports that the onset of MSDs depends on the interaction of three main risk factors: individual factors, mechanical stressors (physical demands) and the psychological characteristics of individuals (psychological demands).

Some authors indicate the heterogeneity of MSDs¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84.,¹⁴14. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004; 14(1):13-23.,¹⁷17. Roquelaure Y, Mariel J, Fanello S, Boissière JC, Chiron H, Dano C, Bureau D, Penneau-Fontbonne D. Active epidemiological surveillance of musculoskeletal disorders in a shoe factory. Occup Environ Med 2002; 59(7):452-458. because they involve different issues and body parts and are common problems in various occupations and work groups¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84.. These disorders include inflammatory and degenerative conditions that affect muscles, tendons, ligaments, joints, blood vessels, peripheral nerves and nerve roots in different body segments, according to Punnett & Wegman¹⁴14. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004; 14(1):13-23..

The presence of MSD symptoms¹⁸18. Rodríguez-Romero B, Pita-Fernández S, Carballo-Costa L. Impact of physical and psychosocial factors on disability caused by lumbar pin amongst fishing sector workers. Rheumatol Int 2013; 33(7):1769-1778.–²¹21. Lipscomb HJ, Loomis D, McDonald MA, Kucera K, Marshall S, Li L. Musculoskeletal symptoms among commercial fishers in North Carolina. Applied Ergonomics 2004; 35(5):417-426. among fish industry workers²²22. Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY. Prevalence of shoulder and upper-limb disorders among workers in the fish-processing industry. Scand J Work Environ Health 1993; 19(2):126-131.,²³23. Nag A, Vyas H, Shah P, Nag PK. Risk Factors and Musculoskeletal Disorders Among Women Workers Performing Fish Processing. Am J Ind Med 2012; 55(9):833843. and populations of rural workers²⁴24. Antonopoulou M, Antonakis N, Hadjipavlou A, Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Fam Pract 2007; 24(3):209-216. has already been reported among shellfish gatherers and fishermen in general.

Knowledge of characteristics of the environments in which shellfish gatherers live, the particularities of these groups of workers and their relationship with the work they perform becomes necessary to understand the factors that may affect neck and upper limb MSDs of these workers. Artisan fishing activity is important for Bahia and Brazil. Thus, MSDs may have impacts on the economy and food security of these populations.

Thus, the present study aims to identify the prevalence of neck/shoulder and distal upper limb MSDs and their main risk factors among artisan fisherwomen/shellfish gatherers in Saubara, Bahia, Brazil.

Methods

This study is included in a larger project titled “Health, Environment and Sustainability of artisan fishing workers” (Saúde, ambiente e sustentabilidade de trabalhadores da pesca artesanal). A literature search and epidemiological research were used in the present study. The literature search, performed in the PubMed Database until February 2014, aimed to identify all the national and international literature on neck and upper limb MSDs already published. The search for scientific articles was performed using the keywords “musculoskeletal disorders of the upper limbs” AND “occupation” AND “epidemiology”. The following inclusion criteria were used: the issue was addressed preferably with women, the study was epidemiological and provided data on neck and upper limb MSD prevalence, the case definition was provided, and the full article was available at the journal website of the Coordination for the Improvement of Higher Education Personnel (Comissão de Aperfeiçoamento de Pessoal de Nível Superior, CAPES).

This cross-sectional epidemiological study was performed with 209 artisan fisherwomen/ shellfish gatherers from the municipality of Saubara, Bahia. The Brazilian versions of the Job Content Questionnaire (JCQ) and the Nordic Musculoskeletal Questionnaire (NMQ) and a questionnaire addressing physical demands²⁵25. Fernandes RCP. Distúrbios musculoesqueléticos e trabalho industrial [tese]. Salvador: Universidade Federal da Bahia; 2004. adapted to the work of shellfish gatherers were used for this study. Informed consent forms were signed by the participating subjects, and the project was approved by the Research Ethics Committee (Comitê de Ética e Pesquisa, CEP) of the School of Medicine, Federal University of Bahia.

Population and area

Saubara is a city located 94 km from Salvador by highway and less than 20 nautical km, in the interior of BTS and near the mouth of the Paraguaçu River. The city covers an area of approximately 163 km² and consists of villages (Cabuçu, Bom Jesus dos Pobres and Araripe)²⁶26. Instituto Brasileiro de Geografa e Estatística (IBGE). Infográficos: dados gerais do município- 2007. [acessado 2013 jan 10]. Disponível em: http://www.cidades.ibge. gov.br/painel/painel.php?codmun = 292975&search = bahia%7Csaubara%7Cinfograficos:-dados-gerais-do -municipio&lang =
http://www.cidades.ibge.gov.br/painel/pa... . According to the 2010 census, it has a population of 11,201 inhabitants²⁷27. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: censo 2010. [acessado 2013 jan 10]. Disponível em: http://www.cidades.ibge.gov.br/xtras/ temas.php?lang = &codmun = 292975&idtema = 1&search = bahia|saubara|censo-demografico-2010:sinopse
http://www.cidades.ibge.gov.br/xtras/tem... , including 48.9% men and 51.1% women. The economically active population (EAP) of Saubara consists of5196 people²⁷27. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: censo 2010. [acessado 2013 jan 10]. Disponível em: http://www.cidades.ibge.gov.br/xtras/ temas.php?lang = &codmun = 292975&idtema = 1&search = bahia|saubara|censo-demografico-2010:sinopse
http://www.cidades.ibge.gov.br/xtras/tem... . Thus, the 568 artisan fishermen registered in the association of shellfish gatherers correspond to 11% of the EAP of Saubara. These data show the importance of artisan fishing for the municipality, which is considered one of the main economic activities.

Sampling and inclusion criteria

Sampling was performed randomly, simply and without replacement, and a drawing of individuals was performed based on the total number of shellfish gatherers registered in the Association of Artisan Fisherwomen/Shellfish Gatherers of Saubara (Associação de Pescadoras Artesanais/Marisqueiras de Saubara). A 50% prevalence, a 5% error and the total population (N) of 426 artisan fisherwomen registered in the association of shellfish gatherers were used to calculate the sample, according to the equation for determining sample size (n) based on the estimated population proportion. The final sample consisted of 209shellfish gatherers, 3% over the expected minimum sample.

Being female, 18 years of age or older and active in shellfish gathering for at least one year were among the inclusion criteria to enter the study because this activity is primarily performed by women in this community. To minimize the healthy worker survival effect, workers who were drawn and were not working in shellfish gathering had the opportunity to participate if they explained that they left the profession because of diseases possibly related to MSDs.

Data were collected from April 10 to May 10, 2013. This was a primary source database. The questionnaire used included the main risk factors reported in the literature. The following items were included in the questionnaire: identification; sociodemographic characteristics; job information; current and past occupational history; time worked in shellfish gathering; daily work hours; lifestyle, including tobacco smoking, alcohol consumption, use of medication, and practice of physical activities; comorbidities; housework; musculoskeletal symptoms; and physical and psychosocial demands at work. Most data were self-reported, except for weight, height and waist circumference (WC), which were measured by trained interviewers. The weight and height measurements were assessed to calculate the body mass index (BMI), and WC was measured to assess the accumulation of fat in the abdominal region.

Physical demands at work were adapted to the work of artisan fisherwomen/shellfish gatherers from the questionnaire prepared by Fernandes²⁵25. Fernandes RCP. Distúrbios musculoesqueléticos e trabalho industrial [tese]. Salvador: Universidade Federal da Bahia; 2004.. Physical demands were evaluated in this adaptation according to the stages of shellfish gathering (gathering, washing, transport, cooking and processing). The questions covered working postures (sitting, standing, walking, crouching, bending over at the waist, twisting the torso, holding the arms aloft), repetitive and precise hand movements, arm muscle strength, and cargo handling. The variables were measured using a 6-point (0 to 5) response scale regarding the frequency, intensity and duration.

Data on psychosocial demands assessed with scores for psychological demand, control and social support at work and job dissatisfaction were collected using the JCQ²⁸28. Karasek R. Job Content Instrument: Questionnaire and User's guide. Massachusetts: University of Massachusetts, Amherst; 1985.,²⁹29. Araújo TM, Karasek R. Validity and reliability of the job content questionnaire in formal and informal jobs in Brazil. SJWEH Suppl 2008; (6):52-59.. Exposure to psychosocial demands was rated according to Devereux³⁰30. Devereux JJ, Vlachonikolis IG, Buckle PW. Epidemiological study to investigate potential interaction between physical and psychosocial factors at work that may increase the risk of symptoms of musculoskeletal disorder of the neck and upper limb. Occup Environ Med 2002; 59(4):269-277 as high and low exposure to psychosocial demands. Psychosocial demands were dichotomized by the medians. The shellfish gatherers with high exposure to these demands received a demand score higher than 34, the control score was equal to or lower than 66, and the social support score was equal to or lower than 13. Low exposure was rated as demand equal to or lower than 34, the control score was higher than 66, and the social support score was higher than 13. At least two of the criteria had to be met for the shellfish gatherer to be rated in each group. Job satisfaction was also analyzed using the median and was stratified as low job satisfaction (satisfaction > 0.40) and high job satisfaction (satisfaction ≤ 0.40).

The data on musculoskeletal symptoms were collected using the expanded version of the NMQ, an instrument used worldwide in research on musculoskeletal disorders. The presence of pain or discomfort in the previous 12 months in anatomical areas of the musculoskeletal system was also assessed, along with the severity, duration and frequency of these symptoms³¹31. Kuorinka I, Forcier L. Work related musculoskeletal disorders (WMSDs): a reference book for prevention. London: Taylor & Francis; 1995.. MSD was defined as pain in the last twelve months lasting at least one week or with a monthly minimum frequency, which motivated the individual to seek medical care or absence from work or to change jobs, with grade 3 or higher severity in a scale from 0 to 5. Shellfish gatherers who suffered acute trauma in the segment of interest were excluded from the MSD calculation.

Statistical methods

The measures of central tendency (means, medians) and dispersion (standard deviations) were calculated for continuous variables. Categorical variables were expressed as absolute values and percentages.

The statistical software programs Ri386 version 2.15.2 and Epi Info version 7.1.3.3 were used for the data analysis.

Results

Shellfish gathering in Saubara is a predominantly female activity encompassing 75% of the individuals registered as shellfish gatherers in the Association of Artisan Fisherwomen/Shellfish Gatherers of Saubara. The sample characteristics are described in Table 1.

The sample predominantly consisted of shellfish gatherers with little schooling and who self-reported as black or brown for ethnicity. The age of the respondents ranged from 21 to 68 years. Only 10.1% reported having children younger than two years of age. The income exclusively from shellfish sales ranged from R$0.0 to R$600.0, averaging R$137.1 (SD = 104.7), corresponding to approximately 20% of the minimum wage at the time, which was R$678.0³²32. Departamento Intersindical de Estatística e Estudos Econômicos (DIEESE). Salário mínimo nominal e necessário. [acessado 2014 abr 10]. Disponível em: http://www.dieese.org.br/analisecestabasica/salarioMinimo.html#2013
http://www.dieese.org.br/analisecestabas... .

The experience of shellfish gatherers in the work they perform, their early age at the start of work and the high average daily working hours exclusively in shellfish gathering are notable among the occupational variables, which are outlined in Table 1. The average years of work was approximately 27 years (SD = 12.9). The average age at the start of work was approximately13 years (SD = 7.2), with a minimum of 4 years and a maximum of 53 years. The average working hours was 8.7 hours (SD = 3.1). There was a high number of weekly hours dedicated to housework in addition to work hours, which was reported by most shellfish gatherers interviewed (76.6%), characterizing a double work shift. Some study participants (29.2%) reported working in another occupation at the time of the interview, although the vast majority (70.8%) only worked in shellfish gathering.

Among the compensation measures, most shellfish gatherers (78.9%) notably consumed alcohol at least once a week. Tobacco smoking was only found in 5.3% (n = 11) of the sample. Most shellfish gatherers (67.5%) reported practicing physical activity during their leisure time, including running, gymnastics, swimming, playing soccer, cycling, walking, and caring for their vegetable garden or backyard at least three times a week for at least 30 minutes at a time. Overweight (BMI ≥ 25 kg/m²2. Bandeira FPSF, Brito RRC. Comunidades pesqueiras na Baía de Todos os Santos: aspectos históricos e etnoecológicos. In: Cardoso C, Tavares F, Pereira C, organizadores. Bahia de Todos os Santos: aspectos humanos. Salvador: EDUFBA; 2011. p. 291-326.) was identifed in 70.3% (n = 147) and obesity (BMI ≥ 30 kg/m²2. Bandeira FPSF, Brito RRC. Comunidades pesqueiras na Baía de Todos os Santos: aspectos históricos e etnoecológicos. In: Cardoso C, Tavares F, Pereira C, organizadores. Bahia de Todos os Santos: aspectos humanos. Salvador: EDUFBA; 2011. p. 291-326.) in 32.5% of the sample. Excess fat in the abdominal area (WC ≥ 80 cm) was present in 74.6% (n = 156) of workers.

Table 2 outlines the prevalence of pain or discomfort in the last twelve months and the MSDs in any body part (upper limbs, lower limbs or back), in the neck or shoulder, in the wrist or hand, in the forearm or elbow and in the distal upper limbs (wrist or hand or forearm or elbow).

The values of musculoskeletal symptoms in the last twelve months and MSDs detected in some body part were 97.6% (n = 204) and 94.7% (n = 198), respectively. High prevalence rates of neck or shoulder (71.3%) and distal upper limb (70.3%) MSDs were noted.

The physical demands at work (means ± SD) are outlined in Table 3, according to the main stages of shellfish gathering.

The main demands identified in the gathering were, in descending order, performing repetitive hand movements (4.55 ± 1.07), using arm or hand muscle strength (4.05 ± 1.14), bending over at the waist (3.94 ± 1.51), physical pressure with hands on a work tool (3.92 ± 1.29) and crouched posture (3.53 ± 1.73). The walking (4.44 ± 1.13), holding the arms aloft (3.54 ± 1.78) and standing (3.22 ± 2.00) postures prevailed during transport, along with the use of arm and hand muscle strength (3.81 ± 1.42) and load lifting (3.60 ± 1.46). The greatest physical demands in shell-fish processing were the sitting posture (4.55 ± 0.99) and performing repetitive (4.54 ± 1.06) and precise and fine (3.70 ± 1.81) movements. The psychosocial demands and job satisfaction are outlined in Table 4.

High psychosocial demand was detected in 50.7%and low job satisfaction in 56% of the shellfish gatherers interviewed. Only eight of the 69 articles gathered in the literature review met the inclusion criteria (Table 5).

Discussion

High prevalence rates of neck or shoulder and distal upper limb MSDs were assessed in artisan fisherwomen/shellfish gatherers. Almost all shell-fish gatherers reported pain or discomfort in any body part in the last year. Only 2.9% (n = 6) of shellfish gatherers with symptoms had no MSDs when applying the severity-rating criterion (higher than or equal to 3 on a scale from zero to 5). This finding illustrates the importance of this painful condition for the population of shellfish gatherers in Saubara.

Lower prevalence rates than those reported in the present study were reported among all the studies assessed that evaluated shellfish gather-ers²⁰20. Rodríguez-Romero B, Pita-Fernández S, Raposo-Vidal I, Seoane-Pillado T. Prevalence, co-occurrence, and predictive factors for musculoskeletal pain among shellfish gatherers. Clin Rheumatol 2012; 31(2):283292., commercial fishermen²¹21. Lipscomb HJ, Loomis D, McDonald MA, Kucera K, Marshall S, Li L. Musculoskeletal symptoms among commercial fishers in North Carolina. Applied Ergonomics 2004; 35(5):417-426., fishing industry workers²²22. Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY. Prevalence of shoulder and upper-limb disorders among workers in the fish-processing industry. Scand J Work Environ Health 1993; 19(2):126-131.,²³23. Nag A, Vyas H, Shah P, Nag PK. Risk Factors and Musculoskeletal Disorders Among Women Workers Performing Fish Processing. Am J Ind Med 2012; 55(9):833843., workers from other branches³⁰30. Devereux JJ, Vlachonikolis IG, Buckle PW. Epidemiological study to investigate potential interaction between physical and psychosocial factors at work that may increase the risk of symptoms of musculoskeletal disorder of the neck and upper limb. Occup Environ Med 2002; 59(4):269-277,³³33. Andersen JH, Haahr JP, Frost P. Risk Factors for More Severe Regional Musculoskeletal Symptoms. Arthritis Rheum 2007; 56(4):1355-1364.,³⁴34. Wang PC, Rempel DM, Harrison RJ, Chan J, Ritz BR. Work-organizational and personal factors associated with upper body musculoskeletal disorders among sewing machine operators. Occup Environ Med 2007; 64(12):806-813. and rural populations²⁴24. Antonopoulou M, Antonakis N, Hadjipavlou A, Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Fam Pract 2007; 24(3):209-216., according to MSDs in some body part, in the neck or shoulder or in the distal upper limbs. Symptoms retrieved from self-reported musculoskeletal pain, per body part, were rated and assessed differently from this study, which considered stricter case definition criteria. However, the high prevalence rates of musculoskeletal pain among shellfish gatherers from other continent, with different cultures, work regulations and hours, are highlighted²⁰20. Rodríguez-Romero B, Pita-Fernández S, Raposo-Vidal I, Seoane-Pillado T. Prevalence, co-occurrence, and predictive factors for musculoskeletal pain among shellfish gatherers. Clin Rheumatol 2012; 31(2):283292..

Self-reported symptoms may often be more informative than physical examination, according to Punnet & Wegman¹⁴14. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol 2004; 14(1):13-23.. The authors argue that objective measures are extremely useful in establishing a safer diagnosis, but subjective measures best capture the impact on the patient.

Some authors mention the difficulty of comparing upper limb MSD studies¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84.,³⁵35. Miranda H, Viikari-Juntura E, Heistaro S, Heliövaara M, Riihimäki H. A population study on differences in the determinants of a specific shoulder disorders versus nonspecifc shoulder pain without clinical fndings. Am J Epidemiol 2005; 161(9):47-55.,³⁶36. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 1998; 55(4):264271.. The comparison difficulties compromise assessing the extent of the problems because the case definitions, diagnostic criteria¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84.,³⁶36. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 1998; 55(4):264271. and official statistics differ between studies¹²12. Armstrong TJ, Buckle P, Fine LJ, Hagberg M, Jonsson B, Kilbom A, Kuorinka IA, Silverstein BA, Sjogaard G, Viikari-Juntura ER. A conceptual model for work-related neck and upper-limb muscoloskeletal disorders. Scand J Work Environ Health 1993; 19(2):73-84.. The shellfish gatherers of Sau-bara noticeably had higher MSD prevalence rates than the other workers, from rural to industrial, even with the stricter MSD rating of the present study. The different MSD ratings and prevalence rates per body part are outlined in Table 5.

In a population of rural Greek workers, 82.6% of respondents reported at least one mus-culoskeletal problem during the previous year, and 48.1% of subjects reported limited activity because of their symptoms during the same time period²⁴24. Antonopoulou M, Antonakis N, Hadjipavlou A, Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Fam Pract 2007; 24(3):209-216..

The study by Andersen et al.³³33. Andersen JH, Haahr JP, Frost P. Risk Factors for More Severe Regional Musculoskeletal Symptoms. Arthritis Rheum 2007; 56(4):1355-1364. showed that nursing assistants and cleaning staff complained of pain in both functional units more than the other workers. The occurrence of pain among these workers was much lower than that found among the shellfish gatherers in Saubara, despite having considerable values.

Chiang et al.²²22. Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY. Prevalence of shoulder and upper-limb disorders among workers in the fish-processing industry. Scand J Work Environ Health 1993; 19(2):126-131. highlighted that the greater the use of strength and the performance of tasks involving repetitive movement, the more muscu-loskeletal symptoms would be reported. Attention was drawn to the shoulder disorders, which nearly tripled in group 2 compared to group 1 (Table 5). The prevalence rates of self-reported symptoms were highest in group 3 for all body parts assessed.

Shellfish gatherers are highly vulnerable to ergonomic hazards at all stages of shellfish gathering. Gathering, transport and processing were the stages considered more important because they require longer time dedicated to the task and greater volume and workload. The posture bending at the waist and/or crouched and performing repetitive movements is the most used in gathering. Hand and arm strength are also used when working with tools and lifting loads, in addition to posture, according to Pena et al.¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392.:

The work of shellfish gatherers in sandy beaches and mangroves consists of walking, wherein dor-siflexion is sustained for extended periods of time. They roam and dig with fast-paced movements of the upper limbs, almost always in dorsiflexion, moving over rocks and sandy beaches, under the intense sun and with eyes fixed on the sand to identify seafood.

In transport, shellfish gatherers usually carry what they gather in overhead buckets, walking from their workplace to their homes. The posture of holding the arms a loft, standing and walking, the use of muscle strength and lifting loads were the physical demands with the highest means, which statistically demonstrate the characterization of this stage. In gathering, shellfish gatherers remain seated, performing repetitive and precise movements almost constantly until the end of this stage. Pena et al.¹⁰, in their study with shellfish gatherers from Ilha de Maré, Bahia, observed muscle overload in the neck, shoulders, back, upper limbs and lower back and repetitive strain injury of the wrist. According to Andersen et al., physical demands at work are related to worsened pain in specific areas³³.

Symptoms, injuries and disabilities have different meanings among individuals, determining a wide variety of psychological and social responses¹⁶16. National Research Council and the Institute of Medicine (NRC/IOM). Commission on Behavioral and Social Sciences and Education. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. W a shington: National Academy Press; 2001.. The explanation for the involvement of psychosocial factors in the onset of MSDs relates to muscle tension secondary to stress³⁷37. Lin TY, Teixeira MJ, Romano MA, Picarelli H, Settimi MM, Greve JMD'A. Distúrbios ósteo-musculares relacionados ao trabalho. Rev. Med. 2001; 80 (ed. esp. pt.2):422-442.,³⁸38. Huang GD, Feuerstein M, Sauter SL. Occupational Stress and Work-Related Upper Extremity Disorders: Concepts and Models. Am J Ind Med 2002; 41(5):298314..

The literature demonstrates that MSDs affect more women than men, and studies should consider the work demands according to gender ²⁴24. Antonopoulou M, Antonakis N, Hadjipavlou A, Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Fam Pract 2007; 24(3):209-216.,³⁹39. Goldman MB, Troisi R, Rexrod KM. Women and health. 2nd ed. London: Academic Press; 2013..

The predominance of women in shellfish gathering activities has been measured or reported in other studies¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392.,⁴⁰40. Carvalho IGS, Rêgo RCF, Larrea-Killinger C, Rocha JCS, Pena PGL, Machado LOR. Por um diálogo de saberes entre pescadores artesanais, marisqueiras e o direito ambiental do trabalho. Cien Saude Colet 2014; 19(10):4011-4022.–⁴²42. Galícia. Santiago de Compostela: Xunta de Galicia, Consellería de Medio Rural e do Mar. Permisos de marisqueo a pé. 2013. [acessado 2014 mar 25]. Disponível em: http://www.pescadegalicia.com/PMP/Informes/1. 2.3.html
http://www.pescadegalicia.com/PMP/Inform... , except in an article with workers – mostly men (88.4%) – who performed fishing and shellfish gathering activities in the sea²¹21. Lipscomb HJ, Loomis D, McDonald MA, Kucera K, Marshall S, Li L. Musculoskeletal symptoms among commercial fishers in North Carolina. Applied Ergonomics 2004; 35(5):417-426..

Rheumatic disorders were the most reported comorbidities (17.2%) among the shellfish gatherers of Galicia²⁰20. Rodríguez-Romero B, Pita-Fernández S, Raposo-Vidal I, Seoane-Pillado T. Prevalence, co-occurrence, and predictive factors for musculoskeletal pain among shellfish gatherers. Clin Rheumatol 2012; 31(2):283292.. The prevalence of diabetes mellitus in the present study was higher than that reported for shellfish gatherers in Galicia, with the illness reported by 3.6% (n = 33) of the sample²⁰20. Rodríguez-Romero B, Pita-Fernández S, Raposo-Vidal I, Seoane-Pillado T. Prevalence, co-occurrence, and predictive factors for musculoskeletal pain among shellfish gatherers. Clin Rheumatol 2012; 31(2):283292.. Conversely, the prevalence of diabetes mellitus in the sample of shellfish gatherers was lower than the percentage of adults (35 years or older) who reported having diabetes in the year 2012, according to the total and the five Brazilian regions⁴³43. Brasil. Ministério da Saúde (MS). Indicadores e Dados Básicos (IDB). [acessado 2013 out 13]. Disponível em: http://tabnet.datasus.gov.br/cgi/idb2012/matriz.htm
http://tabnet.datasus.gov.br/cgi/idb2012... . The difficulty that shellfish gatherers from Saubara experience accessing healthcare services may contribute to the failure to diagnose these diseases. The values are substantial, even with this difficulty, indicating the importance of health actions for these communities.

The overweight and obesity prevalence rates of the study were much higher than the respective prevalence rates among Brazilian women aged 18 years or older (47.5% and 17.9%, respectively, in 2012)⁴³43. Brasil. Ministério da Saúde (MS). Indicadores e Dados Básicos (IDB). [acessado 2013 out 13]. Disponível em: http://tabnet.datasus.gov.br/cgi/idb2012/matriz.htm
http://tabnet.datasus.gov.br/cgi/idb2012... . “A striking level of overweight and obesity” was noted in the community of shellfish gatherers and artisan fishermen of Ilha de Maré, located in Baía de Todos os Santos. Many shellfish gatherers are obese but do not always feel sick⁴⁴44. Silva PB. Os significados socioculturais do corpo obeso em marisqueiras [dissertação]. Salvador: Universidade Federal da Bahia; 2011.. Overweight is described in the literature as a factor related to upper limb MSDs¹⁶16. National Research Council and the Institute of Medicine (NRC/IOM). Commission on Behavioral and Social Sciences and Education. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. W a shington: National Academy Press; 2001.,³³33. Andersen JH, Haahr JP, Frost P. Risk Factors for More Severe Regional Musculoskeletal Symptoms. Arthritis Rheum 2007; 56(4):1355-1364..

Although no report of the role of income in MSD development was found during the literature review, its importance for these populations is emphasized. According to Dias et al.⁴⁵45. Dias RLP, Rosa RS, Damasceno LCP. Aspectos socioeconômicos, percepção ambiental e perspectivas das mulheres marisqueiras da Reserva de Desenvolvimento Sustentável Ponta do Tubarão (Rio Grande do Norte, Brasil). Gaia Scientia 2007; 1(1):25-35., the average monthly income from the shellfish gathering activity was 108.00 Brazilian Reais per month, a value lower than the average income resulting from the sale of seafood in the present study. Pena et al.¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392. reportedan even more extreme situation regarding income from shellfish gathering (approximately 50 Brazilian Reais per month). According to Pena et al.¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392., social misery imposes an intense work pace to generate more products for sale.

Similar to the study conducted by Pena et al.¹⁰10. Pena PGL, Freitas MCS, Cardim A. Trabalho artesanal, cadências infernais e lesões por esforços repetitivos: estudo de caso em uma comunidade de mariscadeiras na Ilha de Maré, Bahia. Cien Saude Colet 2011; 16(8):33833392., the shellfish gatherers of Saubara are also responsible for their work tools and for all stages of production. They have autonomy to decide on their work. However, these women perform their tasks even in the presence of pain to ensure the livelihood that comes from the sea. The shellfish gatherers of the present study noticeably used their production not only to gain income but also to ensure daily access to nutrients. Only the surplus production is sold to middlemen.

The way in which the shellfish-gatherer work is developed and the individual characteristics are important for MSD occurrence. These workers constitute the management forces for their own work and showed great experience in the activity. Although they have autonomy to perform their activities, these shellfish gatherers function for notably long working hours, even with high prevalence rates of MSDs, demonstrating that the need to ensure the livelihood and food security of their families by selling and consuming seafood is included among the determining factors of the permanence of these people in the activity.

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