Abstract

Introduction

The state of health is composed of biological, social, cultural and environmental factors (Minayo; Assis; Oliveira, 2011MINAYO, M. C. de S.; ASSIS, S. G.; OLIVEIRA, R. V. C. Impacto das atividades profissionais na saúde física e mental dos policiais civis e militares do Rio de Janeiro. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 4, p. 2199-2209, 2011.). Work can be viewed in different ways and can have positive and negative repercussions on health. Positive in the sense of highlighting the subject's activity with regards creating and recreating both things and themselves, producing a sensation of physical and emotional well-being, as well as exploring human potential. However, depending on conditions, it can also present dissatisfaction and suffering, feelings of undervalue, overwork and emotional stress (Minayo; Assis; Oliveira, 2011MINAYO, M. C. de S.; ASSIS, S. G.; OLIVEIRA, R. V. C. Impacto das atividades profissionais na saúde física e mental dos policiais civis e militares do Rio de Janeiro. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 4, p. 2199-2209, 2011.; Seligmann-Silva; Neves, 2006SELIGMANN-SILVA, E.; NEVES, M. Y. R. A dor e a delícia de ser (estar) professora: trabalho docente e saúde mental. Estudos e Pesquisas em Psicologia, Rio de Janeiro, v. 6, n. 1, p. 63-75, 2006.).

Since the early 1990s, issues concerning work ability have been approached in studies of workers' health, in terms of individual, social and economic implications (Martinez; Latorre, 2006MARTINEZ, M. C.; LATORRE, M. R. D. O. Saúde e capacidade para o trabalho em trabalhadores de área administrativa. Revista de Saúde Pública, São Paulo, v. 40, n. 5, p. 851-858, 2006.; Martinez; Latorre; Fischer, 2009MARTINEZ, M. C.; LATORRE, M. R. D. O.; FISCHER, F. M. Validade e confiabilidade da versão brasileira do Índice de Capacidade para o Trabalho. Revista de Saúde Pública, São Paulo, v. 43, n. 3, p. 525-532, 2009.).

The concept of work ability (WA) is emphasized as a condition resulting from the combination of human resources in relation to the physical, mental and social demands of work, management, the culture of the organization and community and atmosphere in the workplace (Ilmarinen et al., 1991ILMARINEN, J. et al. Summary and recommendations of a project involving crosssectional and follow-up studies on the aging worker in Finnish municipal occupations (1981-1985). Scandinavian Journal of Work, Environment&Health, Helsinki, v. 17, p. 135-141, 1991. Supplement 1.), expressed as "the better a worker currently is, or will be in the near future, the more capable they will be of carrying out their work according to their state of health and mental and physical capacities" (Tuomi et al., 2005TUOMI, K. et al. Índice de capacidade para o trabalho. São Carlos: EdUFSCar, 2005.).

The World Health Organization (WHO) has defined quality of life (QoL) as "the individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their objectives, expectations, standards and concerns" (The WHOQOL Group, 1995THE WHOQOL GROUP. The World Health Organization Quality of Life Assessment (WHOQOL): position paper from the World Health Organization. Social Science and Medicine, New York, v. 41, n. 10, p. 1403-1409, 1995.).

As well as the demands inherent to providing comprehensive health care and humanizing practices, health care workers are also exposed to situations resulting from poverty and social inequality, as well as with the deficiencies in other levels of the health care system, together with the changes underway in the world of work, from which the health care sector is not exempt, making it more precarious, leading to fear and isolation and submission on the part of the workers (Braga; Carvalho; Binder, 2010BRAGA, L. C.; CARVALHO, L. Q.; BINDER, M. C. P. Condições de trabalho e transtornos mentais comuns em trabalhadores da rede básica de saúde de Botucatu (SP). Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, p. 1585-1596, 2010. Suplemento 1.).

Concerning community health workers (CHWs) in particular, their tasks in the Family Health Strategy (FHS) are specified in subsection 8.14 of Annex I of Ordinance n. 1.886/1997 (Brasil, 1997BRASIL. Ministério da Saúde. Portaria GM/MS n° 1.866, de dezembro de 1997. Dispõe sobre o perfil de competências do Agente Comunitário de Saúde. Diário Oficial da União, Brasília, DF, 18 dez. 1997. Seção 8, p. 5.), requiring physical and mental equilibrium in order to fulfill them. For Resende et al. (2011)RESENDE, M. C. et al. Saúde mental e ansiedade em agentes comunitários que atuam em saúde da família em Uberlândia (MG, Brasil). Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 4, p. 2115-2122, 2011., this health care professional is susceptible to a variety of conditions that can negatively affect their well-being and harmony, leading to feelings of anxiety, fear, insecurity, low self-esteem and even to physiological situations such as hyperventilation and tense muscles, triggering pain, worry and hyperactivity of the autonomic nervous system. Moreover, these health care professionals are subject to a particular labor dynamic of living and working in the same community, which can produce additional pressures and overload.

The health of CHWs and the risks to which they are exposed have therefore been analyzed in studies (Cesar et al., 2002CESAR, J. A. et al. Mudanças em indicadores de saúde infantil em um município com agentes comunitários: o caso de Itapirapuã Paulista, Vale do Ribeira, São Paulo, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1647-1654, 2002.; Frazão; Marques, 2009FRAZÃO, P.; MARQUES, D. Efetividade de programa de agentes comunitários na promoção da saúde bucal. Revista de Saúde Pública, São Paulo, v. 43, n. 3, p. 463-471, 2009.; Levy; Matos; Tomita, 2004LEVY, F. M.; MATOS, P. E. S.; TOMITA, N. E. Programa de agentes comunitários de saúde: a percepção de usuários e trabalhadores da saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, n. 1, p. 197-203, 2004.; Moreira; Zandonade; Maciel, 2010MOREIRA, T. R.; ZANDONADE, E.; MACIEL, E. L. N. Risco de infecção tuberculosa em agentes comunitários de saúde. Revista de Saúde Pública, São Paulo, v. 44, n. 2, p. 332-338, 2010.; Pupin; Cardoso, 2008PUPIN, V. M.; CARDOSO, C. L. Agentes comunitários de saúde e os sentidos de "ser agente". Estudos de Psicologia, Natal, v. 13, n. 2, p. 157-163, 2008.) that show concern in characterizing them, as well as their respective functions, in order to evaluate the process and results of their work.

Camello and Angerami (2004)CAMELLO, S. H. H.; ANGERAMI, E. L. S. Sintomas de estresse nos trabalhadores atuantes em cinco núcleos de saúde da família. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 12, n. 1, p. 14-21, 2004., Custódio et al. (2006)CUSTÓDIO, L. C. et al. Avaliação do estresse ocupacional em agentes comunitários de saúde da região metropolitana de Belo Horizonte - MG. Cadernos de Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 549-553, 2006., Nunes et al. (2002)NUNES, M. O. et al. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1639-1646, 2002., Pedrosa and Teles (2001)PEDROSA, J. I. S.; TELES, J. B. M. Consenso e diferenças em equipes do Programa Saúde da Família. Revista de Saúde Pública, São Paulo, v. 35, n. 3, p. 303-311, 2001. and Souza and Freitas (2011)SOUZA, L. J. R.; FREITAS, M. S. C. O agente comunitário de saúde: violência e sofrimento no trabalho a céu aberto. Revista Baiana de Saúde Pública, Salvador, v. 35, n. 1, p. 96-109, 2011. report how the demands from both parties (health care and community) with whom these workers coexist cause health problems such as stress, anxiety and countless other diseases. Trindade et al. (2007)TRINDADE, L. L. et al. Cargas de trabalho entre os agentes comunitários de saúde. Revista Gaúcha de Enfermagem, Porto Alegre, v. 28, n. 4, p. 473-479, 2007. highlighted the existence of psychological loads and of the difficulties these workers had in finding measures to protect and care for themselves, and Silva and Menezes (2008)SILVA, A. T. C.; MENEZES, P. R. Esgotamento profissional e transtornos mentais comuns em agentes comunitários de saúde. Revista de Saúde Pública, São Paulo, v. 42, n. 5, p. 921-929, 2008., in a study with CHWs, stated that 24.1% of those interviewed presented burnout syndrome, and 43.3% had common mental disorders, highlighting the significance of mental suffering for the health of these workers.

Trindade et al. (2007)TRINDADE, L. L. et al. Cargas de trabalho entre os agentes comunitários de saúde. Revista Gaúcha de Enfermagem, Porto Alegre, v. 28, n. 4, p. 473-479, 2007. observed that these workers were also exposed to ergonomic risks at work, the main problems being the uncomfortable positions adopted whilst working, long walks on potholed, winding streets and the need to sit in incorrect positions during domestic visits, due to a lack of benches or chairs. These factors have been shown to be strongly related to work-related musculoskeletal disorders, constituting a potential source of pain.

Thus, we investigated the CHWs' WA and QoL, whether they had musculoskeletal symptoms while working, the relationship between the presence of these symptoms and different QoL and WA domains.

The results of this study could support public health policies in implementing new strategies to improve the work of these professionals and could have a positive impact on health, both that of the workers and of those they care for.

In this context, the aim of this study is to evaluate WA, socio-economic aspects, QoL and musculoskeletal symptoms, as well as the associations between them in CHWs in Uberaba-MG.

Methodology

Study and sample

This study was a cross-sectional, descriptive piece of field research.

At the time the data were collected, the municipality of Uberaba-MG had 52 Family Health Strategy teams. The convenience sample was composed of 8 of these teams, in which the Universidade Federal do Triângulo Mineiro (UFTM) Health Worker Education Program was in action, totaling 47 CHWs.

Those who were off work or who were not in the health care units on the day data were collected were excluded. Data were collected between January and May 2011.

The study was approved by the UFTM Research Ethics Committee, Protocol n. 1,787 and the CHWs signed informed consent forms.

Data collection instruments

A semi-structured questionnaire, prepared especially for this study, was used, collecting self-reported information on: age; sex; schooling; household income; marital status; and length of time working as a CHW.

Musculoskeletal Symptoms were assessed using the Nordic Questionnaire of Musculoskeletal Symptoms (NGMS) (Kuorinka, 1987KUORINKA, I. et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Applied Ergonomics, Oxford, v. 18, n. 3, p. 233-237, 1987.), which was developed to standardize measuring reports of musculoskeletal symptoms and thus facilitates comparison between studies. It consists of multiple choice or binary questions concerning the occurrence of symptoms in nine areas of the body, namely: neck/cervical region; shoulders; arms; elbows; forearms; wrists/hands/fingers; dorsal; lumbar and hips/legs. The respondent has to report the occurrence of symptoms in the 12 months and the seven days preceding the interview (Pinheiro; Troccoli; Carvalho, 2002PINHEIRO, F. A.; TROCCOLI, B. T.; CARVALHO, C. V. Validação do Questionário Nórdico de Sintomas Osteomusculares como medida de morbidade. Revista de Saúde Pública, São Paulo, v. 36, n. 3, p. 307-312, 2002.).

QoL was evaluated using the Questionnaire on Quality of Life SF-36, a self-applied instrument specifically designed to study overall QoL in health surveys, and has been validated for use in Brazil (Ciconelli et al., 1999CICONELLI, R. M. et al. Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Revista Brasileira de Reumatologia, São Paulo, v. 39, n. 3, p. 143-150, 1999.). The instrument contains 36 items, of which 35 are grouped into eight dimensions (Functional Capacity, Physical aspect, Pain, Overall State of Health, Vitality, social Aspects, emotional aspects and Mental Health) and a final item evaluating changes in health over time. The items are codified, grouped and transformed into a scale from zero (worst state of health) to 100 (best state of health) for each dimension (Aranha et al., 2006ARANHA, L. L. M. et al. Qualidade de vida relacionada à saúde em espanholas com osteoporose. Revista de Saúde Pública, São Paulo, v. 40, n. 2, p. 298-303, 2006.).

WA was evaluated using the Work Ability Index (WAI), an instrument developed by Finnish researchers in the 1980s, the result of self-evaluations of WA in the workers' own perceptions (Renosto et al., 2009RENOSTO, A. et al. Confiabilidade teste-reteste do Índice de Capacidade para o Trabalho em trabalhadores metalúrgicos do sul do Brasil. Revista Brasileira de Epidemiologia, São Paulo, v. 12, n. 2, p. 217-225, 2009.; Martinez; Latorre, 2006MARTINEZ, M. C.; LATORRE, M. R. D. O. Saúde e capacidade para o trabalho em trabalhadores de área administrativa. Revista de Saúde Pública, São Paulo, v. 40, n. 5, p. 851-858, 2006.). The WAI has been translated into Portuguese and tested by researchers from the Universidade de São Paulo (USP) Faculty of Public Health, and professionals from other universities and institutions in Brazil (Tuomi et al., 2005TUOMI, K. et al. Índice de capacidade para o trabalho. São Carlos: EdUFSCar, 2005.). It enables work ability to be evaluated based on ten questions (60 items) synthesized into seven dimensions, the results of which give a measure of work ability between 7 and 49 points, with results classified as poor (7 to 27), moderate (28 to 36), good (37 to 43) and very good (44 to 49) (Tuomi et al., 2005TUOMI, K. et al. Índice de capacidade para o trabalho. São Carlos: EdUFSCar, 2005.). However, this form of calculating scores was based on results obtained for workers aged between 45 and 58, possible resulting in underestimating the work ability of younger workers. Therefore, Kujala et al. (2005)KUJALA, V. et al. Classification of Work Ability Index among young employees. Occupational Medicine, London, v. 55, n. 5 p. 399-401, 2005., indicated another way of classifying the questionnaire results; as adequate or inadequate. According to the authors, for workers aged between 18 and 34, the result of the questionnaire is deemed inadequate when the score is < 40 and adequate when the score is 40; individuals aged 35 and upwards and with WAI < 37 are considered to have inadequate work ability, and those with scores of 37 to have adequate work ability.

Data collection procedures

The CHWs were invited to participate in the study, received information concerning its objectives, the instruments to be used and the data collection procedures. This took place at the work place during working hours, in a room reserved for the purpose, according to availability, so as not to negatively affect them in any way.

Two trained evaluators participated in the data collection. The participants answered the questionnaires, which had previously been read to them by the evaluator, who remained there to clarify any doubts.

The sequence in which the questionnaires were applied was as follows: the CHWs completed the socio-demographic questionnaire first; followed by the NGMS; the Quality of Life Questionnaire SF-36; and the WAI.

Data analysis

Descriptive analysis was shown in frequencies and percentages. Inferential analysis was conducted using the Mann Whitney, Kruskall Wallis and Spearman's correlation tests, with 5% significance. The Statistical Package for the Social Sciences (SPSS) program, version 19.0 was used.

Results

The sample contained 42 women (89%) and 5 men aged between 19 and 64 (M = 37.26 ± 12.74). It was found that 55.32% were married or living with their partner and 44.68% were single, widowed or separated; 65.9% reported a monthly household income of > 3 minimum wages and 68.09% had spent up to three years working as a CHW.

Regarding musculoskeletal symptoms, 82.98% had presented them in the preceding seven days, and 93.62% in the preceding 12 months.

The results indicate that the most implicated QoL domains were pain (M = 48 ± 22.67), followed by vitality (M = 52.23 ± 18.65), social aspects (M = 57.45 ± 24.82), mental health (M = 61 ± 21.27), overall state of health (M = 65.6 ± 18.46), emotional aspects (M = 68.43 ± 39.51), physical aspect (M = 72.07 ± 36.23) and functional capacity (M = 80.53 ± 22.27).

The WA classification showed a mean of 36.51 ± 7.95, with 26 (55.32%) presenting an inadequate ability to work, and 24 (44.68%) an adequate.

Tables 1, 2 and 3 show the inferential analyses between work ability and the other variables.

Significant results were found when comparing sex and WA, indicating that a greater number of women had inadequate work ability.

Although the mean age of those CHWs with inadequate ability was higher, this comparison was not significant.

The results were significant in the comparison between work ability and the presence of symptoms in the preceding 12 months and the preceding 7 days, with a higher incidence of symptoms in CHWs with inadequate ability.

The correlations between WA and QoL indicate that the means for the QoL domains were lower for CHWs with inadequate work ability, with significant values found for mental health, physical aspect, vitality, pain and emotional aspects.

Discussion

The mean age of the CHWs in this study was 37.26 12.74. Studies by Silva and Menezes (2008)SILVA, A. T. C.; MENEZES, P. R. Esgotamento profissional e transtornos mentais comuns em agentes comunitários de saúde. Revista de Saúde Pública, São Paulo, v. 42, n. 5, p. 921-929, 2008., Ursine, Trelha and Nunes (2010)URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010. and Kluthcovsky et al. (2007)KLUTHCOVSKY, A. C. et al. Avaliação da qualidade de vida geral de agentes comunitários de saúde: a contribuição relativa das variáveis sociodemográficas e dos domínios da qualidade de vida. Revista de Psiquiatria do Rio Grande do Sul, Porto Alegre, v. 29, n. 2, p. 176-183, 2007. show similar means. Tuomi et al. (2005)TUOMI, K. et al. Índice de capacidade para o trabalho. São Carlos: EdUFSCar, 2005. indicate that work ability tends to decrease with age, especially if no preventative measures are taken to maintain it. Although this study shows a higher mean age for CHWs with inadequate ability, this correlation was not significant. This may be due to the fact that the population evaluated was young, minimizing the impact of decreases in ability.

The majority (89%) were female. The predominance of young females corroborates different studies on the universe of CHWs (Bezerra; Espirito Santo; Batista Filho, 2005BEZERRA, A. F. B.; ESPIRITO SANTO, A. C. G.; BATISTA FILHO, M. Concepções e práticas do agente comunitário na atenção à saúde do idoso. Revista de Saúde Pública, São Paulo, v. 39, n. 5, p. 809-815, 2005.; Cambuy, 2005CAMBUY, K. Vivências de trabalho de agentes comunitários de saúde de Campinas. 2005. Dissertação (Mestrado em Psicologia Clínica) - Pontifícia Universidade Católica de Campinas, Campinas, 2005.; Ferraz; Aerts, 2005FERRAZ, L.; AERTS, D. R. G. C. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 2, p. 347-355, 2005.; Gessner, 2006GESSNER, C. L. S. Qualidade de vida das equipes de Saúde da Família do município de Timbó/SC. 2006. Dissertação (Mestrado Profissionalizante em Saúde e Gestão do Trabalho) - Universidade Vale do Itajaí, Itajaí, 2006.; Kluthcovsky, 2005KLUTHCOVSKY, A. C. G. C. Qualidade de vida dos agentes comunitários de saúde de um município do interior do Paraná. 2005. Dissertação (Mestrado de Enfermagem em Saúde Pública) - Escola de Enfermagem de Universidade de São Paulo, Ribeirão Preto, 2005.; Nogueira, 2006NOGUEIRA, C. M. O trabalho duplicado: a divisão sexual no trabalho e na reprodução: um estudo das trabalhadoras do telemarketing. Expressão Popular, São Paulo, v. 31, n. 114, p. 173-175, 2006.; Reis, 2005REIS, L. B. Uma análise de dimensão ético-política do trabalho de agentes comunitários de saúde do município de Vitória. 2005. Dissertação (Mestrado em Psicologia) - Universidade Federal do Espírito Santo, Vitória, 2005.; Santos, 2005SANTOS, L. P. G. S. A atuação do agente comunitário de saúde em São Bernardo do Campo: possibilidades e limites para a promoção da saúde. 2005. Dissertação (Mestrado em Saúde Coletiva) - Escola de Enfermagem da Universidade de São Paulo, São Paulo, 2005.; Seabra, 2006SEABRA, D. C. O agente comunitário de saúde na visão da equipe multiprofissional. 2006. Dissertação (Mestrado em Medicina Social) - Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, 2006.; Silva; Dias; Ribeiro, 2011SILVA, T. L.; DIAS, E. C.; RIBEIRO, E. C. O. Saberes e práticas do agente comunitário de saúde na atenção à saúde do trabalhador. Interface: Comunicação, Saúde, Educação, Botucatu, v. 15, n. 38, p. 859-870, 2011.; Silva; Menezes, 2008SILVA, A. T. C.; MENEZES, P. R. Esgotamento profissional e transtornos mentais comuns em agentes comunitários de saúde. Revista de Saúde Pública, São Paulo, v. 42, n. 5, p. 921-929, 2008.; Vasconcellos; Costa-Val, 2008VASCONCELLOS, N. P. C.; COSTA-VAL, R. Avaliação da qualidade de vida dos agentes comunitários de saúde de Lagoa Santa - MG. Revista de Atenção Primária à Saúde, Juiz de Fora, v. 11, n. 1, p. 17-28, 2008.; Ursine; Trelha; Nunes, 2010URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010.). Daune-Richard (2003)DAUNE-RICHARD, A. M. Qualificações e representações sociais. In: MARUANI, M.; HIRATA, H. (Org.). As novas fronteiras da desigualdade: homens e mulheres no mercado de trabalho. São Paulo: Senac, 2003. p. 65-76. states that there are many professions considered as belonging to a world of work in which the necessary skills are of an inherently female nature, a fact that could be closely linked to the role of carer in society being largely performed by women, they being the ones largely responsible for rearing and feeding children, as well as caring for the elderly in the family. This would explain the context of CHWs' work, involving care and dedication. Moreover, for many women, being a CHW presents an employment opportunity (Rosa; Cavicchioli; Brêtas, 2004ROSA, A. S.; CAVICCHIOLI, M. G. S.; BRÊTAS, A. C. P. O significado que o agente comunitário de saúde atribui ao seu trabalho no processo de construção do Sistema Único de Saúde no Brasil. Acta Paulista de Enfermagem, São Paulo, v. 17, n. 3, p. 255-261, 2004.), or a way into the labor market, increasing household income (Nogueira; Silva; Ramos, 2000NOGUEIRA, R.; SILVA, F. B. da; RAMOS, Z. V. O. A vinculação institucional de um trabalhadorsui generis: o agente comunitário de saúde. Brasília, DF: IPEA, 2000. Disponível em: <http://www.dominiopublico.gov.br/download/texto/td_0735.pdf>. Acesso em: 4 jun. 2011.
http://www.dominiopublico.gov.br/downloa... ; Vasconcellos; Costa-Val, 2008VASCONCELLOS, N. P. C.; COSTA-VAL, R. Avaliação da qualidade de vida dos agentes comunitários de saúde de Lagoa Santa - MG. Revista de Atenção Primária à Saúde, Juiz de Fora, v. 11, n. 1, p. 17-28, 2008.).

The results of the comparison between sex and work ability were significant, indicating that a higher number of women had inadequate ability, it is worth noting that 80% of the males showed adequate work ability, whereas for women this values was 46.5%. Among other reasons, these results may be linked to the number of diseases presented, as 4 (80%) of the males reported one or no diseases, whereas this was only 22 (41.8%). The other 21 had at least three diseases. Thus, Souza and Santana (2011)SOUZA, N. S. S.; SANTANA, V. S. Incidência cumulativa anual de doenças musculoesqueléticas incapacitantes relacionadas ao trabalho em uma área urbana do Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 27, n. 11, p. 2124-2134, 2011. highlight gender vulnerability on relation to disease, especially when dealing with musculoskeletal problems and the physical demand of work. It could also be that women have a greater chance of having a lower WAI than men due to the multiple roles they assume and the double working day, associated with child rearing and childcare, approached by Nogueira (2006)NOGUEIRA, C. M. O trabalho duplicado: a divisão sexual no trabalho e na reprodução: um estudo das trabalhadoras do telemarketing. Expressão Popular, São Paulo, v. 31, n. 114, p. 173-175, 2006. and Vasconcellos and Costa-Val (2008)VASCONCELLOS, N. P. C.; COSTA-VAL, R. Avaliação da qualidade de vida dos agentes comunitários de saúde de Lagoa Santa - MG. Revista de Atenção Primária à Saúde, Juiz de Fora, v. 11, n. 1, p. 17-28, 2008., as the above mentioned activities generally form part of the woman's routine, possibly leading to overload, with higher chances of falling ill.

The results show that the majority of CHWs had more than 11 years of schooling. In their study, Ferraz and Aerts (2005)FERRAZ, L.; AERTS, D. R. G. C. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 2, p. 347-355, 2005. also report that the majority of CHWs had completed Basic Education (9 years of schooling), highlighting the positive results stemming from this, as the higher the levels of schooling the better the worker's ability to incorporate new knowledge and guide families regarding their responsibilities. However, the comparison between schooling and work ability was not significant.

The relationship between marital status and WAI was not found to be significant, identifying that, for the population studied, the contribution of family, economic and social responsibilities of married CHWs, to reducing work ability, was not confirmed.

Studies indicate that for CHWs, both low salary and being overworked and undervalued demotivate them towards the profession and feeling undervalued, with this further exacerbated when comparisons are made with the salaries of other FHS members, and this situation influences job satisfaction and contributes negatively to suffering and falling ill (Ursine; Trelha; Nunes, 2010URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010.; Ferraz; Aerts, 2005FERRAZ, L.; AERTS, D. R. G. C. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 2, p. 347-355, 2005.; Gomes et al., 2009GOMES, K. O. G. et al. A práxis do agente comunitário de saúde no contexto do Programa Saúde da Família: reflexões estratégicas. Saúde e Sociedade, São Paulo, v. 18, n. 4, p. 744-755, 2009.).

By contrast, in this study, the comparison between monthly household income and WA was not found to be significant, as many of the 65.96% with household income above three minimum wages had inadequate WA, indicating that income was not the main factor in the adequacy of this ability. However, it should be taken into account that 55.32% of the professionals studied were married or cohabiting and could therefore possibly rely on their partner's support in the household budget, sharing domestic and family outgoings. In this case, a limitation of the study was evaluating household income rather than CHW salaries.

The results concerning the length of time serving as a CHW and WA were not significant, as distribution of adequate and inadequate WA was homogeneous, with approximately three years of service. This factor could be due to the short period of time working, as the majority had been in the position for fewer than three years. Thus, Theisen (2004)THEISEN, N. I. S. Agentes comunitários de saúde (ACS): condições de trabalho e sofrimento psíquico. 2004. Dissertação (Mestrado em Desenvolvimento Social) - Universidade de Santa Cruz do Sul, Santa Cruz do Sul, 2004. observed that factors of suffering and falling ill were not visible at first, as the risks to which the CHWs are exposed have long-term, cumulative effects, such as: the work becoming precarious, living and working in the same place, direct contact with those with serious pathologies and/or difficulties. Longitudinal studies, therefore, could better evaluate these results over time.

It was observed that a large number of CHWs showed musculoskeletal symptoms (82.98% in the preceding seven days and 93.62% in the preceding 12 months). In spite of this, even these data may be an underestimate and should be analyzed with care because, as Kluthcovsky (2005)KLUTHCOVSKY, A. C. G. C. Qualidade de vida dos agentes comunitários de saúde de um município do interior do Paraná. 2005. Dissertação (Mestrado de Enfermagem em Saúde Pública) - Escola de Enfermagem de Universidade de São Paulo, Ribeirão Preto, 2005. mentions, results concerning this parameter may have a bias inherent to cross-sections studies, as they provide a mere snapshot of the situation under investigation, selecting workers at work, excluding those who have symptoms and are off work for that very reason. This fact has been closely analyzed by Vasconcellos and Costa-Val (2008)VASCONCELLOS, N. P. C.; COSTA-VAL, R. Avaliação da qualidade de vida dos agentes comunitários de saúde de Lagoa Santa - MG. Revista de Atenção Primária à Saúde, Juiz de Fora, v. 11, n. 1, p. 17-28, 2008..

The presence of symptoms in the preceding 12 months and the preceding 7 days, as well as the pain domain of the QoL, which evaluated limitations due to pain (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.), were significantly associated with inadequate work ability.

Henríquez, Rivera and Eyzaguirre (2010)HENRÍQUEZ, M. G.; RIVERA, C. F.; EYZAGUIRRE, J. M. Prevalencia de transtornos músculo-esqueléticos de columna lumbar en trabajadoras y límites biomecánicos en el manejo de carga y pacientes. Ciencia & Trabajo, Santiago de Chile, v. 12, n. 37, p. 380-385, 2010. report that pain is the main symptom of musculoskeletal disorders. It can have diverse origins, depending on the characteristics of the work and in the case of CHWs, the following should be observed: biomechanical conditions, lifting heavy objects, prolonged maintenance of posture and undue force. Barbosa, Assunção and Araújo (2012)BARBOSA, R. E. C.; ASSUNÇÃO, A. A.; ARAÚJO, T. M. Distúrbios musculoesqueléticos em trabalhadores do setor saúde de Belo Horizonte, Minas Gerais, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 28, n. 8, p. 1569-1580, 2012. believe that repeated movements of the upper limbs or postures performed in static contraction are associated with the pain these professionals feel in the neck and shoulders.

Moreover, Ursine, Trelha and Nunes (2010)URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010. agree that good locomotion is fundamental to adequately fulfilling CHW duties. However, if they also complain of pain, their conditions for locomotion, walking, could be negatively affected. In this context, in the study by Reis (2005)REIS, L. B. Uma análise de dimensão ético-política do trabalho de agentes comunitários de saúde do município de Vitória. 2005. Dissertação (Mestrado em Psicologia) - Universidade Federal do Espírito Santo, Vitória, 2005., transport can lead to great dissatisfaction with their in CHWs. Another worrying fact concerning physical burnout could be related to the working conditions cited by Ferraz and Aerts (2005)FERRAZ, L.; AERTS, D. R. G. C. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 2, p. 347-355, 2005., such as the lack of openings offered for the post of CHW, together with the large number families for whom they are responsible, as indicated by Ursine, Trelha and Nunes (2010)URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010. in their study.

There may be other factors that contribute to these associations. CHWs are exposed to diverse factors of overload in their work, negatively affecting the quality with which their activities are carried out and, consequently their QoL. Problems concerning workload, targets to be met, lack of privacy and liberty, location of residence, interaction with other professionals and with other members of the community are some factors that constitute difficulties in these professionals' work (Wai, 2007WAI, M. F. P. O trabalho do agente comunitário de saúde na Estratégia Saúde da Família: fatores de sobrecarga e mecanismos de enfrentamento. 2007. Dissertação (Mestrado em Enfermagem Psiquiátrica) - Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo, São Paulo, 2007.).

Moreover, in the literature, emotional issues, especially situations that produce anxiety, frustration, sadness and psychological stress are also described as factors that worsen or trigger pain. Further studies are recommended to seek to clarify the association of emotional and physical variables in this context.

These factors may also explain the significant associations between the physical aspect domain that investigates whether physical problems interfere in work or other daily activities (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.) and inability to work.

The vitality domain in QoL, which analyzes the level of energy available (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.), can be related to the CHWs' working conditions, that is to say, living and working in the same community. This method of work organization means that the CHW is never totally free of carrying out their function, even outside of working hours, as the residents are in contact with them in their community and may require information on services and care in the health care unit. Thus, Huibers et al. (2003)HUIBERS, M. J. H. et al. Fatigue, burnout and chronic fatigue syndrome among employees on sick leave: do attributions make the difference? Occupational and Environmental Medicine, Londres v. 60, p. 26-31, June 2003. and Sluiter et al. (2003)SLUITER, J. K. et al. Need for recovery from work related fatigue and its role in development and prediction of subjective health complaints. Occupational and Environmental Medicine, London, v. 60, p. 62-70, 2003. Supplement 1. explain how the process of fatigue occurs when the work day effort expended is not sufficiently recovered. If this happens, fatigue can accumulate and lead to chronic symptoms. When a period of rest does not affect improvement, the condition is deemed to be that of chronic fatigue, in which sleep disturbances, psychosomatic complaints and mental overload are frequent.

There are, moreover, various studies seeing to identify the functions, actions and concepts of the CHWs' day-to-day work. Results show that they have met with difficulties completing their tasks, due both to the wide range of demands as well as to the limited socio-economic conditions of the families they care for (Nunes et al., 2002NUNES, M. O. et al. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1639-1646, 2002.; Silva; Dalmaso, 2002SILVA, J. A.; DALMASO, A. S. W. Agente comunitário de saúde: o ser, o saber, o fazer. Rio de Janeiro: Fiocruz, 2002.; Levy; Matos; Tomita, 2004LEVY, F. M.; MATOS, P. E. S.; TOMITA, N. E. Programa de agentes comunitários de saúde: a percepção de usuários e trabalhadores da saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, n. 1, p. 197-203, 2004.; Ferraz; Aerts, 2005FERRAZ, L.; AERTS, D. R. G. C. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 2, p. 347-355, 2005.; Zanchetta et al., 2005ZANCHETTA, M. S. et al. Education and professional strengthening of the community health agent - an ethnography study. Online Brazilian Journal of Nursing, Niterói, v. 4, n. 3, 2005. Disponível em: <http://www.objnursing.uff.br/index.php/nursing/article/view/35>. Acesso em: 4 dez. 2007.
http://www.objnursing.uff.br/index.php/n... ; Buchabqui; Capp; Petuco, 2006BUCHABQUI, J. A.; CAPP, E.; PETUCO, D. R. S. Convivendo com agentes de transformação: a interdisciplinaridade no processo de ensino/aprendizado em saúde. Revista Brasileira de Educação Médica, Rio de Janeiro, v. 30, n. 1, p. 32-38, 2006.; Duarte; Silva Junior; Cardoso, 2007DUARTE, R. L.; SILVA JUNIOR, D. S.; CARDOSO, S. H. Construindo um programa de educação com agentes comunitários de saúde. Interface: Comunicação, Saúde, Educação, Botucatu, v. 11, n. 23, p. 439-447, 2007.; Bornstein; Stotz, 2008BORNSTEIN, V. J.; STOTZ, E. M. Concepções que integram a formação e o processo de trabalho dos agentes comunitários de saúde: uma revisão de literatura. Ciência & Saúde Coletiva, Rio de Janeiro, v. 13, n. 1, p. 259-268, 2008.).

Fatigue and possible symptoms of fatigue may also form part of the CHWS' emotional state. Thus, lower scores for the emotional aspect, which evaluates how emotional problems affect work or other day-to-day activities (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.) and for mental health, which evaluates how the individual feels most of the time in relation to feeling nervy, depression, happiness and tranquility (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.) were also shown to be significantly associated with the CHWs' WA.

Workers with appropriate mental health states are often those who are at peace with themselves and is as close as possible to psychological balance. Resende et al. (2011)RESENDE, M. C. et al. Saúde mental e ansiedade em agentes comunitários que atuam em saúde da família em Uberlândia (MG, Brasil). Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 4, p. 2115-2122, 2011. discuss how this condition, among other aspects, contributes to the worker's wellbeing, the balance between professional activity expectations and how they are realized, this being a contributing factor to QoL. This satisfaction includes various conditions, including: income, employment, standard of housing, safety, privacy, affection, motivation, self-esteem, support and social recognition.

According to Nunes et al. (2002)NUNES, M. O. et al. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1639-1646, 2002., Jardim (2007)JARDIM, T. A. Morar e trabalhar na comunidade: a realidade dos agentes comunitários de saúde. 2007. Dissertação (Mestrado em Ciências) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, 2007. and Martines and Chaves (2007)MARTINES, W. R. V.; CHAVES, E. C. Vulnerabilidade e sofrimento no trabalho do agente comunitário de saúde no Programa de Saúde da Família. Revista da Escola de Enfermagem da USP, São Paulo, v. 41, n. 3, p. 426-433, 2007., CHWs are placed in the position of agents of change within the community. Silva and Dalmaso (2002)SILVA, J. A.; DALMASO, A. S. W. Agente comunitário de saúde: o ser, o saber, o fazer. Rio de Janeiro: Fiocruz, 2002. emphasize how CHWs have to continually adapt to the different situations that arise, as being an agent of change carries with it the anguish of seeing no or little change taking place, often at a slow pace, bringing with it doubts concerning performing the function.

Suffering establishes itself to the extent that the professional realizes that, despite being the transforming agent, they do not have the necessary tools, the knowledge nor all of the attributes that theoretically go with this function. Being a professional in the community, then, places them on the pendulum between the reality of the place in which they live and what can, in fact, be done to improve it, even with the theory of what a community health worker is (Nunes et al., 2002NUNES, M. O. et al. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cadernos de Saúde Pública, Rio de Janeiro, v. 18, n. 6, p. 1639-1646, 2002.; Jardim, 2007JARDIM, T. A. Morar e trabalhar na comunidade: a realidade dos agentes comunitários de saúde. 2007. Dissertação (Mestrado em Ciências) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, 2007.; Martines; Chaves, 2007MARTINES, W. R. V.; CHAVES, E. C. Vulnerabilidade e sofrimento no trabalho do agente comunitário de saúde no Programa de Saúde da Família. Revista da Escola de Enfermagem da USP, São Paulo, v. 41, n. 3, p. 426-433, 2007.).

It is worth returning to the idea that the function of the health worker is to serve as a link between the health care unit and the community. Several agents complain that there is little they can do for the community, as they cannot diagnose, medicate nor arrange appointments, i.e. they do not do the same things as other health care professionals (Mendes; Ceotto, 2011MENDES, F. M. S.; CEOTTO, E. C. Relato de Intervenção em Psicologia: identidade social do agente comunitário de saúde. Saúde e Sociedade, São Paulo, v. 20, n. 2, p. 496-506, 2011.).

The social aspects domain, investigating to what extent physical and/or emotional problems interfere with normal social activities, including those related to the family, neighbors, friends or in group (Ware et al., 2000WARE, J. R. et al. SF-36 health survey: manual and interpretation guide. Lincoln: QualityMetric, 2000.) was the third most affected. However, there was no correlation with work ability, despite low scores in this aspect. This could be explained, at least partly, by the fact that their tasks involve building relationships with the community and the Family Health Strategy team, as in the case of receiving and creating links (Ursine; Trelha; Nunes, 2010URSINE, B. L.; TRELHA, C. S.; NUNES, E. F. P. A. O agente comunitário de saúde na Estratégia de Saúde da Família: uma investigação das condições de trabalho e da qualidade de vida. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 122, p. 327-339, 2010.), as the essence of their function is in the relationships established both with the community and within the team, and their activity depends on having good relationships. Thus, although this may be a conflictive aspect of QoL, it is deemed inherent to the profession, minimizing its reflection in WA

Conclusion

Conducting research on QoL, musculoskeletal symptoms and WA in CHWs enabled results to be obtained showing that these aspects were affected due to the physical, emotional and mental demands to which these workers are constantly exposed.

This study identified that a larger number of women had inadequate WA and musculoskeletal symptoms. The components of the domains related to physical and mental capacity of QoL compromised the CHWs' work ability, indicating that the lower the QoL scores, the lower the WAI, showing how important work is in the process of personal and professional self-actualization.

References

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History