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���� ,,,d	�,,,�,,,����Working conditions and prevalence of musculoskeletal symptoms among food service hospital workers in S�o Paulo, Brazil

Abstract 
An epidemiological cross-sectional study was carried out with the application of a questionnaire to 115 workers of the Hospital Food Service to identify musculoskeletal symptoms. The questions were based on the Nordic questionnaire of musculoskeletal symptoms created by Kuorinka et al. The average age of the workers was 37 years, 81% were women and 58% had a college degree. They had been working in the hospital for an average of about 9.3 years on a 40-hour week schedule (79%). As regards working conditions, 69% of the workers worked in a standing and/or walking position. The work was considered the great volume with physical and mental demands; 89% of the subjects reported having felt pain or discomfort related to their work during the last 12 months in the lower members (65%; IC95%:63-87) and shoulders (55%;IC95%:53-73). The movements involved in walking and carrying loads (31%) during the daily activities were the main cause of the symptoms. High levels of musculoskeletal symptoms were discovered in workers of the hospital food service, mainly in lower members and shoulders.
  
Key words:, Working Conditions, Food Service Hospital,  Occupational Health




Introduction
One of the essential services of a hospital is that of Food Service which exists to render nutritional services, by means of the supply of meals, dietotherapeutic guidance and dietary education. 
This service is characterized by the daily, uninterrupted and continuous provision of service to the patients and its activities demand precision, rapidity and good team work. Depending on the function and place of work, its workers are submitted to risk factors both environmental and of work organization such as noise, heat, humidity, risk of accidents, physical and/or mental effort, the pace of intense, monotonous and repetitive work, in motionless postures and with muscular loads that may affect their health.1,2,3,4,5,6,7,8  Absenteeism is frequent, generally being motivated by illness, mainly of the musculoskeletal system and the conjunctive tissue.4, 6, 9, 10
In the light of the limited literature available on Work-Related Musculoskeletal Disorders (WRMSDs) among workers in the sector of Hospital Nutrition, this study set out to characterize the working conditions and the prevalence of musculoskeletal symptoms among workers in a nutrition and dietetic service of a public-reference cardiac hospital in S�o Paulo � SP, Brazil.
Materials  and Methods
The Hospital Food Service (HFS) studied belongs to a teaching hospital, specializing in cardiology, with a total of 450 clinical ands surgical beds, 
 It provides nutritional attendance for both internal and external patients and undertakes both teaching and research activities.
Its staff consists of 130 workers, including nutrition attendants, cooks, office workers, nutrition technicians, nutritionists, chief nutritionists and technical service director.
The universe of this study consisted of the totality of the workers,.
The collection of data was undertaken by means of a previously tested questionnaire, applied by professionals trained for the purpose and from outside this Service. Individual, previously-scheduled, interviews were held, during working hours.
The questionnaire called for data on socio-economic conditions, professional history, present working conditions, and work-related musculoskeletal symptoms. The items on musculoskeletal symptoms were based on the Nordic Questionnaire created by Kuorinka et al.11which is composed of two parts: the first for the identification of those workers with any kind of work-related pain or discomfort, its site and the type of complaint, and the second to characterize the frequency, intensity and duration of the symptoms and their consequences for the worker�s ability to work. Questions were added on �What causes�?�, �What worsens�?� and �What alleviates the symptoms?�.  
The regions of the shoulders and of the lower members were selected as being those with the greatest prevalence of musculoskeletal symptoms. The t- and Anova tests, with a significance level of 5%, were used for the statistical test of the working conditions, by region of the body.
Results
The institution studied forms part of the largest hospital complex in Latin America and as it is associated with a university has, among its objectives, beyond the rendering of services, teaching, research and community actions. 
Principal characteristics of the population studied
The population is constituted, in the larger part, of women, in the age group of from 25 to 34 years, with an intermediate level of schooling, and are married with children. They have worked in the hospital for an average of 9.3 years, the majority of them work as nutrition attendants, in the hospital kitchen or on the hospital wards, for a 40-hour working week (Table 1).
Workers` perception of working conditions as regards environment, work-place, tools and work organization
The workers` perception of their working conditions is to be found set out in Table 2. 
Prevalence and characterization of the musculoskeletal symptoms
The prevalence of work-related pain or discomfort, during the last 12 months, the site of the symptoms related by the workers, as regards the last 12 months, the time of the appearance of the the frequency and the intensity of the symptoms, over the last 12 months, are in the Table 3.
The symptoms, by region of the body, as regards the last 12 months, which did not lead to a loss of working days for the majority of the workers, were the following: hands/wrists/fingers (91%), spine (87%), shoulder (86%), forearm (85%), lower members (81%), lumbar region (80%), neck/cervical region (79%) and elbow (76%). The regions of the body which caused absence, for 1 to 15 days, and the respective percentage of workers involved, were: neck/cervical region (19%), lumbar region (18%), elbow (16%), lower members (15%), shoulder (12%), forearm (12%), spine (10%) and hands/wrists/fingers (9%). The symptoms which led to absence under the Social Welfare scheme, according to the workers, were pains in the: elbows (8%), lower members (4%), spine (3%), neck/cervical region (2%), shoulder (2%) and lumbar region (2%) (Table 3).
In the opinion of the workers, the most frequently quoted cause for the symptoms was: the movement involved in walking (31%), posture (16%) and lifting/transport/unloading of material (15%), during the daily activities. Worsening occurred also with the moving around in the work-place (38%) and in the carrying out of the tasks (25%). Improvement occurred only as a result of the use of medicines (52%) (Table 4).
Factors of working conditions related to the pains in the most commonly affected regions
In the analyses of the factors the following variables were included: spatial layout at work station, noise, lighting, temperature, free passages and corridors for the movement of material and people, layout of the work stations and ease of locomotion, quality of the objects used on the job, working posture, demands made on and tension of the body due to  working activities, risk of accident at the work station, seriousness of the accident, monotonous and repetitive work, physical effort, mental effort, volume of work, peaks during the working day, control over the pace of the work, possibility of requesting the help of colleagues, possibility of asking for the manager`s help, freedom of decision-making on the job, opinion taken into account by the management on the work underway, pauses during the working day, number of personnel in the area, training offered  by the Service, and job satisfaction. The statistically significant variables for the lower members and shoulders are to be seen in Table 5.
Lower members
The factors shown to be significantly associated with the pains present in the lower members (p < 0.05) were: �temperature�, �lack of free passages and corridors for the locomotion of material and people�, �risk of accidents at the work station�, �monotonous and repetitive work�, �physical effort� and �opinion not taken into account by the management� (Table 5). Working posture and the seriousness of the accident, although with p < 0.05, were not considered significant because there are cases which N < 5 for presence or absence of pain.
Shoulders
As regards the shoulders, the significant associated factors were: �monotonous and repetitive work� and �little freedom to take decisions regarding the work done� (Table 5).
Discussion
High levels of musculoskeletal symptoms were discovered, in this study, in workers of the hospital nutrition service. Studies carried out in industrial, university and hotel restaurants, which have investigated the existence of musculoskeletal disturbances among their staff, have been used in this study for purposes of comparison. Casarotto and Mendes6, in a study of 186 workers in the kitchens of 4 university restaurants and a pediatric hospital, with average age, time on the job, and proportion of women, similar to those of our population, found among the 78 workers with work-related complaints, a 37% prevalence of WRMSDs and 36% with back-ache, values lower than those of our study. Chyuan et al.9, in their study of 905 hotel restaurant workers with an average age of 33.3 years and time on the job similar to ours, using a self-applied questionnaire, found a prevalence of 84% of pain reported during the previous month, in some part of the body, a result similar to that found in our study.
As to the site of the symptoms, the prevalence was greatest in the lower members and in the shoulders, as also in Casarotto and Mendes6 study, though with lower percentage values (31.5% in the lower members and 17.3% in the shoulders) than in this present study. Both in our study and that of Casarotto and Mendes6, the assessments were made by means of questionnaires with the worker`s report. Chyuan et al.9 observed similar results for the prevalence in the shoulder (58%), though their study referred to complaints of the symptoms during the preceding 30 days.
As regards the lower members, Chyuan et al.9 analyzed the segments separately, finding prevalences of 22.3% for the upper leg, 33.9% for the knee, 33.6% for the lower leg and 42.8% for the feet and ankle, similarly to Casaroto and Mendes6 who observed 6.8% in the knees, 3.7% in the thighs, 11% in the legs and 10% in the feet. 
The high prevalence of WRMSDs in the lower members in our population is to be explained by the activity exercised in a standing, walking posture by about 70% of the workers who operate in the kitchen and in the clinical nutrition area, with a working day of from 8 to 12 hours, transporting loads and pushing tray-carrying trolleys for the distribution of food to the internal patients. The nutrition attendants and cooks walk as much as from 3 to 12 km. during their working day. And, depending on the type of trolley, on the size and condition of maintenance of the wheels, there is an increase in the demand made on the physical effort necessary for the maneuvering of the same12. The insufficient physical space, without passages and corridors free for the locomotion of material and people, as mentioned by the workers, creates a greater risk of work accidents to the lower members.
According to Bertoldi13, beyond the postural question, environmental conditions such as high temperatures and high relative humidity of the air, the carrying of weights, and the volume of monotonous and repetitive work at an intense pace, are factors which contribute to the triggering off or aggravation of circulatory disturbances, such as edema and venous disease, in the lower members.
In the region of the neck, Chyuan et al.9 observed a higher value (54%) than ours. Casarotto and Mendes 6 found 6.8% of complaints when they assessed the region of the nape of the neck.
The tasks performed in a static posture and with repetitive movements as in the pre-preparation of food (the cutting of meat), in the mixing of foodstuffs with heavy equipment, and in the distribution of trays on the conveyor belt, were, probably, the factors which contributed to the pains in the shoulders and in the neck, in our study, as also in Cann14  and Pehkonen15. Further, the postures adopted to replenish the equipment with foodstuffs put too great a weight on the shoulders. Psychosocial factors such as monotony and the absence of autonomy in the exercise of tasks, especially in operational positions, also explain the pains in these regions, more susceptible to the accumulation of muscular tension16, 17, 18.
For the lumbar region, Chyuan et al.9 found a higher prevalence than ours (53%);  Casarotto and Mendes6 observed 9.8% in the lumbar region and 2% in the buttocks, values below ours. It should be observed that in our study the region of the buttocks was included in the lumbar region, identified in the questionnaire applied by our interviewers, by the drawing of the human figure.
For the region of the hands/fists and fingers, Chyuan et al.9 found a prevalence of 47% just in the region of the fingers and fists, this being a value much higher than that found in this present study. However, Casarotto and Mendes6 observed 7.3% for the right hand and fist and 5.3% for those on the left, totaling 12.6% for the two hands, values below those observed in our study. The static postures in a sitting position, with the use of computers or handwritten and repetitive tasks such as the identification of diets to be supplied to the patients of the 450 beds, mainly among the workers who occupy administrative positions, explain the prevalence of the symptoms in the lumbar region as also in the upper members. It is known that the structures of the upper members are appropriate for movements of great precision and not for the undertaking of tasks which demand muscular effort, such as the carrying of foodstuffs, of utensils containing foodstuffs and the pushing of tray-carrying trolleys, to be observed in the activities of the nutrition attendants and cooks, and which may aggravate the symptoms in the upper members.
With regard to the spine, Chyuan et al.9 recorded a 33% prevalence of pain in the upper part of the spine and of 52% in the lower part, these being values higher than those found in our study; on the other hand, Casarotto and Mendes6 found 7.3% in the dorsal region, a value lower than ours, though, beyond the fact that the result was probably underestimated due to the fact that the questionnaire was self-applied, there may have been some difficulty in understanding on the part of the workers concerned as to the identification of the region affected. The adoption of incorrect postures both among the workers in the administrative areas, in their sitting position, and among the operational workers, in the lifting, transport and handling of loads, was probably the contributory factor to the symptoms in this region. There has been considerable growth of the institution in which this present study was carried out, over the last 30 years, with an increase in the number of beds from 35 to 450 and consequently also in the number of hospitalizations and in the production of meals, which latter has grown from 105,000 to 1,050,000 in 25 years, representing an increase of 1,000%, without there having been any proportional increase in the investment in the supporting areas such as the kitchen. Despite the innovations introduced in the NDS, such as the acquisition of electric combination ovens, of electrically-heated trays and of pre-prepared foodstuffs (meat, vegetables), which have streamlined and simplified the production process, the lack of any extension of the kitchen  or of any proportional increase in the headcount, have had serious consequences for the health of the workers concerned. Apart from that, the worker him or herself, pressed for time, together with the lack of space, ends up by adopting practices which are harmful to his/her own health, such as carrying loads without the help of  appropriate means of transport. And, when pains appear, adopt strategies such as self-medication, calling on the doctor only in extreme situations, which leads to the worker`s leave of absence for long periods, or even for years, under the Social Welfare scheme.
The deficit in the headcount of the HFS, of about 40%, for its present activities, by reason of the increase in production arising from the increase in the number of hospital beds, is aggravated by the daily absenteeism of the workers, which is as high as 7%. By reason of the characteristics of the service and the kind of clientele served, the workers who are present are overloaded in the execution of the duties of their absent colleagues, thus generating a vicious circle. Absenteeism is, therefore, both cause and effect of the musculoskeletal disorders.
The fact that the population is predominantly female is another important factor in the service, because it is known that women in general, and especially those who have children, present higher rates of absenteeism than men. Besides, women were at higher risk for musculoskeletal disorders than men19.  In Isosaki�s study10 with workers of a hospital nutrition service, 123 of them belonging to a public and 162 to a private hospital, the men presented a proportion of lost time 50% (CI 95%: 0.31-0.79) lower than that of the women in the two hospitals and when the rates of the frequency of the episodes in the two hospitals were compared it was found that among the women only the rate was 116% (CI95%: 1.58-2.95) greater among those that were responsible for children than among those who did not have that same responsibility.
As for physical space, normally the kitchen, right from its conception as well as in its construction, presents deficiencies both as regards the acquisition of equipment as also in its work flow, seeing that, from the point of view of the administrators and designers, this area, beyond calling for heavy investment, has no direct relationship with the end-product of the institution. Consequently, to compensate for the resulting physical inadequacies there is the need for the adaptation of production procedures, flows and rhythms, which increases the negative impact of an activity which is already, in and of itself, harmful to the health of the workers involved. The ergonomic question is not even taken into consideration, because, as we suppose, of the lack of awareness of the professionals involved, together with the lack of integration as from the planning stage, of administrators, architects, engineers and users.
Another factor deserving of mention is the insertion of the service in a Brazilian public institution, subject to the notoriously sluggish bureaucratic procedures, budgetary deficits, inadequate investments in health, low level of schooling of the workers, little technological innovation as regards equipment, whether in foodstuffs or in productive processes, which do not provide a favorable environment, differently from countries such as France. 20, 21 Despite the limitations of this study because of its cross-sectional character and the use of the workers` perceptions and not of medical diagnoses, this study is of the greatest importance so that preventive actions, the promotion of health, of improvements in the environmental conditions of the work-place, and of the work organization, may be adopted in nutrition services, absolutely essential to health institutions, though little studied
Bibliographical References
1 Lancman S, Siqueira AR, Queiroz MFF, Varela RCB. Estudo e interven��o no processo de trabalho em um restaurante universit�rio � em busca de novas metodologias. Rev Ter Ocup Univ S�o Paulo. 2000; 11(2/3):79-89.
2 Lemos MP, Proen�a RPC. Contribui�es da ergonomia na melhoria da qualidade higi�ncio-sanit�ria de refei�es coletivas: um estudo de caso. Higiene Alimentar. 2002; 16:29-34.
3 Matos CH de, Proen�a RPC. Condi�es de trabalho e estado nutricional de operadores do setor de alimenta��o coletiva: um estudo de caso. Rev Nutr. 2003; 16(4):493-502. 
4 Isosaki M. Interven��o nas situa�es de trabalho em um servi�o de nutri��o hospitalar de S�o Paulo e repercuss�es nos sintomas osteomusculares. Rev Nutr, v. 24, n. 3, p. 449-462, 2011.
5 Lima F de PA, Ara�jo JNG de, Souza RJ de, Alves GB de O. A produ��o das les�es por esfor�os repetitivos num restaurante universit�rio: an�lise ergon�mica e psicossocial. In: Lima MEA, Ara�jo JNG de, Lima F de PA. Ferreira Junior M. L.E. R: les�es por esfor�os repetitivos � dimens�es ergon�micas e psicossociais. Belo Horizonte: Livraria e editora sa�de; 1998.p.108-77.
6 Casarotto RA, Mendes LF. Queixas, doen�as ocupacionais e acidentes de trabalho em trabalhadores de cozinhas industriais. Rev Brasileira de Sa�de Ocupacional. 2003; 28 (107/108):109-26.
7 Haukka E, Leino-Arjas P, Solovieva S, Ranta R, Viikari-Juntura E, Riihim�ki H. Co-occurrence of musculoskeletal pain among female kitchen workers. Int Arch Occup Environ Health. 2006; 80:141-148.
8 Haukka E, Leino-Arjas P, Ojaj�rvi A, Takala E, Viikari-Juntura E, Riihim�ki H. mental stress and psychosocial factors at work in relation to multiple-site musculoskeletal pain: A longitudinal study of kitchen workers. European Journal of Pain. 2011; 15: 432-438. 
9 Chyuan JY, Du CL, Yeh WY, Li CY. Musculoskeletal disorders in hotel restaurant workers. Occup Med. 2004; 54(1):55-7.
10 Isosaki M. Absente�smo entre trabalhadores de Servi�os de Nutri��o e Diet�tica de dois hospitais em S�o Paulo. Rev Brasileira de Sa�de Ocupacional. 2003; 28 (107/108):107-18.
11 Kuorinka I, Jonson B, Kilbom A, Vinterberg H, Biering-Sorensen F, Andersson G, et al. Standardised Nordic questionnaire for the analysis of musculoskeletal symptoms. Appl Ergon. 1987; 18(3):233-37.
12   Isosaki M, Rocha LE. Contribui�es da ergonomia para melhoria das condi�es de trabalho em Unidades de Alimenta��o e Nutri��o. Revista Nutri��o Profissional. 2010; 5(29): 32-38.
13 Bertoldi CML, Proen�a RPC. Doen�a venosa e sua rela��o com as condi�es de trabalho no setor de produ��o de refei�es. Rev. Nutr. 2008; 21(4):447-454. 
14 Cann AP, Connoly M, Ruuska R, MacNeil M, Birmingham TB, Vandervoort AA, Callaghan JP. Inter-rater of output measures for a posture matching assessment approach: a pilot study with food service workers. Ergonomics. 2008; 51(4): 556-572.
15 Pehkonen I, Miranda H, Haukka E, Luukkonen R, Takala EP, Ketola R et al. Prospective study on shoulder symptoms among kitchen workers in relation to self-perceived and observed work load. Occup Environ Med. 2009; 66:416-423.
16 Jorge AT, Glina DMR, Isosaki M, Ribeiro ACDi CA, Ferreira J�nior M, Rocha LE. Dist�rbios osteomusculares do trabalho: fatores de risco em trabalhadores de nutri��o hospitalar. Rev Bras Med Trab 2009; 7:1-10.
17  Bongers PM, De Winter CR, Kompier MA, Hildebrandt VH. Psychosocial factors at work and musculoskeletal disease. Scandinavian Journal of Work, Environment &  Health. 1993; 19(5):. 297-312.
18 Alamgir H, Swinkels H, Yu S, Yassi A. Occupational injury among cooks and food service in the healthcare sector. Am J Ind Med. 2007; 50(7): 528-535.
19 Shiue HS, Lu CW, Chen CJ, Shih TS, Wu SC, Yang CY, Yang YH, Wu TN. Musculoskeletal Disorder among 52,261 Chinese Restaurant Cooks Cohort: result from the National Helth Insurance Data. J Occup Health. 2008; 50: 163-168.
20 Proen�a RP da C. Novas tecnologias para a produ��o de refei�es coletivas: recomenda�es de introdu��o para a realidade brasileira. Rev Nutr Campinas. 1999; 12 (1):43-53.
21 Sousa AA de, Proen�a RP da C. Tecnologias de gest�o de cuidados nutricionais: recomenda�es para qualifica��o do atendimento nas unidades de alimenta��o e nutri��o hospitalares. Rev Nutr Campinas. 2004; 17 (4):425-36. 
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