Journal of Nursing and Socioenvironmental Health
2014, 1(1):71-78 - http://www.jonse.com.br Received: May 15, 2014 - Accepted: 30 May, 2014 DOI: 10.15696/2358-9884/jonse.v1n1p71-78
Micro and macro-determinants in the conception of health of temporary port workers: elements for occupational nursing Determinants: concepts of health of port workers Valdecir Zavarese da Costa1*, Marta Regina Cezar-Vaz2, Leticia Silveira Cardoso3 ABSTRACT Objective: To comprehend the conception of health of temporary port workers constituted in the port negotiation process. Methodology: Study of qualitative thematic analysis with hermeneutic-dialectical approach, where the software Nvivo 7.0 was used. The local of coverage of this research included the Port of Rio Grande, State of Rio Grande do Sul - Brazil. The period of accomplishment comprises the time range 2010-2012. Results: We highlight the empirical categories “Healthy habits” and “Working conditions” as conceptions of health of temporary port workers by establishing a system of relationships between the social micro-determinants macro-determinants of health. Conclusions: Both categories are articulated in the work product embodied in its reward, the wage, which is configured in the possibility of welfare for the worker. Descriptors: Worker’s Health; Occupational Nursing; Working Conditions
Micro e macrodeterminantes na concepção de saúde dos portuários avulsos: elementos para enfermagem do trabalho Determinantes: concepções de saúde portuários RESUMO Objetivo: Compreender a concepção de saúde dos trabalhadores portuários avulsos constituída no processo de negociação portuário. Metodologia: Estudo de análise qualitativa temática com abordagem hermenêutica-dialética, onde foi utilizado o software de Nvivo 7.0. O local de abrangência da pesquisa incluiu o Porto do Rio Grande, Estado do Rio Grande do Sul - Brasil. O período de realização compreende 2010-2012. Resultados: Destacam-se as categorias empíricas hábitos saudáveis e condições de trabalho como concepções de saúde dos trabalhadores portuários avulsos, estabelecendo um sistema de relações entre os microdeterminantes e os macrodeterminantes sociais da saúde. Conclusões: Ambas as categorias articulam-se no produto do trabalho materializado em sua recompensa, o salário, que se configura na possibilidade de bem estar para o trabalhador. Descritores: Saúde do Trabalhador; Enfermagem do Trabalho; Condições de Trabalho
Micro y macro determinantes en el concepción de la salud: estudio con portuarios Portuarios: concepción de la salud RESUMEN Objetivo: Comprender la concepción de la salud constituida en el proceso de negociación desarrollada por trabajadores portuarios. Metodología: Estudio de análisis cuantitativo, temática con abordaje hermenéutica-dialéctica, donde fue utilizado el software de análisis cuantitativo Nvivo 7.0 La investigación ocurrió en el Puerto de Rio Grande, en el estado del Río Grande del Sur - Brasil. El período de realización comprende 2010-2012. Resultados: Son dignas de destacar las categorías empíricas “hábitos saludables” y “condiciones de trabajo” como concepciones de salud de los trabajadores portuarios independientes, estableciendo un sistema de relaciones entre los micro-determinantes y los macro-determinantes sociales de la salud. Conclusiones: Ambas categorías se basan en el producto de su recompensa, el materializado en sueldo, lo que establece la posibilidad de bienestar para el trabajador. Descriptores: Salud Laboral, Enfermería del Trabajo, Condiciones de Trabajo
Enfermeiro. Doutor em Educação Ambiental - Universidade Federal do Pampa - Campus Uruguaiana. E-mail:
[email protected] Enfermeira. Doutora em Filosofia da Enfermagem - Universidade Federal do Rio Grande - FURG. E-mail:
[email protected] 3 Enfermeira. Doutora em Enfermagem - Universidade Federal do Pampa - Campus Uruguaiana. E-mail:
[email protected] * Autor correspondente: Rua Dr. Theodorico, n. 20. Bairro Medianeira, Santa Maria - RS CEP 97060-290. Telefone: (55) 91245479 1 2
Micro and macro-determinants in the conception of health of temporary port workers: elements for occupational nursing
Introduction The globalization process has stimulated the opening of markets, which demanded the new era in the port order in Brazil. The Law nº 8630/93 deals with the modernization process and provides on the legal regime of exploitation and installations of the organized ports1. Such legislation reproduces the need to increase productivity, from the work developed in the organized ports and from technological mechanisms, in order to lift up the country to the conditions of international competitiveness. To that end, it extinguishes the historical system of hiring labor force, marked by the domination of unions, in a dynamics of spoil and privileges2,3, and establishes the Management Body of Port Labor Force (OGMO, as per its acronym in Portuguese) as sector responsible for the control of labor force and referral of workers to the labor demands of ports. This fact has generated changes in the exercise of work: reduction in the number of workers on the team (shift), intensification of productivity, combined with technologies, thereby demanding “a new worker, with qualifications involving different knowledge, skills, psychological, sociocultural and physical characteristics, often, antagonistic towards those hitherto required” 3: 999. Within this interface that is established in Brazilian ports, health is a space of intense restructuring, both of work and of work environment, especially for temporary port workers (TPAs, as per its acronym in Portuguese) 4-5. Nevertheless, health is an essential element in the social scope of work. Its insertion starts from the design that health is an important biological and social determinant that, within the port environment, is confronted with economic questions that are established in the port restructuring process. Such workers act on a casual basis, without forming an employment bond, are linked to various port operators and are paid only when asked to perform some working activity, in a dynamics that is characterized by a complex of interrelated tasks relating to materials handling, which encompasses manual handling of goods, their lifting, conference, storage and surveillance. In this configuration, the health needs are reshaped, and the re-insertion of workers in the means of production can also be a means of enhancing the health and life of TPAs. The act of discussing 72
the health in the labor negotiation process can establish protective mechanisms to the conditioning factors typical of the port work and its detrimental consequences for the health. Under this perspective, the health-negotiationwork category is seized by the Nursing, through social determination, and embodied in the negotiation process by means of strength/ability of the workers to take up the health-labor relationship, in the solvability of decisions taken collectively. It means asserting that occupational nurses need to be attentive in relation to the organic conditions and the way in which the working conditions are negotiated, with sights to know their outcomes in the workers’ health. This is because the occupational nursing: “covers questions of the daily work that permeate its performance and determine the theoretical and practical knowledge in the worker’s health, the legal aspects involved in the pursuit of health promotion and prevention of occupational accidents and diseases” 6:24 . It holds its base of knowledge constituted of “health promotion and education, health surveillance of workers and nursing consultation”6:28. Furthermore, when one introduces the nursing into the port environment, expands the spectrum of comprehension of the health-disease process in the labor environment, constitutes knowledge for the intervention in the workers' health and, lastly, elements for the performance of occupational nurses. This study had the objective of comprehending the conception of health of TPAs constituted in the negotiation process, because the act of expanding the discussion about health in the port environment is to generate answers to the constant changes that are taking place in Brazilian ports and aggregate values in nursing practice when it comes to the intimate relationship between the categories ‘health’ and ‘work’. That way, this study is justified by the need to produce knowledge for the science of Nursing and by the shortage of studies using the model of social determinants of health involving port workers.
Methods This is a qualitative research, developed in the period from 2010 to 2012, which focuses on the conception of health established in the workhealth relationship constituted in the negotiation process developed by the TPAs. Such relationship is J. Nurs. Socioe. Health, 2014, 1(1):71-78
Costa VZ, Cezar-Vaz MR, Cardoso LS
understood as a social phenomenon, in a given social time. The study location was the Port of Rio Grande, State of Rio Grande do Sul - Brazil. From studies4-5,7, with the same population, we selected a sample of 30 TPAs. The intentional sample was grounded on the interest in obtaining data that could express the essence8 of the conception of health in the temporary port work. As inclusion criteria, we used the diversity of categories of workers and their quantitative. The composition of the sample was elucidated like this: one worker of Block, one Repairman, one Port Worker, one Watcher, twelve Dockers and thirteen Organizers. We used the technique of semi-structured interview, recorded, with the interest in justifying the size and the intentionality of the sample, thereby giving greater credibility to the study to the extent that the technique of data collection allows us to have flexibility, where the researcher-researched might differ from each other, with the interest in detailing their ideas. The data were organized to accomplish the thematic qualitative analysis, with the use of qualitative analysis through the software NVivo 7.0. The data or stretches of the transcribed texts were highlighted and prepared to compose the system of relationships between theoretical and empirical categories of analysis. The process of data analysis took place by means of thematic qualitative analysis by following the hermeneutic-dialectic approach10. The hermeneutic comprehension starts from that the subjects talk about their experience, from their comprehension of the context of work, which is sociohistorical. Accordingly, the subject hermeneutically
comprehends its own experience. In doing so, they unveil the comprehension of the phenomenon under the form of verbal language, which is their own experience in the relationship with themselves and with their jobs. Based on the comprehension of the subject who speaks, the hermeneutics allows the seizure of the most subjective part of the phenomenon10. That way, the dialectical comprehension of the experience of the subjects expressed in the speeches is the source of construction of the text, which contains each one of the livings of the port workers, precontextualized by the most general work in society. Therefore, this socio-historical context is the matter that comprises the work process, in a historical time belonging to the subject who narrates, and the macrocontext of the society, where the phenomenon is inserted. Ethical procedures: We have followed the Resolution 196/1996 of the National Council on Ethics in Research/ Brazilian Ministry of Health. This study was approved by the Research Ethics Committee at the Federal University of Rio Grande (Case nº 23116.6779 / 2005-98).
Results The meaning of health present in the speeches of the TPAs constitutes the thematic categories “Healthy habits” and “Working conditions”, in addition to expressing their conception with respect to health. Empirical attributes are explained in Figure 1. The composition of the analytical matrix derived from the
Healthy habits
Working conditions
Diet, sleep and rest
Compensation Safety
Physical exercises
Access to health services
Social Determinants in Health (SDH)
MACRO MICRO Interactions out of the working environment Diet Sleep-wakefulness Health Family Physical exercises services
MICRO Work value (wage) Safety conditions at work
MACRO Work value (wage) Social safety conditions
Conception of Health
Figure 1 - Categories emerged from the speeches of the TPAs J. Nurs. Socioe. Health, 2014, 1(1):71-78
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Micro and macro-determinants in the conception of health of temporary port workers: elements for occupational nursing
comprehension of health as a determinant element, and also determined, by work, and inversely9. The Healthy habits seized in dietary behavior, sleep-wakefulness, practice of physical activities, among others, gives the status of healthy to the habits that are characterized as micro-determinants9. In this category, health is also comprehended through the absence of illness, which ensures the exercise of work. On the approach in relation to the work, it determines the permanence and maintenance of welfare at work before the absence of illnesses. The Working conditions were presented in the speeches of workers as a reference to health as a form of warranty of work and inversely. Questions relating to financial attributes (compensation), access to health services, besides the inclusion of the family, are characterized in the macro-determinants of health. It establishes an essential interdependence between health and work. The speeches are exemplified in Table 1.
Discussion The category “Healthy habits” encompasses the set of elements that affect the biological and emotional balance of the worker in the different contexts of interaction. In this composition, the understanding of health includes “a system of objective relationships,
able to run autonomously in its complex content” 11:392, where the healthy habits correspond to the concrete form in which the workers will conceive something abstract. The sleep-wakefulness and the physical activities comprise the concrete in the constitution of the health of workers. A study conducted with port workers has found that the sleep is impaired when is related to alternation of working hours or to its duplication (2) . This is a fact highlighted in studies conducted with workers who show characteristics of work and employment bond similar to the ones of the TPAs. In a study conducted with nocturnal workers who perform activities with intense physical effort, the authors suggest a ratio between the indexes of sleep quality and physical effort by arguing that the greater the physical effort, the lower the sleep quality12. Another study links physical activity with dietary profile in truck drivers by delineating that drivers who work during the night have healthier dietary practices, such as intake of cereals, however, the practice of physical activity prevails in those drivers with a greater degree of instruction about two times more13. Both studies emphasize the quality of life through healthy dietary habits and physical activity by presenting qualitative outcomes in the workers’ health. Under this perspective, the practice of physical activity keeps relationship with the social micro-
Table 1 - Examples speeches
REPAIRMAN 20 DOCKER 10 PORT WORKER 12 ORGANIZER 1 ORGANIZER 10 TALLY CLERK 13
ORGANIZER 19
ORGANIZER 15
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Category healthy habits Health means everything because without it I cannot have, I cannot develop my work, and I cannot take care of my family. (...) Work, leisure, I believe that everything that encompasses this type of thing, a nancial stability (...). It’s all that is healthy. Food, work, sport, leisure, all that is healthy for me is health. It’s what provides you with health, having a healthy body, a healthy mind. (...) Without health we cannot work, cannot develop the working activities. (...) Health is what ensures your daily needs, your ability to work, makes you quiet. en , I see health as a priority for any purpose (...). Health is not getting sick, is the welfare, safety in my service (...). Physical and mental welfare. Emotional quietness, as well as the physical health has no diseases. Category working conditions In order to be healthy, you have to be well, mainly in your job. Be better paid. For me, it runs like this, a support, the simplest possible. Health is like having access to health care, having a larger access. One tricky thing I see is the FH, right! When we need a specialist, we have to wait two days in a queue to get a specialist. (...) ere are some things we get by means of agreement, but some things we have to pay for and it requires a lot of money. (...) do you know how much the magnetic resonance exam costs? Seven hundred! It’s an exam that one can conduct in ve, ten minutes. You have only to be scanned in a machine, but it costs seven hundred reais (Brazilian currency). Gosh! Does it weigh to the worker, doesn’t? Of course, we don’t feel it, but many people are out there gaining one minimum wage. It’s hard to them to pay seven hundred reais for an examination like that. J. Nurs. Socioe. Health, 2014, 1(1):71-78
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determinants with regard to individual characteristics, such as motivation, motor capacity, among others, or, on the other hand, shows some characteristics of macrodeterminants, such as access to sporting environments, available time and sociocultural support. Within the port space, such characteristics are influenced by the process of restructuring the work. Concerning the issue of diet, the conception of health of the TPAs emphasizes its maintenance, where the foods must meet all the nutritional requirements essential to the body as an individual protective mechanism against the environmental risks. A study that links cardiovascular diseases with behavioral risk factors has associated inadequate dietary practices and sedentary lifestyle with such morbidities. One should highlight physical inactivity as a prevailing factor for cardiovascular diseases14. Diet constitutes the micro and macro-determinants, endowed with the power/ability to work and with the capability to preserve healthy living conditions, thereby repelling pathological prognostics surrounding health. On the other hand, such reference made by workers is in line with the conception of health presented in the Law nº 8.080/90 of the Brazilian Federal Constitution, which considers the determinant factors of health represented in diet, housing, leisure, access to goods and services, parameters that express the level of social and economic organization of the country15. Such determinants find the correspondence for its maintenance in the world of work. In the category “Healthy habits”, the welfare encourages and maintains the workers in the job. Damages prevent the full development of activities, compromising the workforce. Health is embodied through the relationship between work and organic functions, under the pathological and clinical gaze of health. The pathology would constitute the inability to work and the threat to their subsistence and of their families. Thus, it triggers the proposition that, within the relationship between health and work, the health, seen by pathological aspects, is presented with a focus on the consequences of work, focused on the related diseases or on the environmental risk factors. These factors are interpreted in the allusion to health as safety at work, with characteristics of maintenance of force or safety in the exercise of work. As for the safety relating to the risk factors within the working environment, a study performed at the J. Nurs. Socioe. Health, 2014, 1(1):71-78
port of Rio Grande highlights the implementation of safety measures and the recognition of the TPAs about them. Thus, 97% of the port workers identify the Commission for Preventing Accidents, 67% the Program for Preventing Environmental Risks and 93% the Specialized Service in Safety and Health4. This fact contributes to the understanding that the safety relating to the environmental risk factors is recognized by the TPAs, also grounded on participation by means of the identification and denunciation of risks existing within the port environment. In any case, referring to health from the safety conditions within the port or the absence of illnesses is not enough to define the concept of health, but includes elements that allow TPAs to construct their understanding and subsidize the seizure of new benchmarks in the health-work relationship, thereby articulating the different social interconnections that involve the entirety of health. Hence, health “expresses the synergy with the life and work conditions and might only be considered in its entirety” 16:161. Entirety is a dimension that allows the Nursing to present itself as a workforce producer of the worker’s health, as demonstrated in studies performed by nurses in the port environment and that demonstrate that health promotion is an instrument of nursing professionals to change the health conditions of the TPAs4,5-7-17. Actions such as: advising and following a healthy standard of diet; creating propitious environments and encouraging the practice of regular physical activity; paying attention to the accomplishment of periodic physical, clinical and laboratory examinations; health education, within the port environment, are supportive mechanisms for producing healthy cultural habits on the part of the TPAs and their family members, thereby provoking behavior changes against derogatory actions to health. In the category “Working conditions”, the understanding of health is established by means of macro-determinants, where the financial attribute constitutes the welfare produced by the value relating to the performed work. This proposition contains the condition of social reproduction of the worker, since it will enable the maintenance of its life, including familial, as mentioned by them. This relationship also encompasses the time allocated for the exercise of work. The welfare will comprise, in addition to compensation, the exercise of work in an environment in which the dynamics 75
Micro and macro-determinants in the conception of health of temporary port workers: elements for occupational nursing
corresponds to the expectation of allocation, without the correspondence of the bond. This event was also identified in the port of Santos, where the workers must have “availability of time to win a place in the teams” 2:644. In the port of Rio Grande, the draw for the calling of TPAs to the exercise of work takes place in three shifts and, when it is not called at the first opportunity, it might wait to run for the next ones, but without compensation during this period. It establishes a fundamental relationship of economic interdependence, since the time of exercise of work will determine the compensation of work and, if there is no work, through the uncertainties generated by the lack of employment bond, it will have difficulties in the production of its health. Without health, it will present difficulties to perform the assignments of the job. In the perspective in which time corresponds to remuneration, the worker is subjected to the duplication of working hours with sights to increasing it. This occurrence expands the risk behavior by inducing the TPA to overcome the tolerable human limits. Nonetheless, the approach of the families in relation to the health understanding is a rescue of their needs for social organization and reproduction, where the management of responsibilities relating to their individual and family life is intertwined with the work in the face of the economic needs and health aspects related to it. This constitutes health from a set of actual needs in the structural construction as human and social being, who is subjected to macrodeterminant working conditions9. On the other hand, the welfare might be composed of satisfaction of the human health needs and implies the achievement of physical, psychological or social needs, including referring to access to health care, as reported by the workers. With this purpose, one intends to dissociate it from the concept based on illnesses or accidents, by recognizing it through the satisfaction of the human needs. Access to health care is a good needed in the constitution of health. When referring to the Family Health Strategy and to the Brazilian Social Security (INSS, as per its acronym in Portuguese), the workers approach their actual needs, as if it were a way to prove them. One should abstract the meaning of commodity in the health area, which can be acquired or not, thereby comprehending it through 76
the lack of this element in the constitution of health. In the speech of the worker (A15), the high cost of examinations, when it relates to compensation, and still compared with what is offered in public services, highlights the failure of the health system in the face of its needs. Studies conducted with communities linked to the Family Health highlight the delay in the attendance and the low solvability of health services. Nevertheless, specific studies that correlate the access of workers to health services have not been found. This proposition might represent the absence of comprehensive health care for workers, which stresses the reference made to the access and, consequently, affects the comprehensiveness of actions in this area, because they are not incorporated to the clinical needs of the care for workers. In this parameter, the consideration of health as welfare is distant from the health services offered to the TPAs, since the single access is subjected to the port structure, which is comprehended by the norms that regulate the work and the safety of the worker, besides being restricted to the prevention of accidents, diseases and occupational hygiene. As demonstrated in a study, the access to health services is not effective for 78,3% of the dockers. Moreover, 10% deny the requirement of periodic examinations19. Ultimately, one can see that the workers comprehend the antagonism of “health as a right of all and duty of the State”15. This is a proposition of subjects with rights, who associate their health needs to the duties of the State, of providing access and ensuring attendance, with sights to overcome them, however, it is not always achievable. Within the scope of the worker’s health policy, although it maintains the principles of universality and comprehensiveness, it prioritizes articulations in order to constitute an arsenal of protection and promotion of the workers’ health. In spite of the emphasis given by this policy to the experience and subjectivity of workers as important assumptions20, it has no mechanisms for holding immediate and specific actions aimed at the clinical care. The absence of illness, the attribute ‘value of work’ and the access to health services are forms that embody the health, which can be seen through the production of welfare, with a sense of healthy subject. In the health area, the entirety is constituted by the aggregation of healthy habits and working J. Nurs. Socioe. Health, 2014, 1(1):71-78
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conditions, thereby producing the welfare of the worker due to comprehending the constitution of its life. Such elements constitute knowledge needed to the Nursing, in order to make it more productive in this work context in a scientific way.
Conclusions The changes in the port context have been reflected in the conception of health of the TPAs, mainly related to the factors ‘safety’ and ‘compensation’, arising from the employment bond - temporary. The bond highlights the risks related to mode of operationalization, physical exhaustion and disinterest of the worker in performing the political role within the port working environment. When taken together, these factors represent the attributes whose control lies in the relationship with productivity. This is translated into investment of more time and energy in the working environment in exchange for the increased reward of labor, i.e., wage. Both categories are articulated by the work product embodied in its reward, the wage, configured in the possibility of welfare for the worker, constructed by the micro-determination of health over the work. Under the perspective of the worker’s care, the challenge in the studied reality is to associate the tradition of nursing in family care with the link that influences the worker’s health, where the family institution can be raised as an element in the production of health of TPAs. In the field of public health and in the specificity of the port environment, the Occupational Nursing gathers elements prone to health promotion for the TPAs. We consider the educational processes as measures of utmost importance in creating healthy environments. One should exemplify the creation of favorable environments for healthy practices, which enhances social interaction and provides access to information about the benefits of an active lifestyle, with sights to change behaviors and generate good outcomes in the workers’ health. Therefore, within the labor environment, such actions can define benefits to workers from the collective negotiation on health with the port operators.
Conflicts of Interest “The authors declared that there is no conflict of interest of any nature”. J. Nurs. Socioe. Health, 2014, 1(1):71-78
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