*Article* **Six Years of Sick Leave Spells in a Group of University Civil Workers. Can Modern Work Bring Them a New Health Problem?**

**Adriano Dias 1, João Marcos Bernardes 1, Miriam Malacize Fantazia 1, Carlos Ruiz-Frutos 2,4,\* and Juan Gómez-Salgado 3,4**


Received: 1 November 2018; Accepted: 19 December 2018; Published: 21 December 2018

**Abstract:** The objective of this study is to analyse sick leave episodes of a university's collective of statutory workers in the State of São Paulo, between January 2010 and December 2015. For this, a descriptive study analysed 5776 registered spells of sick leave of four university units: agricultural sciences; human health, health and animal reproduction, and biological sciences; an administrative unit; and a university hospital. The medical expert assessment was carried out by general practitioners and psychiatrists who managed sick leave and return to work cases. Around 52% had up to three sick leave episodes, and 10% of the workers had 20 or more episodes. Each spell of sickness absence lasted a median of 30 days (IQR 8–60 days). Among all of sick leaves, 35% had as a primary cause mental or behavioural diseases, of which 30% were depressive disorders, followed by around 18% related to the musculoskeletal system and the connective tissues. In the medical reports, 80% of the workers reported pain and 30% reported psychological symptoms. The collective, seen as privileged by many for their job stability, has a high percentage of sick leave due to mental illness, with extended periods which affect the levels of disability and reduce possibilities of return.

**Keywords:** sickness absence; public workers; university; psychosocial work environment; occupational health; health workers

### **1. Introduction**

Sickness absence is a complex phenomenon that is strongly influenced by factors other than health [1–3]. It has been suggested that many workers will attend work with conditions that others will be absent with, and that where there are high rates of absence there are also high rates of "presenteeism". Many EU governments have introduced programmes aimed at encouraging long term absentees getting back into the workforce [1].

In Brazil, civil servants may be statutory or public employees. The former are holders of public office and are subject to statutory regimes established by the federal, state and local governments. On the other hand, the latter are subject to the rules of the Consolidation of Labour Laws (CLT), the decree that governs labour relations in Brazil [4].

In Brazilian public universities, the same rule coexists. However, the workers are divided into two other categories, technical-administrative and professors. Also, there may additional differences between the weekly work time, which may be full or part-time, and the type of dedication, exclusive or not. Thus, Brazilian universities have a multiplicity of worker types, not to mention outsourced workers, who deserve a separate analysis.

As many as 12% of Brazilian workers are civil servants, a similar proportion to some Latin American countries, but far from the percentages found in developed countries, where the average is 21%, according to the Organization for Economic Co-operation and Development [5]. It is even further from some Scandinavian countries where more than a third of the economically active population is employed in the public service.

Even though working as a civil servant requires passing a civil service examination, it is highly desirable. This is due to the security and employment stability provided by the organisations, opportunities for professional formation and qualification, possibilities of professional advancement and salary increases through career plans and promotions, coverage of special pension regimes with higher pensions for lower contribution rates [6], while workers in the private sector tend to lead unemployment statistics. As a consequence of the higher level of education needed to be admitted to public service and its development during working years, more than half of civil servants have a higher education degree. On the other hand, in the private sector this percentage is 15% [7]. For example, more than 60% of the employees of a public university have a higher education degree, even though they occupy high school education level positions [8].

Although these benefits still exist or at least part of them, from the 1990s onwards and parallel to the transformations that occurred in business, the Government also reformed itself. It did so through a politico-ideological movement with economic roots, adopting management practices, until then typical of the private sector, and focusing on the search for quality and efficiency [9–13].

The changes in technical devices, management rules and the reorganisation of work environments resulted, for the workers, in an increase in qualification, workload and flexibility, in addition to the reduction of autonomy and remuneration. At the same time, this process accentuated competitive behaviours and disarticulated the capacity for social support, producing feelings of isolation and insecurity in employment [14,15]. In addition, the public service extinguished positions considered non-essential, allowing the hiring of outsourced workers (for a specific period of time, under different contract regimes and with unequal/lower salaries), of whom compliance with goals and an increase in pace and productivity was demanded [15].

A non-ideal work environment was generated as a result of all these changes, increasing psychosocial risk markers for workers' physical and mental health problems: excessive workloads, conflicting work demands, lack of clarity of function, lack of involvement in decision making and of influence on the way work is done, insecurity, ineffective communication and lack of social support from supervisors or colleagues [16,17]. These risk factors affected in quantity and intensity, what contrasts with the improvements in general health conditions of the world population in the same period [18] and, mainly, with the healthy worker effect [19].

The main indicator of workers' health problems is absenteeism [20], here defined as absence to work due to a disease and justified by a medical statement [21]. Studies on absenteeism in civil servants [22–27] indicate that the predominant disease is related to work activities and the professionals involved; and, also, that they are more frequent in female workers and in the age group between 30 and 45 years. Between 2003 and 2006, according to data from all civil servants employed by all departments and agencies related to the Government of São Paulo State (Southeast Brazil), nearly 200,000 sick leaves were granted each year, with mental disorders being responsible for almost 30% of these leaves [22].

In Brazil, official data [28] shows that mental disorders represent 10% of all pension benefits, being surpassed only by musculoskeletal disorders (20%) and external causes (25%). This is certainly resulting from the negative effects of these new work environments on workers' health.

In addition to the impact of absenteeism on productivity and interpersonal relationships at work, workers' illness often results in long-term sick leave. This implies difficulties in returning to work, mainly when it involves changes in job, function and the status derived from the limitations caused by the disease.

Thus, the objective of this study is to present an epidemiological profile of a university group of civil servants' sick leaves over a period of six years, as well as defining work characteristics and possible causes of sick leave.

#### **2. Materials and Methods**

#### *2.1. Study Design and Setting*

This is a descriptive study of sick leaves. Its population was composed of civil servants from a university located in inland São Paulo State, Brazil, that took sick leaves between the months of January 2010 and December 2015.

During the period that the information was collected by the University's Technical Section of Worker's Health, the university campus was composed by four academic units (agricultural sciences, human health, biological sciences and animal health and reproduction), an administration unit, and a university hospital.

#### *2.2. Participants*

The sum of the populations in these units, in the middle of the period (2012), was 4090 workers, among which about 60% were statutory civil servants, while the others were public employees subject to the CLT or outsourced public workers. The approximate proportional distribution of workers per unit, in the middle of the period, was: administration (5%), agricultural sciences (13%), human health and hospital (56%), animal health (11%), biological sciences (15%).

During the six years of the study, 965 workers were examined by physicians, resulting in 5776 episodes of sick leaves, which comprised the study sample. It should be noted that the estimates of the populations made available from each year were fluctuating, which made it difficult to establish precise annual denominators and imposed the need to analyse the data globally.

The institution has its own occupational medical service, who examines all statutory workers who request a sick leave with duration of two days or more. This service is composed by general practitioners, who evaluate sick leave applications due to non-psychiatric morbidity, and psychiatrists, who evaluate sick leave applications due to mental disorders. The service not only manages all sick leaves applications, since it is the only one that can grant or deny them, but also all cases of readaptation to work.

#### *2.3. Variables and Data Sources*

For the exploratory phase of the study, data was extracted from two institutional databases: (a) Integrated Occupational Management Software (IOM) (UNESP, São Paulo, Brazil), which identifies the worker and stores physician's evaluation data; (b) Healthcare Medical System (HMS) (UNESP, São Paulo, Brazil), which records information about cases of work readaptation.

It is important to highlight that the two databases were not integrated or built under the same computational architecture (neither for research purposes), nor did it allow searches or information filtering (in the case of the HMS), which made it necessary to evaluate one by one all cases of work readaptation already made by that service to make them coincide with the valuations of the period.

Then, after retrieving and organising the information, a database was built. It contained variables of the following types: sociodemographic (place of birth, sex, current age and age when hired by the university, marital status and coexistence with partner), job characteristics (position, work unit, rehabilitation history, working time in the institution and total work time), sick leave characteristics (duration of each episode, number of medical evaluations in the period, total duration of all episodes, reason of the leave classified by the International Classification of Diseases (ICD-10) and behaviour of repeated sick leaves) and work readaptation (if it happened, time passed until it happened and if it resulted in any limitations). The reason for each sick leave was defined as the first or main diagnosis

pointed by the physician, since it could have multiple reasons. Thus, it was necessary to create data mining tools to search for the reason of each leave and for variables related to the physicians' evaluations (type of injury, affected part and presence of psychological symptoms) in the IOM, a textual qualitative record base.

#### *2.4. Statistical Analysis*

The variables were analysed using simple and cumulative percentage distributions and measures of central tendency and dispersion (for discrete and continuous variables, respectively), using IBM SPSS software, v.20.0 (IBM, Armonk, NY, USA).

#### *2.5. Ethical and Legal Aspects*

The research has been carried out with the consent and support of the Human Resources of the units involved and was approved by the Ethics Committee of the Botucatu Medical School (protocol 1.874.625, of 12/19/2016).

#### **3. Results**

A total of 5776 spells of sick leave, of two or more days, from 965 workers, were studied. Table 1 shows that workers who took a sick leave had been hired by the university at a young age (28.6 ± 6.7 years), but they had been in the institution for a long time (21.1 ± 7.6 years) before taking the first sick leave during the period studied.


**Table 1.** Sociodemographic and working characteristics of the study population (n = 965).

\* cumulative percentage.

The majority were women (62.7%), lived with a partner (55.8%) and born in the State of São Paulo (98.7%). The largest proportion of workers belonged to the Human Health university unit (77.5%) and occupied mid-level healthcare positions (38.8%).

Table 2 shows that the population had, on average, about 50 years of age when they took the sick leave and that the average total duration of the sick leave per worker was 564 days, varying between 15 to more than 6 thousand days, distributed in single (23.5%) and multiple (76.5%) leaves. It should be highlighted that 23.5% and 17% of the workers had had one and two spells of sick leave, respectively, and almost 80% of the workers had up to 10 episodes during the study period. 10% had 20 or more, reaching a maximum of 59. Each spell of sick leave (n = 5776) had a median length of absence of 30 days (IQR 8–60 days), with minimums and maximums of 2 and 1439 days, respectively.


**Table 2.** Characteristics of sick leaves.


**Table 2.** *Cont.*
