Correlation between quality of life and physical activity level of professionals of the Family Health Support Center (NASF)

| Introduction: Currently, health workers have been living with a high workload, resulting in increased service activities and decreased physical activity, affecting their quality of life. Physical activity is a fundamental aspect of the improvement of motor skills and work performance, allowing a healthy lifestyle. Objective: To verify the correlation between the quality of life and physical activity of family health support professionals. Methods: We evaluated 19 professionals aged (31.05±6.63 years) who worked in the three family health support centers (FHSC) of the city of Vitória de Santo Antão. Whoqol-bref and Baecke questionnaires were applied. Data normality was verified from the Shapiro-Wilk test and the Pearson correlation test was performed. Results: Positive Correlations were found between general score and physical activity during exercise and leisure (r=0, 852; p<0,001) and physical activity at work (r=0,611; p<0.001). There was a positive correlation between the physical domain of quality of life and the general score of habitual physical activity (r=0,520; p<0.05). There was a positive correlation between length of service and physical activity in exercise and leisure (r=-0.649; p<0.001) and physical activity at work (r=-0.559; p<0.05). Conclusion: The results allow us to conclude that there are positive correlations between activity level and quality of life. The practice of a physical activity is fundamental to the maintenance of work activities. Besides reflecting positively on social aspects.


INTRODUCTION
According to Unified Health System (Sistema Único de Saúde-SUS) guidelines, the Family Health Strategy (FHS) is part of primary care services. FHS teams comprise health care providers qualified by SUS to provide individual and collective primary care 1 . Effective operation involves relationships among services, including several communication channels with users, links and receptivity patterns 2 . FHS work is characterized by uncertainty and variation in working conditions and approaches to the organization of services 2 . Many health care providers within the public system have a heavy workload, which often interferes with their personal and leisure activities 3 .
Health care providers' jobs includes coordinated, oriented, individual and collective disease prevention and rehabilitation actions to change the state of health of the population, its determinants and conditioning factors 4 . The work process in health care involves a set of coordinated actions targeting individuals, families and communities, based on a synthesis of knowledge, methods and instruments 4 . The improvement and expansion of primary care services in Brazil notwithstanding, managers still face challenges in the approach to health care 5 . Family Health Support Units (FHSU) were therefore created to fully accomplish the goals of integrated health care and interdisciplinary primary care actions 6 .
FHSUs were established on 24 January 2008 through the Ministry of Health Administrative Ruling no. 154 to meet population demands uncovered by FHS teams and thus improve the quality and efficacy of primary care 7 . FSHUs have several goals, among which to ensure integrated and interdisciplinary actions as a means to consolidate FHS 8 . At a later time FHSUs are expected to improve the quality of care delivery rather than merely satisfying unmet demands, and to contribute to necessary changes in the SUS culture, which has historically prioritized the amount at the expense of the quality of services 9 .
Within this project to develop an approach to health care to broaden the scope of SUS through the inclusion of new knowledge and procedures in collective health, the "health of those who produce health" is a topic of considerable debates. The ongoing changes and practices within the health system came to raise concern with the quality of wotk and the quality of life (QoL) of health care workers (HCW) 10 . QoL may be understood as a set of factors which contribute to preserve well-being, and may apply to either individuals or groups 11 . In addition, QoL has strong relationship with the occupational activities people perform within society 11 .
The health of HCW has been related to QoL, long working hours being considered as its most complex component as a function of aspects such as practice of the profession, emotional factors, environment characteristics, exposure to pain and to patients under extreme suffering 12 , physical exhaustion, job dissatisfaction, and low salary 13 . Within this context, we call the attention to the work process at FHSUs devised to accomplish the ideal goal of broad scoped clinical practice, without reducing the number of users as a function of their diagnosis or the professional field of providers. This is to say, it seeks to help health care providers and managers see clinical practice beyond its fragmentary components, without dismissing or failing to take profit of their multiple sources of knowledge 14 .
The work process in the everyday work of HCW is often restricted to the accomplishment of quantitative goals and performance of preset procedures at the expense of the quality of services 15 . The creation of FHSUs broke with this pattern through the implementation of highly qualified actions to improve the problem-solving ability of teams, and the consideration of determinants of health and disease jointly with service users 16 . The National Policy of Health Promotion, launched in 2006, established the inclusion of Body Practices and Physical Activity within the basic health network and in the community, together with availability of physical educators at primary care facilities and in FHSU teams 17 . Physical activity is understood as any type of body movement that demands an energy expenditure above that at rest 18 . Low levels of physical activity have negative impact, and are intimately related to the state of health of people, with consequent impact on QoL 19 . Physical activity is described as an optimal means to improve QoL when regularly performed and under adequate supervision. Under such conditions it is considered a decisive factor for the control of problems such as obesity, hypertension and coronary artery disease. When physical activity becomes a healthy habit, work-related and motor responses improve, as well as QoL 20 . Physical activity influences everyday life for several reasons, including QoL aspects such as sleep, occupation, leisure and activities at home 21 . In turn it is influenced by several factors-for instance, according to ecological theories, by the relationship between individuals and their physical environment, among other individual, social and political determinants 22 . Thus investigating factors which have etiological interactions with active life (home, work and leisure) is highly valuable within public health 23 .
Given the aforementioned considerations, the aim of the present study was to test correlations between QoL and levels of physical activity among FHSU workers.

SAMPLING
Nineteen HCW at the three FHSUs in Vitória de Santo Antão, Pernambuco, Brazil, were recruited by means of non-probabilistic, or convenience, sampling for the present cross-sectional quantitative study. The principal investigator invited eligible subjects, none of whom refused since participation did not interfere with their routine. Similarly, no participant dropped out or was excluded from analysis.
FHSU teams are part of the staff at health care facilities with the aim to satisfy unmet demands. As a rule, team members gather in a separate room to hold meetings and plan activities. FHSUs were established following a survey of the main needs of service users. Therefore, teams seek to detect needs and shortages in their area taking into account geographical aspects to thus identify strong and weak points. We chose to perform data collection individually in these meeting rooms not to interfere with the routine of services and ensure confidentiality. At this moment we did not sort the participants according to their occupational category nor in the analysis of the collected data.
Participants were aged 31.05±6.63. Inclusion criteria were: having been hired by the city government of Vitória de Santo Antão and the municipal Secretariat of Health, being allocated to primary care and a member of a FHSU team. Refusal to respond any item on the administered questionnaires was considered an exclusion criterion.
The study was approved by the research ethics committee of Health Science Center, Federal University of Pernambuco, ruling no. 1,628,454. Participants were requested to read and sign an informed consent form that described all the study procedures.

ASSESSMENT QUESTIONNAIRES
Usual physical activity was assessed by means of a questionnaire developed by Baecke et al. 24 and adapted and validated for use in Brazil by Florindo and Latorre 25 . This instrument comprises 16 items relative to the three components of physical activity: the first 8 to physical activity at work/school (WSA), items #9 to 12 to leisure time exercising (ELA), and items #13 to 16 to leisure and locomotion physical activity to the exclusion of exercising (LLA). Item #1 inquires about the respondent's occupation, which is categorized as mild, moderate or vigorous according to Ainsworth et al.'s compendium 26 . Household chores are categorized as mild. Items #2 to 8 address proper physical activity at work. The ELA section begins with item #9, which includes questions on the intensity, duration and frequency of physical activity. Items #10 to 12 compare the respondent's ELA to that of same-age individuals, investigate sweating during leisure time, and frequency of exercise. LLA items include watching television (sedentary lifestyle), walking, cycling and time (minutes per day) spent walking/cycling to and from work, school and shopping. The global score is calculated by adding the three domain scores. In the case of missing answers, we considered the average score of the corresponding domain.
QoL was investigated by means of the World Health Organization's WHOQOL-BREF. This is a self-report questionnaire with two general items on QoL and satisfaction with health and further 24 questions which correspond to the 24 facets of the original WHOQOL, distributed across domains physical health, psychological, social relationships and environment. Items are responded on a Likert scale with options ranging from "not at all" to "an extreme amount," "extremely" or completely," "very poor" to "very good," "very dissatisfied" to "very satisfied," or "never" to "always." Responses are scored 1 to 5, except for items #3, 4 and 26 which have reverse scores (1=5, 2+4, 3=3, 4=1, 5=1). The scale does not provide a global score, because it is based on the idea that QoL is a multidimensional construct. Therefore, each domain is scored separately. For calculation, we considered the average score of all items in each domain and multiplied it times 4. As a result, possible scores ranged from 0 to 100, the higher the score, the better QoL 25 .

DATA ANALYSIS
We created a database on Excel and calculated measures of central tendency and dispersion and performed inferential analysis. Normality was investigated by means of the Shapiro-Wilk test, and the data were subjected to the Pearson correlation. All the analysis were performed with software Statistical Package for the Social Sciences for Windows (SPSS) version 17.0, from 2010. The significance level was set to p<0.05.

RESULTS
The sample comprised 19 HCW from three FHSUs, including three social workers (15.78%), three psychologists (15.78%), three nutritionists (15.78%), three physical educators (15.78%), five physical therapists (26.31%), one speech therapist (5.26%) and one occupational therapist (5.26%). Only three participants were male (15.78%). Table 1 describes the participants' occupation, number, sex, working hours and FHSU modality. Table 2 brings the results of descriptive analysis (mean, standard deviation, minimum and maximum) of variables age, years in the job, level of physical activity and scores on QoL domains. Table 3 depicts the correlation matrix for demographic data, physical activity domain scores and QoL. We found significant positive correlation between QoL social relationships with the psychological (r=0.714, p<0.001) and environment (r=0.526, p<0.05) domains and between QoL physical health domain and the global score on usual physical activity (r=0.520, p<0.05). We further found significant correlation between the global score on physical activity and the score on ELA (r=0.852, p<0.001) and WSA (r=0.611, p<0.001). The global score on physical activity also exhibited significant correlation with variable years in the job (r=-0.627, p<0.001) which was also significantly correlated to ELA (r=-0.649, p<0.001) and OSA (r=-0.559, p<0.05). Table 4 describes partial correlation coefficients between physical activity domains and QoL. Following control for age, years in the job, FHSU team, sex and occupation, only QoL social relationships domain remained significantly correlated to QoL psychological (r=0.891, p<0.001) and physical health (r=0.580, p<0.05) domains.

DISCUSSION
The results of the present study evidenced positive correlation between usual physical activity and years in the job (r=0.627). This finding diverges from those of another study that categorized the participants as very active, active, irregularly active or sedentary, and found that the individuals with 15 years of the job were the least irregularly active or sedentary 27 .
Workers need to perform physical activity on a steady basis, because benefits reflect on their job tasks 28 . A study conducted with FHSU workers in São Paulo, Brazil, found that an eight-hour workday interfered with the performance of activities relevant to QoL. However, the participants who worked four hours a day reported they did not have time enough to deal with their workload 29 .
Variable years in the job also exhibited positive correlation with ELA (r=0.649, p<0.001) and WSA (r=0.559, p<0.05). Work processes need to be globally thought over to achieve balance between work and QoL. According to the literature, quantifying productivity interferes with the pace of work, time for interaction, problem solving ability and teamwork 29 . In other words, when productivity goals are the main determinant of everyday actions at work and daily activities.
We further found significant correlation between QoL physical health domain and the global score on usual physical activity (r=0.520, p<0.50). This domain represents aspects such as sleep, activities of daily living, work capacity and pain, and thus that which people can or cannot do in their everyday routine 29 .
Neither QoL nor physical activity exhibited significant association according to age, sex, years in the job, allocated FHSU or occupation. In turn, we found positive correlation between the QoL social relationships and the psychological (r=0.891, p<0.001) and physical health (r=0.580, p<0.05) domains.
The results evidenced significant correlation between usual physical activity and QoL, particularly in regard to occupational activities, exercise and leisure. Variable years in the job exhibited strong correlation with some domains of the usual physical activity scale and with the physical health, psychological and social relationships domains of QoL indicative of improvement in both outcomes.
The main limitations of the present study derive from the small sample size, since there are only three FHSUs in the analyzed city. To this we should add some difficulty in the approach to participants as a function of the nature of their workplace and a heavy workload that restricted their availability for data collection.