Health Intervention Research with Women Babassu Coconut Breakers in Northeast Brazil

Health Intervention Research with Women Babassu Coconut Breakers in Northeast Brazil | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Health Intervention Research with Women Babassu Coconut Breakers in Northeast Brazil Scheila Regina Gomes Alves Vale, Eliana Napoleão Cozendey-Silva, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8571677/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Babassu coconut breakers (BCBs) in Brazil experience musculoskeletal pain associated with their labor activities. This population is part of the Countryside, Forest, and Waters Population (CFWP) and is predominantly composed of women whose health, quality of life, and income may be affected by chronic pain. This study aimed to evaluate changes in musculoskeletal pain following community-based interventions among BCBs. Methods An evaluation study of a community-based health intervention was conducted with BCBs aged 18 years or older from 25 villages in Northeast Brazil. A total of 316 individuals participated in the pre-intervention stage, 189 in the intervention stage, and 125 in the post-intervention stage. The study followed a non-randomized, pre–post design without a control group. The interventions included the implementation of work breaks and self-care exercises. Health-related quality of life (HRQoL) was assessed using the SF-36 questionnaire. Paired t-tests and repeated-measures analysis of variance were used for data analysis. Results Among participants who engaged in the self-care exercises, a significant reduction in pain perception was observed, particularly during the dry season. Post-intervention results showed improvements in five SF-36 domains: physical role limitations, pain, social functioning, emotional role limitations, and mental health. Favorable changes were observed across both dry and rainy seasons in within-group comparisons over time. Conclusions The interventions were associated with reductions in musculoskeletal pain and improvements in self-reported health-related quality of life among BCBs. These findings support the relevance of incorporating health promotion strategies focused on self-care and pain management within primary health care contexts serving rural working populations. Health sciences/Health care Health sciences/Medical research Health-related quality of life health education health promotion health research evaluation community-based research participatory research Figures Figure 1 Figure 2 Figure 3 Contributions to the literature This study provides an empirical evaluation of musculoskeletal pain interventions among BCBs, a traditional women-dominated workforce engaged in labor-intensive extractive activities. By assessing outcomes across both dry and rainy seasons, the study provides evidence on how environmental and work-intensity variations are associated with pain perception and intervention effectiveness. The findings indicate that simple, community-based strategies — work breaks and self-care exercises — may contribute to reductions in pain and improvements in HRQoL in rural settings with limited resources. The intervention model is low-cost, feasible, and culturally grounded, supporting its potential applicability within primary health care and health-promotion practices for manual-labor populations. INTRODUCTION Health is a fundamental human right and an essential resource. Health promotion and educational interventions delivered through Primary Health Care (PHC) play a central role in advancing universal health coverage, a cornerstone of the sustainable development agenda [1,2]. In Brazil, health promotion (HP) actions are primarily implemented within PHC [3], which is responsible for addressing health needs across diverse territories and population groups, including rural and traditional communities. Although the Countryside, Forest and Waters Population (CFWP) holds the universal right to health, this population continues to face challenges in accessing health promotion strategies, particularly in rural and remote areas. Babassu coconut breakers (BCBs) are part of the broader CFWP and predominantly consist of women. In Brazil, BCBs are legally recognized as traditional peoples and communities, a designation applied to culturally distinct social groups with specific ways of life and work [4]. BCBs preserve their cultural and economic practices through the sustainable extraction of products from babassu palm trees (Attalea speciosa and A. vitrivir), an activity closely linked to their livelihoods and territorial contexts in northern and northeastern Brazil [5,6]. These traditional agro-extractive activities are carried out primarily through manual labor and are shaped by environmental conditions, seasonal cycles, and collective work arrangements. The collection and cracking of babassu coconuts are traditionally performed collectively, involving gatherings of women and constituting a daily ritual marked by conversation, singing, and the exchange of experiences [7]. Among BCBs, the babassu palm holds symbolic meaning as a maternal figure, associated with collective identity, autonomy in work, and the generation of income to support their families [8]. These social and cultural dimensions contribute to how BCBs perceive their health and well-being. The traditional work process involves collecting coconuts during the dry season (July to December) and storing them for cracking during the rainy season (January to June). During collection, coconuts are transported in bags carried on the head, shoulders, or back. To crack the coconuts, BCBs sit on the ground and use a simple manual tool consisting of an upward-facing blade stabilized under one leg, striking the coconut to open it and remove the almonds [7]. This work organization requires repetitive movements, sustained postures, and prolonged physical effort. Musculoskeletal pain is a well-recognized occupational health issue and represents a public health concern due to its association with reduced work capacity, diminished quality of life, and increased vulnerability to chronic conditions. Among labor-intensive rural workers, pain is often normalized as an inherent aspect of work, contributing to delayed care-seeking and limited access to preventive interventions. In traditional extractive contexts, these challenges are compounded by social inequities, geographic isolation, and restricted access to structured health services. Health-related quality of life (HRQoL) has been widely used as an indicator to assess the broader impacts of occupational exposures on physical, emotional, and social well-being. Instruments such as the SF-36 allow for a multidimensional evaluation of how pain and working conditions affect daily functioning beyond clinical outcomes alone. Despite increasing recognition of musculoskeletal disorders among rural and extractive workers, there remains a paucity of intervention-based studies assessing strategies to manage pain and improve HRQoL in these populations, particularly those grounded in community participation and local contexts. In this context, the present study aimed to introduce and evaluate a community-based health intervention focused on work breaks and self-care exercises to manage musculoskeletal pain among babassu coconut breakers. By assessing changes in pain perception and health-related quality of life across different seasonal conditions, this study seeks to contribute evidence on feasible health promotion strategies for traditional extractive workers within a public health framework. METHODS This was an evaluation study of a community-based health intervention [9] conducted among women BCBs between March 2018 and December 2020. The study adopted a non-randomized, pre–post intervention design without a control group and was not conducted as a randomized study. The intervention was implemented and evaluated under a participatory action research framework [10], and mixed methods were applied [11]. The research team consisted of academics, healthcare professionals, and a communication professional. In addition, a local government rural education practitioner, with a history of respectful relationships and support for the participating BCB community, was involved in the study. Sample BCBs aged 18 years or older who engaged in the traditional collection and cracking of babassu coconuts were selected. Sample size was calculated using the Winpepi program [12], considering α = 5%, β = 10%, and a prevalence of low back pain of 57%. The estimated sample size for the study sample was 377 BCBs. Sampling was convenience-based. Participants were not randomly allocated, and all eligible individuals who agreed to participate were included according to availability and continuity in the intervention activities. The study included 316 participants in the pre-intervention stage, 189 in the intervention stage, and 125 in the post-intervention stage. Loss to follow-up occurred over the study period due to the voluntary nature of participation and contextual constraints inherent to community-based field research. Participants were from 25 villages across three districts of Caxias, the fifth-largest city in the state of Maranhão (Caxias-MA), Northeast Brazil (latitude 4°52′29″ South, longitude 43°20′49″ West). Pre-and post-intervention stages In the pre-intervention stage, the validated SF-36 questionnaire was administered to 316 BCBs. In the post-intervention stage, the questionnaire was administered to the 125 BCBs who remained in the study until its completion. No parallel control group was used; comparisons were performed within participants across time points. The SF-36, which has established reliability and validity, includes items related to living and working conditions and assesses overall health status across multiple domains. Intervention Over eighteen months of field research, 189 BCBs participated in three workshops and three general BCB meetings. In addition, eight follow-up meetings were conducted in each participating village, all held within the same week. The first two workshops provided guidance to BCB research volunteers on the two proposed interventions: self-care exercises for the musculoskeletal system and work breaks. During the intervention stage, participants implemented the prescribed self-care exercises and work breaks. Intervention exposure was not standardized across participants and reflected real-world adherence within a participatory and community-driven context. Intervention assessments were conducted both qualitatively, through dialogues held during monthly meetings, and quantitatively, using a three-question scale administered weekly. Individual questionnaires were completed by participants and delivered to the researcher at each monthly meeting. The three-question survey asked research volunteers which intervention was used and whether work productivity was affected. The third question consisted of a zero-to-ten self-rated pain scale aligned with facial expressions, addressing the presence and severity of musculoskeletal pain. Details of the intervention activities are described below. Exercise and self-care related to pain A health self-management program based on the McKenzie Method of Mechanical Diagnosis and Therapy (MDT), with a focus on education and self-care, was developed. MDT is recommended as a treatment option for musculoskeletal conditions in several countries and may be applied in acute, subacute, or chronic stages, as well as to different body regions [13–15]. During the intervention period, exercises were performed autonomously by the BCBs, guided by strategies aimed at preventing and alleviating pain according to individual needs (Figure 1). Participants were instructed to perform the exercises before, during, or after work activities, depending on the period that provided greater relief and well-being. INSERT Figure 1. Standing and prone lumbar extension exercises, seated cervical extension with retraction, and shoulder extension exercises performed by babassu coconut breakers during the intervention. Because pain represents a relevant constraint in the work of BCBs [7], this variable was selected to assess the outcomes of the health intervention, despite its complex and subjective nature and its influence by multiple personal factors [16–18]. Due to its ease of application [15], the facial pain scale was used to quantify pain intensity and severity. Work breaks Recommendations for work breaks were based on a Brazilian regulatory standard and the existing literature. Brazilian Regulatory Norm 17 [16] addresses working conditions and organizational practices, including mandatory work breaks. According to this norm, in electronic data processing activities, a minimum 10-minute break is required for every 50 minutes of activity. Kroemer and Grandjean [19] highlight the importance of rest breaks as a physiological requirement for maintaining performance and efficiency, regardless of whether work involves manual labor or tasks that strain the nervous system. The authors estimate that rest breaks should generally account for approximately 15% of total working time, with up to 20–30% considered acceptable or necessary in certain occupations. In this study, a passive break of 10 minutes every two hours of work was recommended and agreed upon by the participants. This break was intended to prevent and alleviate fatigue and to facilitate physiological recovery. Data analysis Observations of work situations were conducted through analysis of the actual activities performed by BCBs, based on theoretical assumptions of Ergonomics [20]. Descriptive analyses, including frequencies, means, and standard deviations, were applied to data collected at all stages. Paired t-tests and repeated-measures analysis of variance were performed to compare outcomes before and after the interventions using SPSS software, version 20.0. Given the non-randomized design and absence of a control group, analyses were interpreted as within-group comparisons over time. Comparisons were made between BCBs who participated in all interventions over the 18-month period (n = 189) and those who did not participate in all intervention activities (n = 127). Ethics approval and consent to participate The study was approved by the Research Ethics Committee of the National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation (ENSP/Fiocruz), under Opinion No. 2,287,163. The study was also registered in the National System for the Management of Genetic Heritage and Associated Traditional Knowledge (SisGen), under Protocol number AE5F09A. Written informed consent was obtained from all participants. Consent for publication Written informed consent for publication was obtained from all participants. RESULTS Sociodemographic aspects A total of 316 individuals participated voluntarily in the study during the pre-intervention stage. Among these participants, 97.8% were female, with a median age of 44 years (Table 1). INSERT Table 1. Sociodemographic characteristics and living and working conditions of agro-extractive workers in the city of Caxias-MA. Health self-perception Table 2 presents the comparative analysis of the eight domains of the general health questionnaire (SF-36) in the pre- and post-intervention stages. Statistically significant differences were observed in five of the eight domains. The domains related to limitations due to physical and emotional aspects, pain, social aspects, and mental health showed significant changes. Mean scores increased after the intervention, suggesting an improvement in BCBs’ self-perceived health status over time. INSERT Table 2. Comparison of the general health status of agroextractive babassu coconut breakers in the municipality of Caxias-MA, Brazil, in the pre-intervention (N = 316) and post-intervention (N = 125) stages. Self-perception of work production Northeastern Brazil is characterized by two distinct seasons. Analyses were stratified by season (dry or rainy), considering variations in BCBs’ work production between these periods. Work production was reduced during the rainy season due to difficulties in accessing babassu palm trees. In contrast, during the dry season—when babassu collection is more intensive—a higher frequency of musculoskeletal pain was reported according to the three-question scale (Figure 2 and Table 3). INSERT Figure 2. Number of interventions according to data collection month and work production. INSERT Table 3. Percentage of babassu coconut breakers according to the period of the year, type of intervention and perceptions of reduced pain and work production. Figure 3 shows the distribution of interventions among BCBs (work breaks, exercises, or both) according to month of the year and self-perceived work production. Repeated-measures analysis indicated statistically significant differences for one or both interventions comparing participants reporting no intervention exposure with those reporting one or both intervention components (F = 2.46; p = 0.01), based on within-participant comparisons over time, as well as significant effects across seasons (dry: F = 4.69; p < 0.01; rainy: F = 12.03; p < 0.01). INSERT Figure 3. Percentage of babassu coconut breakers according to season, type of intervention and perceptions of pain and work production. Self-rated pain scale Regarding musculoskeletal pain in relation to work breaks and seasonality, reduced pain perception was observed in both periods (dry: 11.7; p < 0.01; rainy: 28.4; p < 0.01). With respect to the association between pain perception and the performance of self-care exercises, reduced pain perception was observed during the dry season (21.6; p < 0.01) (Table 3). Figure 3 also illustrates the distribution of interventions among BCBs (work breaks, exercises, or both) according to month of the year and pain perception. Repeated-measures testing showed statistically significant differences for one intervention compared with no intervention (p = 0.03), as well as between one and two interventions (p < 0.01), for both seasons (dry: F = 9.04; p < 0.01; rainy: F = 7.54; p < 0.01). Co-production of the Pain Self-Care Guide An illustrated guide was developed to support regular exercise practice for pain self-management. The guide was co-produced and validated by study participants, with the aim of facilitating knowledge translation and reaching a broader audience [21]. DISCUSSION This study implemented, monitored, and evaluated two interventions integrated into the daily work activities of BCBs in Caxias-MA, Brazil, within a non-randomized, community-based pre–post design, with the aim of increasing the degree of control exercised by the BCB population over their health and assessing whether the interventions improved self-reported health status across the SF-36 domains associated with health-related quality of life (HRQoL). Reading and Wien [22], in discussing the approach of poverty as a determinant of health, propose a perspective on Indigenous communities that differs from income-based conceptualizations of poverty. For this community, for example, “the good life does not mean making money, buying things, or winning awards. Rather, it has to do with taking care of yourself, your family, and your community” (community in the study: 10). This perception contrasts with and complements the factors that influence the positive self-perception of health expressed by the BCBs population. According to Weyers et al. [23], social determinants should be considered in strategies aimed at improving health behaviors among populations in lower social strata. Furthermore, countries that reorient their health systems toward Primary Health Care (PHC) are better positioned to advance global health and development agendas than those with systems focused on curative medical treatment [1]. The intervention actions were validated by the BCBs participating in the study. The workshops organized during the intervention process contributed to a better understanding of the demands imposed by agro-extractive work. Participants reported increased capacity for self-care, particularly in relation to the musculoskeletal system, including fatigue prevention and improvements in posture and movement through health self-management practices. These elements are consistent with approaches aimed at promoting health at work and supporting quality of life [24]. When assessed using the SF-36, five of the eight domains—limitations due to physical aspects, pain, social aspects, emotional aspects, and mental health—showed improvements in the post-intervention stage, which is consistent with the study hypothesis, that improvements in working conditions combined with self-care practices, exercises, and work breaks may favor BCB health. The Social Aspects domain presented the highest mean scores in both study stages, indicating higher HRQoL values in this dimension during the pre-intervention (85.28) and post-intervention (90.10) periods. The high proportion of participants reporting leisure activities (96.8%), including cultural, social, religious, and ancestral practices, may have contributed to these findings. Evidence from other populations engaged in traditional and labor-intensive activities provides relevant context. An epidemiological study involving artisanal fishers and shellfish gatherers [25], which applied the Disabilities of the Arm, Shoulder and Hand (DASH) instrument and the SF-36, identified negative effects of work on upper limb function among women and demonstrated that functional capacity and pain domains significantly interfered with daily life and work activities. Similarly, in the present study, the SF-36 domains related to limitations due to physical aspects and pain showed the lowest mean scores in both assessment stages, indicating greater impairment in these dimensions of HRQoL among BCBs. These findings are consistent with evidence from a systematic review examining community-based interventions for chronic musculoskeletal conditions in rural and remote populations [26]. That review identified education combined with exercise as the most consistent intervention associated with reductions in musculoskeletal pain, while educational interventions alone produced heterogeneous effects. Ergonomic modifications yielded variable and context-dependent outcomes. The authors also highlighted the limited number of high-quality intervention studies in rural and remote settings and emphasized the importance of culturally and contextually adapted strategies. In this regard, the present study contributes to the existing literature by suggesting that community-based interventions incorporating self-care practices and work organization strategies may be associated with reductions in pain and improvements in HRQoL among rural women engaged in agro-extractive labor. Data from the Global Burden of Disease, Injuries, and Risk Factors Study [27] indicate that low back and neck pain were the leading causes of disability worldwide in 2015, with musculoskeletal disorders accounting for 18.5% of years lived with disability. Although years of life lost due to musculoskeletal disorders have declined, years lived with disability have remained relatively stable, suggesting that these conditions are likely to continue to represent a substantial public health burden. In Brazil, Bezerra et al. [28] reported a high prevalence of chronic musculoskeletal conditions, affecting approximately one in five adults, with higher prevalence among women. Data from the 2013 National Health Survey indicated a 40% higher prevalence of chronic musculoskeletal conditions among women compared to men. Despite the existence of a public, universal health system, the economic burden associated with chronic conditions remains considerable, reinforcing the relevance of strengthening PHC-oriented strategies. With regard to work breaks and self-care exercises, stratified analyses by season and perceived work production showed statistically significant differences for the intervention groups compared with participants who did not engage in the interventions. These findings are consistent with observations reported by Hipólito et al. [29] and Biman et al. [30]. Babassu coconuts and their derivatives play an important role in the subsistence of traditional communities, contributing to food security and income generation through commercialization [5]. Reduced perception of musculoskeletal pain associated with work breaks was observed in both dry and rainy seasons. In relation to self-care exercises, reduced pain perception was observed during the dry season. These results are consistent with findings reported by Isosaki et al. [31], who observed reductions in work-related musculoskeletal symptoms and improvements in work conditions following the implementation of educational interventions, work breaks, and posture-related guidance in a hospital nutrition service. Similarly, qualitative findings from the present study suggest that the co-production of the Pain Self-Care Guide supported the development of self-care capacities among BCBs, particularly regarding musculoskeletal health, posture, and fatigue prevention. Several limitations should be considered when interpreting the findings. These include the reduction in sample size over the study period, low levels of formal education among participants, and irregular completion of follow-up questionnaires, which may have affected the quantitative analyses by reducing statistical power and influencing measures of variability. In addition, individual productivity could not be directly measured, necessitating the use of self-reported assessments. Despite these limitations, sustained dialogue throughout the field research period enabled discussions on work processes and their relationship with health, including autonomy, self-regulation of work pace, self-care practices, load handling, and the adoption of exercises aimed at musculoskeletal health. Discussions also addressed possibilities for improving agro-extractive activities through qualification, diversification, and commercialization of babassu-derived products, with potential implications for income generation. The educational actions focused on musculoskeletal self-care were interdisciplinary and multiprofessional. Within the participatory research framework, an illustrated guide was developed to support recall and performance of the recommended exercises. This material aimed to support injury prevention in body segments most affected by agro-extractive work. The guide was written in Cordel format, a form of popular literature widely used in northern and northeastern Brazil [32], employing accessible language and illustrations to facilitate comprehension and dissemination among BCBs. Finally, interactions facilitated through workshops, food production activities, and meetings to validate the interventions and the Pain Self-Care Guide fostered exchanges among BCBs from different villages and municipalities. Collaboration with professionals from public institutions, including ENSP/Fiocruz, Brazilian Agricultural Research Corporation (Embrapa), the State Department of Family Agriculture, and the Municipal Agriculture Department, contributed to broader recognition of the value of agro-extractive work and the rights of BCBs as a traditional community. The participatory methodology and instruments employed in this study were shown to be feasible and may be applicable to similar populations, particularly in contexts characterized by low levels of formal education and challenges in data collection. From the perspective of social determinants of health, the findings highlight the importance of combining health-related knowledge and self-care practices with broader actions aimed at strengthening local processing units for babassu-derived products. Such initiatives may contribute to the valuation of work, income generation, and the participation of women in decision-making processes related to extractive activities. These factors may influence quality of life, innovation, and the retention of younger generations within their territories [33,34]. Overall, the findings suggest that improvements in working conditions combined with health self-care practices, exercises, and work breaks were associated with favorable outcomes for BCB health. In addition, the actions developed through this study contributed to strengthening collective identity and social organization among women engaged in babassu agro-extractive activities. CONCLUSION The research, conducted in Caxias, Maranhão, used a participatory action research approach, focusing on women BCBs who engage in physically demanding tasks that often result in musculoskeletal pain. The intervention involved implementing work breaks and self-care exercises, specifically based on the McKenzie Method of MDT for musculoskeletal problems, within a non-randomized, community-based framework. The results of the study indicated reduced musculoskeletal pain among BCBs, particularly during the physically strenuous dry season. This decrease was observed among participants who adopted work breaks as well as those who practiced self-care exercises, with greater reductions in pain perception observed during the dry season. The post-intervention phase also showed improvements in several domains of the SF-36 questionnaire, including limitations due to physical aspects, pain, social aspects, emotional aspects, and mental health. These findings suggest that the combined intervention of improved working conditions and health self-care practices, including exercises and work breaks, was associated with better self-reported health and quality of life among BCBs. The study offers a model for addressing work-related health issues in low-resource settings and highlights the relevance of community-participatory approaches for improving health-related quality of life among populations engaged in labor-intensive activities. The findings underscore the importance of prioritizing worker health by demonstrating that interventions based on minimal resources and community engagement may contribute to meaningful health improvements. For health systems, particularly in regions with a high prevalence of manual and extractive labor, this study illustrates a preventive and health-promoting approach that may help reduce the long-term burden associated with chronic musculoskeletal conditions. These interventions are consistent with broader public health goals focused on prevention and health promotion and may inform similar strategies in other settings. Abbreviations BCB Babassu Coconut Breaker CFWP Countryside, Forest, and Waters Population DASH Disabilities of the Arm, Shoulder and Hand HRQoL Health–Related Quality of Life MA Maranhão MDT Mechanical Diagnosis and Therapy PHC Primary Health Care Declarations Ethics approval and consent to participate The study was approved by the Research Ethics Committee of xxxx (Opinion No. 2,287,163). It was also registered in the National System for the Management of Genetic Heritage and Associated Traditional Knowledge (SisGen), under protocol number AE5F09A. All procedures performed in this study were conducted in accordance with the ethical principles of the Declaration of Helsinki and with applicable national research ethics regulations. Written informed consent to participate was obtained from all participants. Consent for publication Written informed consent for publication was obtained from all participants. Funding This work was supported by the Fundação de Amparo à Pesquisa e ao Desenvolvimento Científico e Tecnológico do Maranhão (FAPEMA) under Grant No. 01109/18 (Edital 002/2018); by the Inova Fiocruz Program – Knowledge Generation (Grant No. VPPCB-007-FIO-18-2-47); and by the Federal Institute of Education, Science and Technology of Maranhão (IFMA) through the Support for the Publication of Scientific Articles – Public Servant program (PRPGI No. 269/2021). Availability of data and materials All data supporting the findings of this study are included in the manuscript. The datasets generated and analyzed—comprising intervention records, pain assessment measures, and SF-36 domain scores—are presented in the tables and figures within the article. No additional datasets are publicly available beyond the material presented in the manuscript. Competing interests The authors declare that they have no competing interests. References Hone, T., Macinko, J. & Millett, C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? Lancet 392 (10156), 1461–1472. 10.1016/S0140-6736(18)31829-4 (2018). Ekinci, G. The impact of maternal and child health on sustainable development goals: evidence from Turkic Republics (2000–2020). BMC Public. Health . 25 , 4031. 10.1186/s12889-025-25172-z (2025). Lotta, G. & Nunes, J. COVID-19 and health promotion in Brazil: community health workers between vulnerability and resistance. Glob Health Promot . 29 (1), 14–22. 10.1177/17579759211012375 (2022). Calegare, M. G. A., Higuchi, M. I. G. & Bruno, A. C. S. Traditional peoples and communities: From protected areas to the political visibility of Social groups having ethnical and collective identity. Ambient Soc. 17 (3), 115–134. doi.org/10.1590/S1414-753X2014000300008 (2014). Porro, R. The invisible babassu economy and its importance for livelihoods in agro-extractivist communities. Bol. Mus. Para Emílio Goeldi Cienc. Hum. 14 (1), 169–188. 10.1590/1981.81222019000100011 (2019). Instituto Brasileiro de Geografia e Estatística. Senhoras das palmeiras. Retratos: a revista do IBGE. ;(15):8–13. (2019). Available from: https://biblioteca.ibge.gov.br/visualizacao/periodicos/2929/rri_2019_n15_jan.pdf Vale, S. R., Bonfatti, R. J., Souza, A. G. & Teixeira, L. R. Ergonomic analysis of the traditional babassu coconut opening in the city of Itapecuru-Mirim, Maranhão, Brazil. Rev. Bras. Saude Ocup . 43 , e2. 10.1590/2317-6369000002416 (2018). Sax, S. & Angelo, M. Brazil’s ‘coconut breakers’ feel the squeeze of Cerrado development. Mongabay . Nov 12 [cited 2025 Dec 14]. (2019). Available from: https://news.mongabay.com/2019/11/brazils-coconut-breakers-feel-the-squeeze-of-cerrado-development/ Martin, J., Cheng, D. & Stranges, S. Population health intervention research: myths and misconceptions. Int. J. Public. Health . 62 , 845–847. 10.1007/s00038-017-0992-3 (2017). Cordeiro, L., Soares, C. B. & Rittenmeyer, L. Unscrambling method and methodology in action research traditions: theoretical conceptualization of praxis and emancipation. Qual. Res. 17 (4), 395–407. 10.1177/1468794116674771 (2017). Ivankova, N. & Wingo, N. Applying mixed methods in action research: methodological potentials and advantages. Am. Behav. Sci. 62 (7), 978–997. 10.1177/0002764218772673 (2018). Abramson, J. H. WINPEPI updated: computer programs for epidemiologists, and their teaching potential. Epidemiol. Perspect. Innov. 8 (1), 1. 10.1186/1742-5573-8-1 (2011). May, S. & Donelson, R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J. 8 (1), 134–141. 10.1016/j.spinee.2007.10.017 (2008). Poitras, S., Blais, R., Swaine, B. & Rossignol, M. Management of work-related low back pain: a population-based survey of physical therapists. Phys. Ther. 85 (11), 1168–1181. 10.1093/ptj/85.11.1168 (2005). Spoto, M. M. & Collins, J. Physiotherapy diagnosis in clinical practice: a survey of orthopedic certified specialists in the USA. Physiother Res. Int. 13 (1), 31–41. 10.1002/pri.390 (2008). Ciena, A. P. et al. Influência da intensidade da dor sobre as respostas nas escalas unidimensionais de mensuração da dor em uma população de idosos e de adultos jovens. Semina Cienc. Biol. Saude . 29 (2), 201–212. 10.5433/1679-0367.2008v29n2p201 (2008). Marques, J. O. A dor e os seus aspectos multidimensionais. Cienc. Cult. 63 (2), 28–32. 10.21800/S0009-67252011000200010 (2011). Masulo, L. J., Martins, M. L. S., Costa, D. R. & Nicolau, R. A. Methods for qualitative and quantitative analysis of pain and quality of life validated in Brazil: systematic review. Rev. Gaucha Odontol. 67 , e20190022. 10.1590/1981-86372019000223435 (2019). Kroemer, K. H. E. & Grandjean, E. Manual de ergonomia: adaptando o trabalho ao homem 5th edn (Bookman, 2005). Van Schalkwyk, R. D. & Steenkamp, R. J. A review and exploration of sociotechnical ergonomics. Int. J. Occup. Saf. Ergon. 23 (3), 297–306. 10.1080/10803548.2016.1216356 (2017). Canadian Institutes of Health Research. Guide to knowledge translation planning at CIHR: integrated and end-of-grant approaches. Ottawa: Government of Canada. [cited 2023 Jun 9]. (2012). Available from: http://www.cihr-irsc.gc.ca/e/45321.html Reading, C. L. & Wien, F. Health inequalities and social determinants of Aboriginal Peoples’ health (National Collaborating Centre for Aboriginal Health, 2009). Weyers, S., Dragano, N., Richter, M. & Bosma, H. How does socio-economic position link to health behaviour? Sociological pathways and perspectives for health promotion. Glob Health Promot . 17 (2), 25–33 (2010). Bauman, A., Phongsavan, P., Schoeppe, S. & Owen, N. Physical activity measurement: a primer for health promotion. Promot Educ. 13 (2), 92–103. 10.1177/10253823060130020103 (2006). Müller, J. S. et al. Artisanal fisherwomen/shellfish gatherers: analyzing the impact of upper limb functioning and disability on health-related quality of life. Cien Saude Colet . 22 (11), 3635–3644. 10.1590/1413-812320172211.13392016 (2017). Rajan, P. et al. Community-based interventions for chronic musculoskeletal health conditions in rural and remote populations: a systematic review. Health Soc. Care Community . 29 (6), e1621–e1635. 10.1111/hsc.13263 (2021). Vos, T. et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388 (10053), 1545–1602. 10.1016/S0140-6736(16)31678-6 (2016). Bezerra, A. M., Hellwig, N., Pinheiro, R. C. & Lopes, C. S. Prevalence of chronic musculoskeletal conditions and associated factors in Brazilian adults—National Health Survey. BMC Public. Health . 18 (1), 287. 10.1186/s12889-018-5192-4 (2018). Hipólito, M. C. V., Masson, V. A., Monteiro, M. I. & Gutierrez, G. L. Quality of working life: assessment of intervention studies. Rev. Bras. Enferm . 70 (1), 189–197. 10.1590/0034-7167-2015-0069 (2017). Biman, S., Maharana, S., Metri, K. G. & Nagaratna, R. Effects of yoga on stress, fatigue, musculoskeletal pain, and quality of life among employees of the diamond industry: a new approach in employee wellness. Work 70 (2), 521–529. 10.3233/WOR-213589 (2021). Isosaki, M., Cardoso, E., Glina, D. M. R., Pustiglione, M. & Rocha, L. E. Intervention in a hospital foodservice and its effects on musculoskeletal symptoms. Rev. Nutr. 24 (3), 449–462. 10.1590/S1415-52732011000300008 (2011). Brown University Library. Literatura de cordel . Brasiliana collection. Available from: https://library.brown.edu/create/brasiliana/cordel/ [cited 2025 Dec 15]. UN Women Eastern and Southern Africa. Promoting women’s participation in the extractive industries sector: examples of emerging good practices. Nairobi: UN Women Eastern and Southern Africa. (2016). Available from: https://africa.unwomen.org/sites/default/files/Field%20Office%20Africa/Attachments/Publications/2016/10/Promoting%20Womens%20Participation%20in%20the%20Extractive%20Industries%20Sector-%20Examples%20of%20Emerging%20Good%20Practices-Web-Spreads.pdf International Finance Corporation. Investing in women’s employment: good for business, good for development. Washington (DC): World Bank Group. [cited 2025 Dec 14]. (2013). Available from: http://hdl.handle.net/10986/16257 Tables Table 1. Sociodemographic characteristics and living and working conditions of agro-extractive workers in the city of Caxias-MA. Variable Category n Percentage (%) Gender Female 309 97.8 Male 7 2.2 Age 18 – 20 8 2.5 21 – 30 48 15.2 31 – 40 84 26.6 + 40 176 55.7 Schooling None 77 24.4 1 to 4 years 126 39.9 5 to 8 years 58 18.4 9 years (Complete elementary school) 17 5.4 10 to 11 years 21 6.6 12 years (Complete high school) 17 5.4 Children Yes 300 94.9 No 16 5.1 Leisure Yes 306 96.8 No 10 3.2 Domestic overload (Tertile) 1 Low load 107 107 Average load 102 102 High load 101 101 Weekly workload Less than 10 hours 3 0.9 11 to 8 hours 64 20.3 21 to 29 hours 109 34.5 30 to 40 hours 139 44 Over 40 hours 1 0.3 Means of transport used for commuting home x work On foot 306 96.8 Own transport 4 1.3 Private transport 6 1.9 1 Absence of information for the specific variable Table 2. Comparison of the general health status of agroextractive babassu coconut breakers in the municipality of Caxias (MA), Brazil, in the pre-intervention (N = 316) and post-intervention (N = 125) stages. Dimension Pre-intervention Post-intervention T test p Means (S.D.) Means (S.D) Functional capacity 76.69 (21.06) 79.96 (21.26) 1.82 0.07 Limitation due to physical aspects 63.37 (43.66) 76.00 (39.83) 3.63 <0.01 Ache 64.08 (26.41) 70.00 (24.81) 2.73 <0.01 General health status 63.44 (25.28) 70.34 (25.28) 1.15 0.25 Vitality 70.69 (21.62) 72.56 (19.82) 0.76 0.45 Social aspects 85.28 (23.37) 90.10 (19.46) 2.16 0.03 Limitation due to emotional aspects 68.78 (42.69) 88.00 (30.35) 4.89 <0.01 Mental health 76.89 (20.78) 81.41 (19.18) 2.15 0.03 Table 3. Percentage of babassu coconut breakers according to the period of the year, type of intervention and perceptions of reduced pain and work production. Season Perception Categories Interventions None % Break % Self-care exercises % Both % Dry period (Jul-Dec) Pain perception None 16.5 6.4 4.8 10.5 Slight 64.8 74.5 68.3 76.4 Moderate 18.7 19.1 26.9 13.1 Reduced production No 53.8 58.5 84.6 67.5 Yes 46.2 41.5 15.4 32.5 Rainy period (Jan-Jun) Pain perception None 28.3 0.9 2.7 9.8 Slight 34.0 85.3 83.8 82.3 Moderate 37.7 13.8 13.5 7.9 Decreased production No 30.2 54 73.3 64 Yes 69.8 46 26.7 36 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8571677","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":598882404,"identity":"18abe4ad-5db4-4fdc-964c-2bbfb54f1b21","order_by":0,"name":"Scheila Regina Gomes Alves Vale","email":"","orcid":"","institution":"Federal Institute of Education, Science and Technology of Maranhão","correspondingAuthor":false,"prefix":"","firstName":"Scheila","middleName":"Regina Gomes Alves","lastName":"Vale","suffix":""},{"id":598882405,"identity":"c1cef1c6-1bd1-4b47-9de3-4b6fd65b37c3","order_by":1,"name":"Eliana Napoleão 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05:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8571677/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8571677/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104346022,"identity":"8c37bc5e-6542-4aeb-aaed-8ec51e85808b","added_by":"auto","created_at":"2026-03-10 17:41:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":127397,"visible":true,"origin":"","legend":"\u003cp\u003eStanding and prone lumbar extension exercises, seated cervical extension with retraction, and shoulder extension exercises performed by babassu coconut breakers during the intervention.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8571677/v1/50a3c87e1aae3b45899fa48c.jpg"},{"id":104346023,"identity":"71f8c0b5-2118-4a5b-8570-4ac4f7a42308","added_by":"auto","created_at":"2026-03-10 17:41:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79398,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of interventions according to data collection month and reduced work production.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8571677/v1/5bd805f5037debd611a7a0b4.jpg"},{"id":104346024,"identity":"8b348508-92f9-4f80-8b17-aeaa194a4b25","added_by":"auto","created_at":"2026-03-10 17:41:14","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74779,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of babassu coconut breakers according to season, type of intervention and perceptions of pain and work production.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8571677/v1/ffab8f55544b47e452f252fe.jpg"},{"id":105699586,"identity":"505df957-951f-4e7f-a86c-7934c9e3388a","added_by":"auto","created_at":"2026-03-30 05:25:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1152454,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8571677/v1/130b2e3e-a97d-4b18-92bb-706e29044ec9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health Intervention Research with Women Babassu Coconut Breakers in Northeast Brazil","fulltext":[{"header":"Contributions to the literature","content":"\u003cp\u003eThis study provides an empirical evaluation of musculoskeletal pain interventions among BCBs, a traditional women-dominated workforce engaged in labor-intensive extractive activities.\u003c/p\u003e\n\u003cp\u003eBy assessing outcomes across both dry and rainy seasons, the study provides evidence on how environmental and work-intensity variations are associated with pain perception and intervention effectiveness.\u003c/p\u003e\n\u003cp\u003eThe findings indicate that simple, community-based strategies \u0026mdash; work breaks and self-care exercises \u0026mdash; may contribute to reductions in pain and improvements in HRQoL in rural settings with limited resources.\u003c/p\u003e\n\u003cp\u003eThe intervention model is low-cost, feasible, and culturally grounded, supporting its potential applicability within primary health care and health-promotion practices for manual-labor populations.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eHealth is a fundamental human right and an essential resource. Health promotion and educational interventions delivered through Primary Health Care (PHC) play a central role in advancing universal health coverage, a cornerstone of the sustainable development agenda [1,2]. In Brazil, health promotion (HP) actions are primarily implemented within PHC [3], which is responsible for addressing health needs across diverse territories and population groups, including rural and traditional communities.\u003c/p\u003e\n\u003cp\u003eAlthough the Countryside, Forest and Waters Population (CFWP) holds the universal right to health, this population continues to face challenges in accessing health promotion strategies, particularly in rural and remote areas. Babassu coconut breakers (BCBs) are part of the broader CFWP and predominantly consist of women. In Brazil, BCBs are legally recognized as traditional peoples and communities, a designation applied to culturally distinct social groups with specific ways of life and work [4].\u003c/p\u003e\n\u003cp\u003eBCBs preserve their cultural and economic practices through the sustainable extraction of products from babassu palm trees (Attalea speciosa and A. vitrivir), an activity closely linked to their livelihoods and territorial contexts in northern and northeastern Brazil [5,6]. These traditional agro-extractive activities are carried out primarily through manual labor and are shaped by environmental conditions, seasonal cycles, and collective work arrangements.\u003c/p\u003e\n\u003cp\u003eThe collection and cracking of babassu coconuts are traditionally performed collectively, involving gatherings of women and constituting a daily ritual marked by conversation, singing, and the exchange of experiences [7]. Among BCBs, the babassu palm holds symbolic meaning as a maternal figure, associated with collective identity, autonomy in work, and the generation of income to support their families [8]. These social and cultural dimensions contribute to how BCBs perceive their health and well-being.\u003c/p\u003e\n\u003cp\u003eThe traditional work process involves collecting coconuts during the dry season (July to December) and storing them for cracking during the rainy season (January to June). During collection, coconuts are transported in bags carried on the head, shoulders, or back. To crack the coconuts, BCBs sit on the ground and use a simple manual tool consisting of an upward-facing blade stabilized under one leg, striking the coconut to open it and remove the almonds [7]. This work organization requires repetitive movements, sustained postures, and prolonged physical effort.\u003c/p\u003e\n\u003cp\u003eMusculoskeletal pain is a well-recognized occupational health issue and represents a public health concern due to its association with reduced work capacity, diminished quality of life, and increased vulnerability to chronic conditions. Among labor-intensive rural workers, pain is often normalized as an inherent aspect of work, contributing to delayed care-seeking and limited access to preventive interventions. In traditional extractive contexts, these challenges are compounded by social inequities, geographic isolation, and restricted access to structured health services.\u003c/p\u003e\n\u003cp\u003eHealth-related quality of life (HRQoL) has been widely used as an indicator to assess the broader impacts of occupational exposures on physical, emotional, and social well-being. Instruments such as the SF-36 allow for a multidimensional evaluation of how pain and working conditions affect daily functioning beyond clinical outcomes alone. Despite increasing recognition of musculoskeletal disorders among rural and extractive workers, there remains a paucity of intervention-based studies assessing strategies to manage pain and improve HRQoL in these populations, particularly those grounded in community participation and local contexts.\u003c/p\u003e\n\u003cp\u003eIn this context, the present study aimed to introduce and evaluate a community-based health intervention focused on work breaks and self-care exercises to manage musculoskeletal pain among babassu coconut breakers. By assessing changes in pain perception and health-related quality of life across different seasonal conditions, this study seeks to contribute evidence on feasible health promotion strategies for traditional extractive workers within a public health framework.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was an evaluation study of a community-based health intervention [9] conducted among women BCBs between March 2018 and December 2020.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study adopted a non-randomized, pre–post intervention design without a control group and was not conducted as a randomized study. The intervention was implemented and evaluated under a participatory action research framework [10], and mixed methods were applied [11]. The research team consisted of academics, healthcare professionals, and a communication professional. In addition, a local government rural education practitioner, with a history of respectful relationships and support for the participating BCB community, was involved in the study.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eBCBs aged 18 years or older who engaged in the traditional collection and cracking of babassu coconuts were selected. Sample size was calculated using the Winpepi program [12], considering α = 5%, β = 10%, and a prevalence of low back pain of 57%. The estimated sample size for the study sample was 377 BCBs. Sampling was convenience-based. Participants were not randomly allocated, and all eligible individuals who agreed to participate were included according to availability and continuity in the intervention activities. The study included 316 participants in the pre-intervention stage, 189 in the intervention stage, and 125 in the post-intervention stage. Loss to follow-up occurred over the study period due to the voluntary nature of participation and contextual constraints inherent to community-based field research. Participants were from 25 villages across three districts of Caxias, the fifth-largest city in the state of Maranhão (Caxias-MA), Northeast Brazil (latitude 4°52′29″ South, longitude 43°20′49″ West).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePre-and post-intervention stages\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the pre-intervention stage, the validated SF-36 questionnaire was administered to 316 BCBs. In the post-intervention stage, the questionnaire was administered to the 125 BCBs who remained in the study until its completion. No parallel control group was used; comparisons were performed within participants across time points. The SF-36, which has established reliability and validity, includes items related to living and working conditions and assesses overall health status across multiple domains.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOver eighteen months of field research, 189 BCBs participated in three workshops and three general BCB meetings. In addition, eight follow-up meetings were conducted in each participating village, all held within the same week. The first two workshops provided guidance to BCB research volunteers on the two proposed interventions: self-care exercises for the musculoskeletal system and work breaks.\u003c/p\u003e\n\u003cp\u003eDuring the intervention stage, participants implemented the prescribed self-care exercises and work breaks. Intervention exposure was not standardized across participants and reflected real-world adherence within a participatory and community-driven context. Intervention assessments were conducted both qualitatively, through dialogues held during monthly meetings, and quantitatively, using a three-question scale administered weekly. Individual questionnaires were completed by participants and delivered to the researcher at each monthly meeting.\u003c/p\u003e\n\u003cp\u003eThe three-question survey asked research volunteers which intervention was used and whether work productivity was affected. The third question consisted of a zero-to-ten self-rated pain scale aligned with facial expressions, addressing the presence and severity of musculoskeletal pain. Details of the intervention activities are described below.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eExercise and self-care related to pain\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA health self-management program based on the McKenzie Method of Mechanical Diagnosis and Therapy (MDT), with a focus on education and self-care, was developed. MDT is recommended as a treatment option for musculoskeletal conditions in several countries and may be applied in acute, subacute, or chronic stages, as well as to different body regions [13–15]. During the intervention period, exercises were performed autonomously by the BCBs, guided by strategies aimed at preventing and alleviating pain according to individual needs (Figure 1). Participants were instructed to perform the exercises before, during, or after work activities, depending on the period that provided greater relief and well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Figure 1.\u003c/em\u003e\u003cem\u003eStanding and prone lumbar extension exercises, seated cervical extension with retraction, and shoulder extension exercises performed by babassu coconut breakers during the intervention.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBecause pain represents a relevant constraint in the work of BCBs [7], this variable was selected to assess the outcomes of the health intervention, despite its complex and subjective nature and its influence by multiple personal factors [16–18]. Due to its ease of application [15], the facial pain scale was used to quantify pain intensity and severity.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eWork breaks\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eRecommendations for work breaks were based on a Brazilian regulatory standard and the existing literature. Brazilian Regulatory Norm 17 [16] addresses working conditions and organizational practices, including mandatory work breaks. According to this norm, in electronic data processing activities, a minimum 10-minute break is required for every 50 minutes of activity. Kroemer and Grandjean [19] highlight the importance of rest breaks as a physiological requirement for maintaining performance and efficiency, regardless of whether work involves manual labor or tasks that strain the nervous system. The authors estimate that rest breaks should generally account for approximately 15% of total working time, with up to 20–30% considered acceptable or necessary in certain occupations. In this study, a passive break of 10 minutes every two hours of work was recommended and agreed upon by the participants. This break was intended to prevent and alleviate fatigue and to facilitate physiological recovery.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eObservations of work situations were conducted through analysis of the actual activities performed by BCBs, based on theoretical assumptions of Ergonomics [20]. Descriptive analyses, including frequencies, means, and standard deviations, were applied to data collected at all stages. Paired t-tests and repeated-measures analysis of variance were performed to compare outcomes before and after the interventions using SPSS software, version 20.0. Given the non-randomized design and absence of a control group, analyses were interpreted as within-group comparisons over time. Comparisons were made between BCBs who participated in all interventions over the 18-month period (n = 189) and those who did not participate in all intervention activities (n = 127).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of the National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation (ENSP/Fiocruz), under Opinion No. \u0026nbsp;2,287,163. The study was also registered in the National System for the Management of Genetic Heritage and Associated Traditional Knowledge (SisGen), under Protocol number AE5F09A. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003ch2\u003e\u003cstrong\u003eSociodemographic aspects\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA total of 316 individuals participated voluntarily in the study during the pre-intervention stage. Among these participants, 97.8% were female, with a median age of 44 years (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Table 1. Sociodemographic characteristics and living and working conditions of agro-extractive workers in the city of Caxias-MA.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eHealth self-perception\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eTable 2 presents the comparative analysis of the eight domains of the general health questionnaire (SF-36) in the pre- and post-intervention stages. Statistically significant differences were observed in five of the eight domains. The domains related to limitations due to physical and emotional aspects, pain, social aspects, and mental health showed significant changes. Mean scores increased after the intervention, suggesting an improvement in BCBs\u0026rsquo; self-perceived health status over time.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Table 2. Comparison of the general health status of agroextractive babassu coconut breakers in the municipality of Caxias-MA, Brazil, in the pre-intervention (N = 316) and post-intervention (N = 125) stages.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSelf-perception of work production\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNortheastern Brazil is characterized by two distinct seasons. Analyses were stratified by season (dry or rainy), considering variations in BCBs\u0026rsquo; work production between these periods. Work production was reduced during the rainy season due to difficulties in accessing babassu palm trees. In contrast, during the dry season\u0026mdash;when babassu collection is more intensive\u0026mdash;a higher frequency of musculoskeletal pain was reported according to the three-question scale (Figure 2 and Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Figure 2. Number of interventions according to data collection month and work production.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Table 3. Percentage of babassu coconut breakers according to the period of the year, type of intervention and perceptions of reduced pain and work production.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3 shows the distribution of interventions among BCBs (work breaks, exercises, or both) according to month of the year and self-perceived work production.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRepeated-measures analysis indicated statistically significant differences for one or both interventions comparing participants reporting no intervention exposure with those reporting one or both intervention components (F = 2.46; p = 0.01), based on within-participant comparisons over time, as well as significant effects across seasons (dry: F = 4.69; p \u0026lt; 0.01; rainy: F = 12.03; p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINSERT Figure 3. Percentage of babassu coconut breakers according to season, type of intervention and perceptions of pain and work production.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSelf-rated pain scale\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eRegarding musculoskeletal pain in relation to work breaks and seasonality, reduced pain perception was observed in both periods (dry: 11.7; p \u0026lt; 0.01; rainy: 28.4; p \u0026lt; 0.01). With respect to the association between pain perception and the performance of self-care exercises, reduced pain perception was observed during the dry season (21.6; p \u0026lt; 0.01) (Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 3 also illustrates the distribution of interventions among BCBs (work breaks, exercises, or both) according to month of the year and pain perception. Repeated-measures testing showed statistically significant differences for one intervention compared with no intervention (p = 0.03), as well as between one and two interventions (p \u0026lt; 0.01), for both seasons (dry: F = 9.04; p \u0026lt; 0.01; rainy: F = 7.54; p \u0026lt; 0.01).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCo-production of the Pain Self-Care Guide\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAn illustrated guide was developed to support regular exercise practice for pain self-management. The guide was co-produced and validated by study participants, with the aim of facilitating knowledge translation and reaching a broader audience [21].\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study implemented, monitored, and evaluated two interventions integrated into the daily work activities of BCBs in Caxias-MA, Brazil, within a non-randomized, community-based pre\u0026ndash;post design, with the aim of increasing the degree of control exercised by the BCB population over their health and assessing whether the interventions improved self-reported health status across the SF-36 domains associated with health-related quality of life (HRQoL).\u003c/p\u003e\n\u003cp\u003eReading and Wien [22], in discussing the approach of poverty as a determinant of health, propose a perspective on Indigenous communities that differs from income-based conceptualizations of poverty. For this community, for example, \u0026ldquo;the good life does not mean making money, buying things, or winning awards. Rather, it has to do with taking care of yourself, your family, and your community\u0026rdquo; (community in the study: 10). This perception contrasts with and complements the factors that influence the positive self-perception of health expressed by the BCBs population. According to Weyers et al. [23], social determinants should be considered in strategies aimed at improving health behaviors among populations in lower social strata. Furthermore, countries that reorient their health systems toward Primary Health Care (PHC) are better positioned to advance global health and development agendas than those with systems focused on curative medical treatment [1].\u003c/p\u003e\n\u003cp\u003eThe intervention actions were validated by the BCBs participating in the study. The workshops organized during the intervention process contributed to a better understanding of the demands imposed by agro-extractive work. Participants reported increased capacity for self-care, particularly in relation to the musculoskeletal system, including fatigue prevention and improvements in posture and movement through health self-management practices. These elements are consistent with approaches aimed at promoting health at work and supporting quality of life [24]. When assessed using the SF-36, five of the eight domains\u0026mdash;limitations due to physical aspects, pain, social aspects, emotional aspects, and mental health\u0026mdash;showed improvements in the post-intervention stage, which is consistent with the study hypothesis, that improvements in working conditions combined with self-care practices, exercises, and work breaks may favor BCB health.\u003c/p\u003e\n\u003cp\u003eThe Social Aspects domain presented the highest mean scores in both study stages, indicating higher HRQoL values in this dimension during the pre-intervention (85.28) and post-intervention (90.10) periods. The high proportion of participants reporting leisure activities (96.8%), including cultural, social, religious, and ancestral practices, may have contributed to these findings.\u003c/p\u003e\n\u003cp\u003eEvidence from other populations engaged in traditional and labor-intensive activities provides relevant context. An epidemiological study involving artisanal fishers and shellfish gatherers [25], which applied the Disabilities of the Arm, Shoulder and Hand (DASH) instrument and the SF-36, identified negative effects of work on upper limb function among women and demonstrated that functional capacity and pain domains significantly interfered with daily life and work activities. Similarly, in the present study, the SF-36 domains related to limitations due to physical aspects and pain showed the lowest mean scores in both assessment stages, indicating greater impairment in these dimensions of HRQoL among BCBs.\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with evidence from a systematic review examining community-based interventions for chronic musculoskeletal conditions in rural and remote populations [26]. That review identified education combined with exercise as the most consistent intervention associated with reductions in musculoskeletal pain, while educational interventions alone produced heterogeneous effects. Ergonomic modifications yielded variable and context-dependent outcomes. The authors also highlighted the limited number of high-quality intervention studies in rural and remote settings and emphasized the importance of culturally and contextually adapted strategies. In this regard, the present study contributes to the existing literature by suggesting that community-based interventions incorporating self-care practices and work organization strategies may be associated with reductions in pain and improvements in HRQoL among rural women engaged in agro-extractive labor.\u003c/p\u003e\n\u003cp\u003eData from the Global Burden of Disease, Injuries, and Risk Factors Study [27] indicate that low back and neck pain were the leading causes of disability worldwide in 2015, with musculoskeletal disorders accounting for 18.5% of years lived with disability. Although years of life lost due to musculoskeletal disorders have declined, years lived with disability have remained relatively stable, suggesting that these conditions are likely to continue to represent a substantial public health burden.\u003c/p\u003e\n\u003cp\u003eIn Brazil, Bezerra et al. [28] reported a high prevalence of chronic musculoskeletal conditions, affecting approximately one in five adults, with higher prevalence among women. Data from the 2013 National Health Survey indicated a 40% higher prevalence of chronic musculoskeletal conditions among women compared to men. Despite the existence of a public, universal health system, the economic burden associated with chronic conditions remains considerable, reinforcing the relevance of strengthening PHC-oriented strategies.\u003c/p\u003e\n\u003cp\u003eWith regard to work breaks and self-care exercises, stratified analyses by season and perceived work production showed statistically significant differences for the intervention groups compared with participants who did not engage in the interventions. These findings are consistent with observations reported by Hip\u0026oacute;lito et al. [29] and Biman et al. [30]. Babassu coconuts and their derivatives play an important role in the subsistence of traditional communities, contributing to food security and income generation through commercialization [5].\u003c/p\u003e\n\u003cp\u003eReduced perception of musculoskeletal pain associated with work breaks was observed in both dry and rainy seasons. In relation to self-care exercises, reduced pain perception was observed during the dry season. These results are consistent with findings reported by Isosaki et al. [31], who observed reductions in work-related musculoskeletal symptoms and improvements in work conditions following the implementation of educational interventions, work breaks, and posture-related guidance in a hospital nutrition service. Similarly, qualitative findings from the present study suggest that the co-production of the Pain Self-Care Guide supported the development of self-care capacities among BCBs, particularly regarding musculoskeletal health, posture, and fatigue prevention.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be considered when interpreting the findings. These include the reduction in sample size over the study period, low levels of formal education among participants, and irregular completion of follow-up questionnaires, which may have affected the quantitative analyses by reducing statistical power and influencing measures of variability. In addition, individual productivity could not be directly measured, necessitating the use of self-reported assessments.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, sustained dialogue throughout the field research period enabled discussions on work processes and their relationship with health, including autonomy, self-regulation of work pace, self-care practices, load handling, and the adoption of exercises aimed at musculoskeletal health. Discussions also addressed possibilities for improving agro-extractive activities through qualification, diversification, and commercialization of babassu-derived products, with potential implications for income generation.\u003c/p\u003e\n\u003cp\u003eThe educational actions focused on musculoskeletal self-care were interdisciplinary and multiprofessional. Within the participatory research framework, an illustrated guide was developed to support recall and performance of the recommended exercises. This material aimed to support injury prevention in body segments most affected by agro-extractive work.\u003c/p\u003e\n\u003cp\u003eThe guide was written in Cordel format, a form of popular literature widely used in northern and northeastern Brazil [32], employing accessible language and illustrations to facilitate comprehension and dissemination among BCBs.\u003c/p\u003e\n\u003cp\u003eFinally, interactions facilitated through workshops, food production activities, and meetings to validate the interventions and the Pain Self-Care Guide fostered exchanges among BCBs from different villages and municipalities. Collaboration with professionals from public institutions, including ENSP/Fiocruz, Brazilian Agricultural Research Corporation (Embrapa), the State Department of Family Agriculture, and the Municipal Agriculture Department, contributed to broader recognition of the value of agro-extractive work and the rights of BCBs as a traditional community. The participatory methodology and instruments employed in this study were shown to be feasible and may be applicable to similar populations, particularly in contexts characterized by low levels of formal education and challenges in data collection.\u003c/p\u003e\n\u003cp\u003eFrom the perspective of social determinants of health, the findings highlight the importance of combining health-related knowledge and self-care practices with broader actions aimed at strengthening local processing units for babassu-derived products. Such initiatives may contribute to the valuation of work, income generation, and the participation of women in decision-making processes related to extractive activities. These factors may influence quality of life, innovation, and the retention of younger generations within their territories [33,34].\u003c/p\u003e\n\u003cp\u003eOverall, the findings suggest that improvements in working conditions combined with health self-care practices, exercises, and work breaks were associated with favorable outcomes for BCB health. In addition, the actions developed through this study contributed to strengthening collective identity and social organization among women engaged in babassu agro-extractive activities.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe research, conducted in Caxias, Maranh\u0026atilde;o, used a participatory action research approach, focusing on women BCBs who engage in physically demanding tasks that often result in musculoskeletal pain. The intervention involved implementing work breaks and self-care exercises, specifically based on the McKenzie Method of MDT for musculoskeletal problems, within a non-randomized, community-based framework.\u003c/p\u003e\n\u003cp\u003eThe results of the study indicated reduced musculoskeletal pain among BCBs, particularly during the physically strenuous dry season. This decrease was observed among participants who adopted work breaks as well as those who practiced self-care exercises, with greater reductions in pain perception observed during the dry season. The post-intervention phase also showed improvements in several domains of the SF-36 questionnaire, including limitations due to physical aspects, pain, social aspects, emotional aspects, and mental health. These findings suggest that the combined intervention of improved working conditions and health self-care practices, including exercises and work breaks, was associated with better self-reported health and quality of life among BCBs.\u003c/p\u003e\n\u003cp\u003eThe study offers a model for addressing work-related health issues in low-resource settings and highlights the relevance of community-participatory approaches for improving health-related quality of life among populations engaged in labor-intensive activities. The findings underscore the importance of prioritizing worker health by demonstrating that interventions based on minimal resources and community engagement may contribute to meaningful health improvements. For health systems, particularly in regions with a high prevalence of manual and extractive labor, this study illustrates a preventive and health-promoting approach that may help reduce the long-term burden associated with chronic musculoskeletal conditions. These interventions are consistent with broader public health goals focused on prevention and health promotion and may inform similar strategies in other settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBabassu Coconut Breaker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFWP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCountryside, Forest, and Waters Population\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisabilities of the Arm, Shoulder and Hand\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHRQoL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth\u0026ndash;Related Quality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaranh\u0026atilde;o\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMechanical Diagnosis and Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of xxxx (Opinion No. 2,287,163). It was also registered in the National System for the Management of Genetic Heritage and Associated Traditional Knowledge (SisGen), under protocol number AE5F09A. All procedures performed in this study were conducted in accordance with the ethical principles of the Declaration of Helsinki and with applicable national research ethics regulations. Written informed consent to participate was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Funda\u0026ccedil;\u0026atilde;o de Amparo \u0026agrave; Pesquisa e ao Desenvolvimento Cient\u0026iacute;fico e Tecnol\u0026oacute;gico do Maranh\u0026atilde;o (FAPEMA) under Grant No. 01109/18 (Edital 002/2018); by the Inova Fiocruz Program \u0026ndash; Knowledge Generation (Grant No. VPPCB-007-FIO-18-2-47); and by the Federal Institute of Education, Science and Technology of Maranh\u0026atilde;o (IFMA) through the Support for the Publication of Scientific Articles \u0026ndash; Public Servant program (PRPGI No. 269/2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this study are included in the manuscript. The datasets generated and analyzed\u0026mdash;comprising intervention records, pain assessment measures, and SF-36 domain scores\u0026mdash;are presented in the tables and figures within the article. No additional datasets are publicly available beyond the material presented in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHone, T., Macinko, J. \u0026amp; Millett, C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? \u003cem\u003eLancet\u003c/em\u003e \u003cb\u003e392\u003c/b\u003e (10156), 1461\u0026ndash;1472. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(18)31829-4\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(18)31829-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkinci, G. The impact of maternal and child health on sustainable development goals: evidence from Turkic Republics (2000\u0026ndash;2020). \u003cem\u003eBMC Public. Health\u003c/em\u003e. \u003cb\u003e25\u003c/b\u003e, 4031. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-025-25172-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-025-25172-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLotta, G. \u0026amp; Nunes, J. COVID-19 and health promotion in Brazil: community health workers between vulnerability and resistance. \u003cem\u003eGlob Health Promot\u003c/em\u003e. \u003cb\u003e29\u003c/b\u003e (1), 14\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/17579759211012375\u003c/span\u003e\u003cspan address=\"10.1177/17579759211012375\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalegare, M. G. A., Higuchi, M. I. G. \u0026amp; Bruno, A. C. S. Traditional peoples and communities: From protected areas to the political visibility of Social groups having ethnical and collective identity. \u003cem\u003eAmbient Soc.\u003c/em\u003e \u003cb\u003e17\u003c/b\u003e (3), 115\u0026ndash;134. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1590/S1414-753X2014000300008\u003c/span\u003e\u003cspan address=\"10.1590/S1414-753X2014000300008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorro, R. The invisible babassu economy and its importance for livelihoods in agro-extractivist communities. \u003cem\u003eBol. Mus. Para Em\u0026iacute;lio Goeldi Cienc. Hum.\u003c/em\u003e \u003cb\u003e14\u003c/b\u003e (1), 169\u0026ndash;188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/1981.81222019000100011\u003c/span\u003e\u003cspan address=\"10.1590/1981.81222019000100011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstituto Brasileiro de Geografia e Estat\u0026iacute;stica. Senhoras das palmeiras. Retratos: a revista do IBGE. ;(15):8\u0026ndash;13. (2019). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://biblioteca.ibge.gov.br/visualizacao/periodicos/2929/rri_2019_n15_jan.pdf\u003c/span\u003e\u003cspan address=\"https://biblioteca.ibge.gov.br/visualizacao/periodicos/2929/rri_2019_n15_jan.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVale, S. R., Bonfatti, R. J., Souza, A. G. \u0026amp; Teixeira, L. R. Ergonomic analysis of the traditional babassu coconut opening in the city of Itapecuru-Mirim, Maranh\u0026atilde;o, Brazil. \u003cem\u003eRev. Bras. Saude Ocup\u003c/em\u003e. \u003cb\u003e43\u003c/b\u003e, e2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/2317-6369000002416\u003c/span\u003e\u003cspan address=\"10.1590/2317-6369000002416\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSax, S. \u0026amp; Angelo, M. Brazil\u0026rsquo;s \u0026lsquo;coconut breakers\u0026rsquo; feel the squeeze of Cerrado development. \u003cem\u003eMongabay\u003c/em\u003e. Nov 12 [cited 2025 Dec 14]. (2019). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://news.mongabay.com/2019/11/brazils-coconut-breakers-feel-the-squeeze-of-cerrado-development/\u003c/span\u003e\u003cspan address=\"https://news.mongabay.com/2019/11/brazils-coconut-breakers-feel-the-squeeze-of-cerrado-development/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin, J., Cheng, D. \u0026amp; Stranges, S. Population health intervention research: myths and misconceptions. \u003cem\u003eInt. J. Public. Health\u003c/em\u003e. \u003cb\u003e62\u003c/b\u003e, 845\u0026ndash;847. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00038-017-0992-3\u003c/span\u003e\u003cspan address=\"10.1007/s00038-017-0992-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCordeiro, L., Soares, C. B. \u0026amp; Rittenmeyer, L. Unscrambling method and methodology in action research traditions: theoretical conceptualization of praxis and emancipation. \u003cem\u003eQual. Res.\u003c/em\u003e \u003cb\u003e17\u003c/b\u003e (4), 395\u0026ndash;407. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1468794116674771\u003c/span\u003e\u003cspan address=\"10.1177/1468794116674771\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvankova, N. \u0026amp; Wingo, N. Applying mixed methods in action research: methodological potentials and advantages. \u003cem\u003eAm. Behav. Sci.\u003c/em\u003e \u003cb\u003e62\u003c/b\u003e (7), 978\u0026ndash;997. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0002764218772673\u003c/span\u003e\u003cspan address=\"10.1177/0002764218772673\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbramson, J. H. WINPEPI updated: computer programs for epidemiologists, and their teaching potential. \u003cem\u003eEpidemiol. Perspect. Innov.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e (1), 1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1742-5573-8-1\u003c/span\u003e\u003cspan address=\"10.1186/1742-5573-8-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay, S. \u0026amp; Donelson, R. Evidence-informed management of chronic low back pain with the McKenzie method. \u003cem\u003eSpine J.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e (1), 134\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.spinee.2007.10.017\u003c/span\u003e\u003cspan address=\"10.1016/j.spinee.2007.10.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoitras, S., Blais, R., Swaine, B. \u0026amp; Rossignol, M. Management of work-related low back pain: a population-based survey of physical therapists. \u003cem\u003ePhys. Ther.\u003c/em\u003e \u003cb\u003e85\u003c/b\u003e (11), 1168\u0026ndash;1181. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ptj/85.11.1168\u003c/span\u003e\u003cspan address=\"10.1093/ptj/85.11.1168\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpoto, M. M. \u0026amp; Collins, J. Physiotherapy diagnosis in clinical practice: a survey of orthopedic certified specialists in the USA. \u003cem\u003ePhysiother Res. Int.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e (1), 31\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/pri.390\u003c/span\u003e\u003cspan address=\"10.1002/pri.390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCiena, A. P. et al. Influ\u0026ecirc;ncia da intensidade da dor sobre as respostas nas escalas unidimensionais de mensura\u0026ccedil;\u0026atilde;o da dor em uma popula\u0026ccedil;\u0026atilde;o de idosos e de adultos jovens. \u003cem\u003eSemina Cienc. Biol. Saude\u003c/em\u003e. \u003cb\u003e29\u003c/b\u003e (2), 201\u0026ndash;212. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5433/1679-0367.2008v29n2p201\u003c/span\u003e\u003cspan address=\"10.5433/1679-0367.2008v29n2p201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarques, J. O. A dor e os seus aspectos multidimensionais. \u003cem\u003eCienc. Cult.\u003c/em\u003e \u003cb\u003e63\u003c/b\u003e (2), 28\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21800/S0009-67252011000200010\u003c/span\u003e\u003cspan address=\"10.21800/S0009-67252011000200010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasulo, L. J., Martins, M. L. S., Costa, D. R. \u0026amp; Nicolau, R. A. Methods for qualitative and quantitative analysis of pain and quality of life validated in Brazil: systematic review. \u003cem\u003eRev. Gaucha Odontol.\u003c/em\u003e \u003cb\u003e67\u003c/b\u003e, e20190022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/1981-86372019000223435\u003c/span\u003e\u003cspan address=\"10.1590/1981-86372019000223435\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroemer, K. H. E. \u0026amp; Grandjean, E. \u003cem\u003eManual de ergonomia: adaptando o trabalho ao homem\u003c/em\u003e 5th edn (Bookman, 2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Schalkwyk, R. D. \u0026amp; Steenkamp, R. J. A review and exploration of sociotechnical ergonomics. \u003cem\u003eInt. J. Occup. Saf. Ergon.\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e (3), 297\u0026ndash;306. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10803548.2016.1216356\u003c/span\u003e\u003cspan address=\"10.1080/10803548.2016.1216356\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanadian Institutes of Health Research. Guide to knowledge translation planning at CIHR: integrated and end-of-grant approaches. Ottawa: Government of Canada. [cited 2023 Jun 9]. (2012). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.cihr-irsc.gc.ca/e/45321.html\u003c/span\u003e\u003cspan address=\"http://www.cihr-irsc.gc.ca/e/45321.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReading, C. L. \u0026amp; Wien, F. \u003cem\u003eHealth inequalities and social determinants of Aboriginal Peoples\u0026rsquo; health\u003c/em\u003e (National Collaborating Centre for Aboriginal Health, 2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeyers, S., Dragano, N., Richter, M. \u0026amp; Bosma, H. How does socio-economic position link to health behaviour? Sociological pathways and perspectives for health promotion. \u003cem\u003eGlob Health Promot\u003c/em\u003e. \u003cb\u003e17\u003c/b\u003e (2), 25\u0026ndash;33 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauman, A., Phongsavan, P., Schoeppe, S. \u0026amp; Owen, N. Physical activity measurement: a primer for health promotion. \u003cem\u003ePromot Educ.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e (2), 92\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/10253823060130020103\u003c/span\u003e\u003cspan address=\"10.1177/10253823060130020103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;ller, J. S. et al. Artisanal fisherwomen/shellfish gatherers: analyzing the impact of upper limb functioning and disability on health-related quality of life. \u003cem\u003eCien Saude Colet\u003c/em\u003e. \u003cb\u003e22\u003c/b\u003e (11), 3635\u0026ndash;3644. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/1413-812320172211.13392016\u003c/span\u003e\u003cspan address=\"10.1590/1413-812320172211.13392016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajan, P. et al. Community-based interventions for chronic musculoskeletal health conditions in rural and remote populations: a systematic review. \u003cem\u003eHealth Soc. Care Community\u003c/em\u003e. \u003cb\u003e29\u003c/b\u003e (6), e1621\u0026ndash;e1635. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hsc.13263\u003c/span\u003e\u003cspan address=\"10.1111/hsc.13263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVos, T. et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990\u0026ndash;2015: a systematic analysis for the Global Burden of Disease Study 2015. \u003cem\u003eLancet\u003c/em\u003e \u003cb\u003e388\u003c/b\u003e (10053), 1545\u0026ndash;1602. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(16)31678-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(16)31678-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezerra, A. M., Hellwig, N., Pinheiro, R. C. \u0026amp; Lopes, C. S. Prevalence of chronic musculoskeletal conditions and associated factors in Brazilian adults\u0026mdash;National Health Survey. \u003cem\u003eBMC Public. Health\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e (1), 287. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-018-5192-4\u003c/span\u003e\u003cspan address=\"10.1186/s12889-018-5192-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHip\u0026oacute;lito, M. C. V., Masson, V. A., Monteiro, M. I. \u0026amp; Gutierrez, G. L. Quality of working life: assessment of intervention studies. \u003cem\u003eRev. Bras. Enferm\u003c/em\u003e. \u003cb\u003e70\u003c/b\u003e (1), 189\u0026ndash;197. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0034-7167-2015-0069\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167-2015-0069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiman, S., Maharana, S., Metri, K. G. \u0026amp; Nagaratna, R. Effects of yoga on stress, fatigue, musculoskeletal pain, and quality of life among employees of the diamond industry: a new approach in employee wellness. \u003cem\u003eWork\u003c/em\u003e \u003cb\u003e70\u003c/b\u003e (2), 521\u0026ndash;529. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/WOR-213589\u003c/span\u003e\u003cspan address=\"10.3233/WOR-213589\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsosaki, M., Cardoso, E., Glina, D. M. R., Pustiglione, M. \u0026amp; Rocha, L. E. Intervention in a hospital foodservice and its effects on musculoskeletal symptoms. \u003cem\u003eRev. Nutr.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (3), 449\u0026ndash;462. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/S1415-52732011000300008\u003c/span\u003e\u003cspan address=\"10.1590/S1415-52732011000300008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown University Library. \u003cem\u003eLiteratura de cordel\u003c/em\u003e. Brasiliana collection. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://library.brown.edu/create/brasiliana/cordel/\u003c/span\u003e\u003cspan address=\"https://library.brown.edu/create/brasiliana/cordel/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [cited 2025 Dec 15].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUN Women Eastern and Southern Africa. Promoting women\u0026rsquo;s participation in the extractive industries sector: examples of emerging good practices. Nairobi: UN Women Eastern and Southern Africa. (2016). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://africa.unwomen.org/sites/default/files/Field%20Office%20Africa/Attachments/Publications/2016/10/Promoting%20Womens%20Participation%20in%20the%20Extractive%20Industries%20Sector-%20Examples%20of%20Emerging%20Good%20Practices-Web-Spreads.pdf\u003c/span\u003e\u003cspan address=\"https://africa.unwomen.org/sites/default/files/Field%20Office%20Africa/Attachments/Publications/2016/10/Promoting%20Womens%20Participation%20in%20the%20Extractive%20Industries%20Sector-%20Examples%20of%20Emerging%20Good%20Practices-Web-Spreads.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Finance Corporation. Investing in women\u0026rsquo;s employment: good for business, good for development. Washington (DC): World Bank Group. [cited 2025 Dec 14]. (2013). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://hdl.handle.net/10986/16257\u003c/span\u003e\u003cspan address=\"http://hdl.handle.net/10986/16257\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Sociodemographic characteristics and living and working conditions of agro-extractive workers in the city of Caxias-MA.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e97.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e18 \u0026ndash; 20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e21 \u0026ndash; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e31 \u0026ndash; 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e26.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e+ 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e55.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eSchooling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e1 to 4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5 to 8 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e9 years (Complete elementary school)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e10 to 11 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e12 years (Complete high school)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eChildren\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e94.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eLeisure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e96.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eDomestic overload (Tertile)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLow load\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAverage load\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eHigh load\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eWeekly workload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLess than 10 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e11 to 8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e21 to 29 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e30 to 40 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eOver 40 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eMeans of transport used for commuting home x work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eOn foot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e96.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eOwn transport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePrivate transport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Absence of information for the specific variable\u003c/p\u003e\n\u003cp\u003eTable 2. Comparison of the general health status of agroextractive babassu coconut breakers in the municipality of Caxias (MA), Brazil, in the pre-intervention (N = 316) and post-intervention (N = 125) stages.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"85%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Dimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeans (S.D.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeans (S.D)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eFunctional capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e76.69 (21.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e79.96 (21.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eLimitation due to physical aspects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e63.37 (43.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e76.00 (39.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eAche\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e64.08 (26.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e70.00 (24.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e2.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eGeneral health status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e63.44 (25.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e70.34 (25.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eVitality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e70.69 (21.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e72.56 (19.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eSocial aspects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e85.28 (23.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e90.10 (19.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eLimitation due to emotional aspects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e68.78 (42.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e88.00 (30.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eMental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e76.89 (20.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e81.41 (19.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Percentage of babassu coconut breakers according to the period of the year, type of intervention and perceptions of reduced pain and work production.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eSeason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePerception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 50px;\"\u003e\n \u003cp\u003eInterventions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003eBreak\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eSelf-care exercises\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 16px;\"\u003e\n \u003cp\u003eDry period\u003c/p\u003e\n \u003cp\u003e(Jul-Dec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePain perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eSlight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e64.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e74.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e68.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e76.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReduced production\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e58.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e84.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e41.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e32.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 16px;\"\u003e\n \u003cp\u003eRainy period\u003c/p\u003e\n \u003cp\u003e(Jan-Jun)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePain perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eSlight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e85.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e83.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e82.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e37.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003eDecreased production\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e69.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health-related quality of life, health education, health promotion, health research evaluation, community-based research, participatory research","lastPublishedDoi":"10.21203/rs.3.rs-8571677/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8571677/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBabassu coconut breakers (BCBs) in Brazil experience musculoskeletal pain associated with their labor activities. This population is part of the Countryside, Forest, and Waters Population (CFWP) and is predominantly composed of women whose health, quality of life, and income may be affected by chronic pain. This study aimed to evaluate changes in musculoskeletal pain following community-based interventions among BCBs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn evaluation study of a community-based health intervention was conducted with BCBs aged 18 years or older from 25 villages in Northeast Brazil. A total of 316 individuals participated in the pre-intervention stage, 189 in the intervention stage, and 125 in the post-intervention stage. The study followed a non-randomized, pre\u0026ndash;post design without a control group. The interventions included the implementation of work breaks and self-care exercises. Health-related quality of life (HRQoL) was assessed using the SF-36 questionnaire. Paired t-tests and repeated-measures analysis of variance were used for data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong participants who engaged in the self-care exercises, a significant reduction in pain perception was observed, particularly during the dry season. Post-intervention results showed improvements in five SF-36 domains: physical role limitations, pain, social functioning, emotional role limitations, and mental health. Favorable changes were observed across both dry and rainy seasons in within-group comparisons over time.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe interventions were associated with reductions in musculoskeletal pain and improvements in self-reported health-related quality of life among BCBs. These findings support the relevance of incorporating health promotion strategies focused on self-care and pain management within primary health care contexts serving rural working populations.\u003c/p\u003e","manuscriptTitle":"Health Intervention Research with Women Babassu Coconut Breakers in Northeast Brazil","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 17:41:09","doi":"10.21203/rs.3.rs-8571677/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56824ae8-015d-4209-b34c-990faa73d1b7","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63727149,"name":"Health sciences/Health care"},{"id":63727150,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-30T05:25:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 17:41:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8571677","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8571677","identity":"rs-8571677","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}