A Humanização e a Formação Médica na Perspectiva dos Estudantes de Medicina da Universidade Federal do Rio Grande do Norte

The aim of this study is to understand the perception of medical students at the Federal University of Rio Grande do Norte (UFRN) about humanization in the context of their medical formation, using a qualitative approach. The focus group and participant observation techniques were used, involving a multidisciplinary team composed of professionals from the areas of anthropology and psychology, as well as professors from the medical course, who studied two groups of nine students in their final year. The data were analyzed using the categorical thematic content analysis technique, from which emerged three categories: student/patient relationship, teaching/learning and student/professor relationship. The first allows us to identify that student-patient contact is an essential experience for adopting a more humanized view of the disease process. The second category shows that unqualified professors in the pedagogic practices inherent to the teaching profession and the theory the practical dichotomy hinder the autonomous and holistic formation of knowledge. Similarly, the lack of practices outside the academic environment and the absence of multiprofessional stimulation interfere in the construction of an integral view of the individual. From the third category, the student/professor relationship, emerge two opposing subcategories (professor model and assymetric relationships), which reflect the importance of the professor`s ethical humanist position, as opposed to an authoritarian attitude, to form the professional attitude of the student. The results point important aspects of the medical formation that may open a discussion about humanization, in the context of new national curricular guidelines

Fatores litogênicos em pacientes com litíase urinária de Fortaleza, Ceará

Lithiasis is considered a public health issue due to its high prevalence and rates of recurrence. Objective: To identify risk factors for lithiasis in kidney stone patients from Fortaleza, Brazil. In the first stage of the study, the medical records of 197 patients with urinary lithiasis covering the period 1996 2006 were analyzed with regard to clinical and metabolic data. In the second stage, 340 kidney stones were submitted to morphological examination under 10x magnification. According to the external morphology and the cut surface, the stones were classified as pure or mixed, and major and minor components were identified. In addition, the stone fragments of 25 patients treated with lithotripsy were submitted to morphological analysis. In the third stage, a subsample of 50 stones was used in a double-blind comparison of morphological and chemical findings. Results were expressed as concordant, partly concordant (discordant for minor components) or discordant (discordant for major components). The average age of first symptoms was 35.8±13.3 years, with no significant difference between the genders. The male/female ratio was 1:1.7. Recurrence was reported in 53.3% of cases. The main metabolic changes observed were hypernatriuria (80.7%), hypercalciuria (48.7%), low urine volume (43.7%), hyperoxaluria (30.5%) and hyperuricosuria (17.3%). Pure stones represented 34.7% of the total sample of 340 stones. The most common route of elimination was spontaneous for pure stones (49.1%) and surgical for mixed stones (50.5%). Pure stones consisted most frequently of calcium oxalate (OxCa) (59.3%) and uric acid (UA) (23.7%), the former prevalent in women, the latter prevalent in men. The most frequently observed component in mixed stones was OxCa (67.1%), followed by carbapatite (11.2%) and struvite (7.9%). The main components were OxCa and UA for men, and carbapatite and struvite for women. Nearly half (48%) the 25 analyzed fragments were pure, consisting of calcium oxalate dihydrate (COD) (56%), calcium oxalate monohydrate (COM) (48%), phosphate (32%) and UA (20%). Four patients (16%) had infectious stones. In the chemical analysis of the subsample of 50 stones, the most 64 frequently observed major components were calcium (70%), oxalate (66%), ammonium (56%), urate (28%) and carbonate (24%). In the morphological analysis, the main components were calcium and magnesium phosphate (32%), COM (24%), UA (20%), COD (18%) and cystine (6%). Morphological and chemical findings were totally concordant for 38% of the stones, partly concordant in 52% and discordant in 10%. Conclusion: The risk factors for lithiasis in kidney stone patients from Fortaleza (Brazil) were hyperoxaluria, hypercalciuria with or without hypernatriuria, hyperuricosuria and low urine volume

Suplementação oral de zinco pode diminuir o perfil sérico de ferro em crianças saudáveis

Conselho Nacional de Desenvolvimento Científico e Tecnológico

Investigação farmacoepidemiológica do uso do clonazepam no distrito sanitário leste em Natal-RN

Prescription errors are the most serious type of medication errors found in the health system. The main purpose of this study was to evaluate the quality of clonazepam prescriptions. A descriptive and observational study with retrospective data collection was conducted at 30 community pharmacies in Natal/RN, Brazil, after informed consent was obtained from the pharmacists. A sample of 313 prescription notifications was randomly collected in October 2009. They were analyzed for legible handwriting and completeness. During the study, one researcher, two pharmacists, and one pharmacy undergraduate student evaluated patient and purchaser identification, pharmaceutical form, dosing regimen, administration route, and prescription by generic name. This research was approved by the institutional Ethics Committee. Among the 313 collected notifications, only 44.1% were legible. A total of 55.91% (175/313) had at least one illegible item, 100% contained incomplete information, and 97.12% (304/313) contained one or more abbreviations. The proportion of illegible handwriting related to the patient s identification (p=0.0001) was statistically significantly greater than that related to the drug purchaser s identification (p=0.0004). Contrary to legal requirements, prescriptions with the generic name accounted for 13.42% (42/313) of the total. All the examined notifications were handwritten. Prescription errors, which potentially can have serious consequences, have been evaluated worldwide, although little is known about this subject as it relates to community pharmacies. This study showed high percentages of prescribing problems, which justifies the development of future research about medication errors in community pharmacies and education activities for prescribers

Ensaio clínico randomizado sobre a prática da atenção farmacêutica nas farmácias comunitárias

Introdução: A criação de programas de equipe multiprofissional de saúde desponta como uma alternativa eficiente para controlar a evolução dos pacientes portadores de diabetes, e a inserção do farmacêutico em tais programas tem contribuído para melhorar o acompanhamento desses pacientes. Objetivo: Avaliar o impacto da intervenção do farmacêutico no acompanhamento dos pacientes diabéticos tipo 2, em farmácias comunitárias. Métodos: Ensaio clínico randomizado, uni-cego envolvendo 100 pacientes diabéticos tipo 2 de ambos os gêneros, usuários de farmácia comunitária, com idade igual ou superior a 30 anos, em uso de hipoglicemiantes orais com adição ou não de insulina e foram acompanhados por 6 meses. Os pacientes do grupo controle receberam o tratamento habitual existente em qualquer farmácia, e os de intervenção receberam o acompanhamento do farmacêutico incluindo intervenções aos problemas relacionados aos medicamentos. Os desfechos primários avaliados foram os valores da hemoglobina glicada (HbA1c), glicose basal e um questionário de qualidade de vida validado denominado de Diabetes Quality of Life Measure (DQOL) - Brasil; e como desfechos secundários as dosagens dos triglicérides, colesterol total, (HDL) colesterol, (LDL) colesterol, tensão arterial e a satisfação do usuário com o serviço prestado. Essa pesquisa contou com a colaboração de vários profissionais das diferentes áreas do conhecimento a seguir nominados: médico, farmacêutico bioquímico, enfermeiro, nutricionista e estatístico. Resultados: Finalizaram o estudo 89 pacientes. Durante o acompanhamento 95,7% (45/47) dos pacientes no grupo intervenção apresentaram problemas relacionados aos medicamentos (PRM), perfazendo um total de 141, com uma média de 3 eventos por paciente, ocorrendo uma resolutividade de 61,7% (87/141). A categoria que mais apresentou PRM foi a de efetividade com 34,1% (48/141) e a classe farmacológica mais utilizada foi a dos hipoglicemiantes orais com 35% (49/141). As variáveis de desfechos primários como hemoglobina glicada (HbA1c) e a glicose basal não apresentaram valores estatisticamente significantes quando comparadas o final com o inicial do acompanhamento nos grupos intervenção e controle considerando um p<0,05, mas o questionário de qualidade de vida DQOL Brasil apresentou resultados estatisticamente significante com um p=0,000. Os desfechos secundários, com exceção da satisfação do usuário, não apresentaram valores xi estatisticamente significantes quando comparados o final com o início do acompanhamento nos grupos de intervenção e controle. Conclusão: Os resultados indicam que as modificações das variáveis clínicas não apresentaram valores significativos no controle da enfermidade e comorbidades, enquanto que na avaliação da qualidade de vida os pacientes afirmaram que melhoraram; portanto, pode-se postular que a intervenção farmacêutica é uma atividade necessária, mas que a prática do Pharmaceutical Care trará benefícios com sustentabilidade para os pacientes se houver uma efetiva integração do farmacêutico numa equipe multiprofissional de saúde, o que está indisponível nas Farmácias Comunitárias

Ação da cafeína sobre o rendimento esportivo de ciclistas em condições de calor e umidade

Objetivo: Verificar a ação da cafeína no tempo de rendimento, a taxa de esforço percebido (RPE), os níveis plasmáticos de glicose, sódio e potássio, a temperatura timpânica (Tt), o peso corporal (PC), freqüência cardíaca (FC) e concentração urinária da cafeína com a ingestão de doses de 5 e 9 mg/kg de cafeína e placebo, em provas ciclísticas sob condições de alto risco térmico. Métodos: Foram estudados 8 ciclistas treinados e aclimatizados em 3 provas de 45 km utilizando o modelo experimental e duplo-cego com randomização intra-sujeitos. Resultados: Não foram observadas diferenças significativas entre as variáveis avaliadas, entretanto o tempo de rendimento e a RPE foram menores com as doses de 5 e 9 mg/kg de cafeína que com a dose placebo. Conclusões: Estes dados indicam que as condições de calor e umidade podem ser suficientes para mascarar o benefício ergogênico da cafeína, entretanto deve-se considerar que a cafeína pode exercer influencia sobre a percepção subjetiva de esforço podendo levar à redução dos sinais de fadiga durante o exercício e conseqüente melhora do desempenho esportivo

Análise do vetor de impedância bioelétrico na avaliação da suplementação de zinco em crianças prepuberais e sadias

Conselho Nacional de Desenvolvimento Científico e Tecnológico

A influência do método pilates sobre a qualidade de vida em mulheres climatéricas

Objetivo: Avaliar a influência do método Pilates sobre a qualidade de vida em mulheres climatéricas atendidas pelo Sistema Único de Saúde. Métodos: Trata-se de um estudo prospectivo do tipo ensaio clínico randomizado, cego para avaliador, com amostra por conveniência, composta por 51 mulheres divididas em grupo controle (n=25) e experimental / Pilates (n=26), ao longo de 12 semanas. Os instrumentos usados para coleta foram: o Medical Outcome Study 36-item Short Form Health Survey (MOS SF-36 Health Survey) versão brasileira e o índice menopausal de Blatt e Kupperman. Os dados foram tratados com estatística descritiva e inferencial (teste t para amostra pareada e de Wilcoxon), com p≤0,05. Resultados: Observou-se que a amostra estudada apresentava idade média de 53,7±4,07 e 53,9±5,52 anos, IMC médio de 25,2Kg/m2±3,71 e 26,06 Kg/m2±2,56, no grupo controle e experimental, respectivamente. A maioria era casada, sem trabalho formal e com pelo menos o 2º grau completo. O grupo submetido ao método Pilates apresentou efeitos positivos sobre a diminuição dos sintomas climatéricos (19,6 para 12,2) com p= 0,001 (GE) e p=0,062 (GC), bem como apresentou significância estatística para comparação no parâmetro de capacidade funcional (p=0,001), limitação por aspectos físicos (p=0,05), dor (p=0,001), estado geral de saúde (p=0,001), vitalidade (p=0,001), aspectos sociais (p=0,027) e saúde mental (p=0,001) em mulheres na meia idade. Conclusões: Os resultados do estudo mostraram que 12 semanas de intervenção com o método Pilates apresentaram efeitos positivos sobre a diminuição dos sintomas climatéricos, bem como melhora nos domínios de qualidade de vida nestas mulheres, possibilitando efetivas propostas de intervenção profissional às especificidades deste público, com foco na promoção de saúde através de ações interdisciplinares

Avaliação da eficácia de um programa de "Escola de Coluna" para lombalgia crônica inespecífica

The Back School has been used to prevent and to treat back pain since 1969, however its effectiveness still is controversy in literature. The objective of this study was to evaluate the effectiveness of a program of "Back School" in patients with nonspecific chronic low back pain, directed by rheumatologists and orthopedic doctors to Physiotherapy School Clinic of Universidade Potiguar (UnP) Natal/RN- Brazil, in period of May/2002 to December/2003. Seventy patients, with age varying from 18 to 60 years, were randomized in two groups: Experimental group (group A) with 34 patients, which was subdivided in groups with 6 to 8 components. This group participated of a theoretician and practical program of Back School with 4 lessons, one day per week, with 60 minutes of duration; to the Control group (group B), with 36 patients, was explained that the group should stay four months in a waiting list . Both groups, had been carried through three evaluations, by a blind, to patient group, independent observer: initial evaluation, after four and sixteen weeks. The following variables were analyzed: pain intensity, measured by analog visual scale (AVS), functional disability, measured by disability questionnaire of Roland and Morris and the spinal mobility measured by Schöber s method. In statistical analysis it was used variance analysis ANOVA, the test of Newman-Keuls multiple comparations, and the Pearson correlation coefficient, with significance level p<0.05. Thirteen patients (18,6%) didn t complete the evaluations, (5 from experimental group and 8 from control group). At last, 57 patients were studied, (29 from Experimental group and 28 from Control group), it was observed a significant statistical improve just for Experimental group in variables pain intensity (p=0,0001), functional disability

Influência do tratamento com ácido lipoico sobre o metabolismo ósseo e perfil antioxidante de mulheres na perimenopausa

Bone is a dynamic tissue that is in constant process of remodeling in response to mechanical stress and hormonal changes. This study aimed to understand the relationship between the biochemical changes, which women in the menopausal transition are subject to, and how the use of an alternative therapy with lipoic acid (LA) could influence these changes. The study of double-blind, was carried out in perimenopausal women that underwent a three month treatment with 600 mg of AL compared with another group that received placebo during the same period. This study showed that women had a waist circunference and body mass index above the values recommended by WHO (WC ≥ 80 cm; BMI > 25kg/m2). Associated with this, these women had increased concentrations of total cholesterol and triglycerides, and borderline LDL (Total Cholesterol > 200mg/dL; Triglycerides > 150mg/dL; LDL >130mg/dL). These changes were not affected by treatment with AL. There were no shifts in liver profile (ALT, AST and GGT), kidney profile (urea, creatinine, total protein and albumin), mineral profile (Total Calcium, Ionized Calcium, Phosphorus and Magnesium) as well in bone markers (osteocalcin, Total Alkaline Phosphatase and Tartrate Resistant Acid Phosphatase) after treatment with LA. The results of the oxidative profile showed that treatment with LA decreased GPx activity (p < 0,01), while for the TBARS, GSH and SOD activity there were no differences. With regard to SOD, this enzyme will submit to be high in the placebo group after 3 months of study (p<0,05). The expression of RANKL mRNA was reduced (p < 0,05) and of RANK increased (p <0.001), after treatment with LA, while the expression of IL-6 and TNF-ɑ genes were no changed. We conclude that women already in the perimenopause stage have changes in lipid profile and body composition that could induce shifts in oxidative and bone metabolism. However, LA treatment has provided an effective effect in the oxidative and bone profile since the earliest markers such as GPx activity and mRNA expression of RANKL, respectively, were reduced associated with no change in SOD activity. These results suggest a beneficial and protective effect of LA, indicating it potential as an alternative treatment to help the to prevent the complications associated with estrogen deficiency

Família, aluno e professor: as forças tipológicas da educação básica na região metropolitana de Natal

This work was developed in the research line: "The habitus of study: builder of a new reality in the basic education of metropolitan area Natal" which is being developed with the support of CAPES by the Centre for Education. Acts, especially the problem of academic performance of students in basic education of the public in the Metropolitan Region of Natal (RMN). Thus, the aim of this paper is to construct a typology of students in the 9th year of basic education, attending the public schools (state or municipal) of MRN, 2009, and assess, according to these profiles, what personal characteristics student and their families: economic, social and cultural capital as well as teaching practices create environments capable of favoring a good educational development as measured by the performance obtained in the assessments in mathematics and English language. The data used were provided through the microdata Brazil Exam 2009 held by INEP. We used the methods Grade of Membership (GoM) for construction of profiles relevance of students according to the characteristics already mentioned. With these profiles was verified, which were effectively generating good performance in school curriculum components evaluated. The findings indicate that students belonging to the profile considered good environment, able to achieve better school performance both in Portuguese as in Mathematics, compared to the extreme profiles and adverse deficit

Efeito do ácido alfa-lipóico sobre biomarcadores de estresse oxidativo, inflamação e fatores de risco cardiovascular em hipertensos

Alpha-lipoic acid (ALA) is a potent antioxidant with favourable anti-inflammatory, metabolic and endothelial effects, and has been widely investigated due to its potential against cardiovascular risk factors. This study aimed to evaluate the effect of oral ALA supplementation on oxidative stress biomarkers, inflammation and cardiovascular risk factors in patients with hypertension. This is a double-blind placebo-controlled randomized clinical trial, where the intervention was evaluated prospectively comparing results in both groups. The sample consisted of 64 hypertensive patients who were randomly distributed into ALA group (n = 32), receiving 600 mg / day ALA for twelve weeks and control group (n = 32), receiving placebo for the same period. The following parameters were evaluated before and after intervention: lipid peroxidation, content of reduced glutathione (GSH), enzymatic activities of glutathione peroxidase (GPx) and superoxide dismustase, ultrasensitive C-reactive protein (hs-CRP), triglycerides, total cholesterol and fractions, fasting glucose and anthropometric indicators. There was a statistically significant reduction (p <0.05) in serum concentrations of total cholesterol, very low density lipoprotein (VLDL), high density lipoprotein (HDL), triglycerides and blood glucose. There was a reduction in body weight and waist, abdominal and hip circumferences in the group that received ALA. In addition, there was a statistically significant increase (p <0.05) in the contents of reduced glutathione (GSH) and glutathione peroxidase (GPx) in the group receiving ALA. Oral administration of ALA appears to be a valuable adjuvant therapy, which may contribute to decrease the damage caused by oxidative stress and other risk factors associated with the atherosclerotic process

As relações entre os saberes pedagógicos do formador na formação docente

Las relaciones de saberlos pedagógicos en la formación de enseñanza, el dirigir de la tesis, si presentes como ocasión de reflejar en saber básico pedagógico el profesor práctico a él, en especial a la formación de profesores. Se considera que con éstos que saben, el profesor adquiere sensibilidad para desarrollar su elemento formativo práctico. Su función principal es favorecer a la relación teoría práctica usándose, para el, de la reflexión como ocasión de concreción de las direcciones. Actuando en diversos cursos de la formación de enseñanza, el nivel de la graduación y algunas instituciones, fue parecido con situaciónproblemas cuál si está instigado, para buscar cada tiempo más para entender porqué en esos diversos contextos prácticos el pedagógico si está configurado diferentemente. Con propósito para entender las direcciones de los formadores de los profesores en cuanto a las relaciones de saberlas pedagógicos en la formación de enseñanza, la investigación se convierte en un continente académico - tres instituciones públicas de educación superior que actúan en el estado del gran río del norte - UFRN, UERN e IFESP. Los participantes de la investigación, entrevistadas con, de 12 profesores-formadores de funcionamiento de los cursos de las matemáticas (licenciatura), de Pedagogía y de normal superior de estas instituciones. Metodología pauta desarrollada en la entrevista comprensiva, el subir de metodológica de la naturaleza cualitativa, básica para interpretar las direcciones y los valores para ser explicitados en el acuerdo los discursos entrevistados. Finalmente, se considera que los cuatro saber si explique para la interrelación que poseen. Para saber para saber si une con para saber para hacer para dar y concebir la idea para hacer. Para saberlos para hacer y para saber se ha sentido solamente habrá tenido con quién a la parte para saber para coexistir. Para saber para ser él será solamente significativo frente las lecciones de los otros para saber. El formador va a redimensionar, gradualmente y concienzudo, cada uno de éstos a saber con la educación. La dirección de aprender se desarrolla en un proceso inverso a la educación, puesto que, el aprendiz, una época el saber a ser, sabe para coexistir con sus pares, sabe para hacer e. Finalmente, sabe para saber. A este movimiento puede ser llamado de sociointeracionismo. Toda esta mediación solamente sucede si el aprendiz sujeto, el estudiante o el profesor, es concienzudo de su desarrollo y de la transformación gradual de la educación y de la sociedad. Saberlos, las filas en práctico son, otra vez, conocimiento constituido desarrollado, complejo y transformado para rehacer el paso. De este modo, si percibe la necesidad de una base para saber destinado pedagógico al profesor y a los ayudadores prácticos de la formación continuada de profesores

Dos tempos de escola aos dias atuais: reminiscências duradouras da experiência escolar

Este estudo trata sobre as marcas da experiência escolar no processo de individuação do sujeito e tem como objetivo geral conhecer de que forma essas experiências, a despeito das questões curriculares e pedagógicas, influenciam esse processo. Buscou-se interpretar as experiências reforçadas durante a escolarização e as trajetórias de enfrentamento das diversas situações vividas na escola. Tentou-se, também, compreender o sentido dos acontecimentos escolares críticos e igualmente como o meio familiar pode influenciar nas escolhas e formação dos sujeitos através do investimento pedagógico. Ademais, refletiu-se sobre os motivos que levaram alguns a permanecerem no ambiente escolar seja como estudante ou mais tarde, do lado de lá, como professor. Para tanto, foi realizada uma pesquisa qualitativa de inspiração fenomenológica utilizando-se de entrevistas narrativas com quatro sujeitos, a partir das quais se identificou as principais características, estrutura, condições de origem, o contexto social, as estratégias escolares, as formas como foram manejadas e suas conseqüências. A análise dos relatos deixou claro dois eixos fundamentais da experiência escolar que se destacam na constituição dos sujeitos: de um lado a dinâmica do ambiente escolar vivido deixou marcas indeléveis na memória que foram determinantes para as escolhas pessoais; por outro lado, a referência familiar, através das suas várias formas de investimento pedagógico, teve uma influência decisiva. As marcas combinadas da escola e da família deixaram um legado importante para formação dos sujeitos e para as escolhas que fizeram durante as suas vidas, especialmente no direcionamento da suas carreiras profissionais. Invariavelmente, percebeu-se na investigação, que muito do aluno que se foi persiste no adulto e profissional de hoje. Assim, o Eu escolar é parte do Eu profissional que existe em cada um. O cidadão, a pessoa e o profissional são derivados dos processos de socialização e individuação, os quais em grande parte se definem durante a vida escolar. E é com o uso desse "capital escolar" , adquirido nos tempos de escola, que temos condições de desenvolver os muitos papéis sociais nos dias atuais.

O dia mais feliz da minha vida: a entrada na universidade segundo os alunos recém-ingressos no curso de Pedagogia da UFRN(2004.1)

The present work, based on the methodological principles of the Comprehensive Discourse Analysis, aimed, through the speech of twelve newly arrived students at the Pedagogy course of the Federal University of Rio Grande do Norte, to understand the moment students start university. It also aimed to analyze the relationship between the schools they were coming from and university entrance as well as the relationship between university and their new students. In the first part of the work, which focused on school knowledge, a comprehensive listening of the speeches of the students led primarily to a distinction, established by the students, between public and private schools, a distinction especially based on the view of superiority of private schools against public ones. The abovementioned interpretation is found in the discussion of the structural duality of Brazilian education which, historically, offers different pedagogical appliances among students of more priviledged social classes and those who come from lower levels of society. The overcome of this duality, aspired by the Brazilian Constitution of 1988, was stopped by the advent of a new economic model neoliberalism, which reinforced the differences between public and private when it prioritized the market on the economic, political and social relations, including educational projects. Impoverishment of public institutions and pauperization of the work of professors affected also the relationship between teachers and studens at the current institution. This is how the teacher becomes the greatest villain at the public management system. All of these references concerning differences in the quality of teaching at public and private schools, expressed by the students interviewed, however, were centered in the preparation for the entrance exam, called vestibular, thus showing a view that the relationship between the student and the school he came from is of a propedeutic kind and even so, reduced to a preparation for an entrance exam. In the second part of the work, which analyzed the relationship between newly arrived students and their university, it was noticed that the latter represents a whole new world. This world is seen as the change at the student´s social statute for now he is grown, takes more responsibilities and is socially respected. This change of attitude established by society and the discovery of a new world which requires more independence from the students, creates in them feelings of pride and fear and they feel insecure when it comes to making decision in the campus because now their decisions deliver a greater load of responsibility. This is when students understand they need to develop autonomy, which is seen, in this work, as the capacity to make conscious decisions. Nevertheless students expressed an understanding of autonomy as something that comes as a gift for those who enter university and not as a process that is constructed from social experiences. For these students, the need to be autonomous refers to the relationships with their teachers and the search for information. This search, however, is also related, according to interviews, to public school financial cuts, which penalize university, and to the lack of employers