This research describes the experiences, perceptions and opinions of HHs and key informants about the work of HHs, their health problems and their strategies to solve them. HHs reported musculoskeletal problems, stress and anxiety, and attributed them to the tasks they performed daily at high pace. When having health problems, the most commonly reported strategies were use of : (i) medication and (ii) health services (specialist services in winter and general acute care in summer). Other less commonly reported strategies were use of individual protection equipment, ergonomics and physical activity. HHs positively assessed public health care when treated by their family doctor, but were rather unsatisfied with specialist care.
Regarding health problems, HHs equally emphasized MSD, stress and anxiety. In contrast, some key informants hardly mentioned stress and anxiety. Respiratory and dermatological problems were less reported. A perception shared by most participants was the association between hotel housekeeping and MSD. However, the occupational health specialist believed that work was a trigger for health problems rather than the cause.
Various studies associate working conditions of HHs with health problems . The European Agency for Safety and Health at Work (EU-OSHA)  identified occupational physical risks such as carrying heavy loads (i.e., the housekeeping cart), which can cause MSD. Of the 941 HHs interviewed by Krause et al. (2005) in Las Vegas , 78% reported having had pain in the last 12 months. HHs perceived that the pain could have been caused or aggravated by their job. The authors concluded that pain was associated with significant physical effort and non-ergonomic work conditions. In a study by Buchanan et al. (2010) conducted in 55,327 hotel workers (21% were HHs) in the United States, estimated injury incidence rates in HHs doubled injury rates of the other hotel workers .
Qualitative studies confirm the HHs’ perception of the relationship between their job and their health problems. In the study by Kensbock et al. (2016), HHs reported that the excessive physical demands of their jobs made them work daily with pain . Hunter Powell & Watson (2006) collected the experiences of HHs related to exposure to some risk factors, such as the use of cleaning products and the movement of the housekeeping cart . Hsieh et al. (2016) interviewed HHs, who associated MSD with repetitive movements carried out at work, and dry hands to the use of cleaning products . All these experiences corroborate the information provided by the HHs and key informants participating in this study.
Since most HHs are women, and taking into account that women are usually in charge of domestic and care tasks, they could be doubly exposed to physical and psychological stressors . Additionally, these women lack the time to recover from physical fatigue and to perform beneficial physical activity to prevent or improve MSD . Previous results recently published corroborate that HHs perceived that the high demands of their job caused work-life imbalance . Usually, the demands of the job depleted their personal resources, depriving them of energy to attend to the demands of private life such as caring for dependents and enjoying family life and leisure . This high level of perceived stress and the characteristics of the HHs job (high demands combined with low control) could partly explain the perception of the relationship between MSD and work, as published by Herr et al. (2015) .
On the other hand, some key informants interviewed attributed the prevalence of MSD to age. However, the study by Krause et al (2005) contradicts this perception, observing few significant differences in the relationship between age and pain, with only knee pain more common in older women .
Our results reveal different strategies undertaken by HHs for health issues, such as taking medication for pain, including anxiolytic agents. Similarly, Krause et al (2005) reported that 85% of HHs had taken some medication during the last four weeks due to pain while working .
Another strategy reported was to follow ergonomics recommendations. However, HHs reported difficulties due to time pressure and furniture arrangement, implying the prioritisation of job performance before their health. Bernhardt et al (2006) also reported the difficulty caused by time pressure derived from the number of rooms to be cleaned . In the work of Krause et al (2005) 75% of those surveyed stated that “my job requires working very quickly” .
When suffering from a health problem, some HHs considered taking SL, or their doctor suggested this option. However, many carried on with a “sickness presenteeism” resulting from feeling pressured to go to work when sick . HHs refused the prescribed SL for fear of being punished by the company or due to solidarity between workers . Albarracín & Castellanos (2013)  state that fear of unemployment has put pressure on workers after the economic crisis that began in 2007. Some of the attitudes towards illness or pain and the choice of taking SL corroborated the experiences of HHs from Las Vegas : among the reasons for not communicating pain and work-related injuries, 44% believed that the pain would subside, and 26% declared that they were afraid of being fired or having "problems".
Regarding the use of health services, during the busier seasons (firstly summer and secondly spring), HHs consulted health services for acute conditions. In contrast, during the months that HHs did not work or when the work burden was lower, they requested appointments for preventive activities and consultations with specialists. Notably, the HHs use of health services was more determined by the labour market than by the health needs of HHs.
Similarly, the use of health services was influenced by the practice of changing days off, which transforms the worker into a subject/object on permanent stand-by to meet the needs of the productive system, without taking into account the needs of the personal and familiar domain. Companies do not assume the costs of having more staff to ensure worker’s rights. Consequently, the employees' working conditions deteriorate. A workforce constituted almost exclusively by women in an “unskilled” job magnifies this conception of the worker. However, when confronted with the practice of changing days off, most HHs claim their rights. On the other hand, many also accepted that in "summer they work and cannot do much else."
HHs showed satisfaction with the care received in the PC centre, corroborating the findings of Arrazola-Vacas et al (2015) . It should be emphasized that when they were not treated by their family doctor, HHs perceived lack of empathy and considered that the encounter should be more personalised. Staff empathy, personalised treatment and communication with the doctor have been described as sources of satisfaction in PC users [50–52]. Besides, variables associated with quality of care are related with the health professional, information received, and trust in the doctor .
In addition, HHs felt that of all health professionals, only their family doctor/nurse listened to them, a perception also described in the qualitative study by Arman et al (2020) . According to the occupational health specialist, this feeling might respond to psychosocial aspects underpinning the health conditions of many HHs, which could partly explain why expectations were not met by the health services as a whole; as expressed by Arman et al, (2020; 777): "the combination of physical and mental health issues becomes a challenge in women's encounters with the health system".
People with moderate or high work-related stress use more frequently health services . Since the tourism sector has been identified as one of the most stressful working environments , HHs frequently consult health services with complex problems beyond musculoskeletal pain, but professionals tend to focus on the symptom without searching for the cause. Furthermore, some doctors attribute a psychosomatic origin to symptoms of musculoskeletal injuries in women, and fail to adequately treat the physical problem .
Regarding limitations, we should mention the possible bias that results from family doctors selecting FG participants: (i) overrepresentation of the discourses of the HHs with more health problems, because they attend the health centre more regularly and (ii) overrepresentation of the discourses of the HHs with more job stability, since the family doctor may not know the temporary HHs. Recruitment of young HHs and HHs with a temporary contract was difficult, and thus their discourses are underrepresented. On the other hand, recruitment unrelated to the company or trade unions made them feel safer when explaining their health and occupational experiences. Limitations intrinsic to qualitative studies are weak external validity of results and limited capacity to measure stress incidence among HHs. However, qualitative methods plunge deeply into the explanations of the phenomena, obtain rich information and identify shared explanations of events and experiences.
This study is part of a larger project. The information collected and analysed here was used to design a descriptive study on working conditions, perceived health status and occupational risks with a representative sample of more than 1,000 HHs. The larger study should verify whether the perceptions and experiences expressed in the interviews and FG are shared by the larger community of HHs.
In conclusion, the work of HHs is considered physically demanding and is associated with specific health conditions, mainly MSD. Compared with other occupations, few studies address the perception and health problems of HHs. The results of this study underscore that HHs perceive a causal relationship between their occupation and their health issues (mainly MSD, anxiety and stress). When they feel unwell, HHs usually resort to medication and attend health services, which they consider mostly adequate.