Perception of elderly singers on the promotion of vocal health

Corresponding address: Aline Megumi Arakawa-Belaunde Campus Reitor João David Ferreira Lima, s/n – Trindade CEP: 88040-900 – Florianópolis, Santa Catarina, Brasil E-mail: arakawa.aline@ufsc.br ABSTRACT Purpose: to check the understanding of elderly participants of a singing group on the promotion of voice health. Methods: a qualitative approach linked to Paulo Freire’s research itinerary consisting of three dialectic moments: thematic investigation; encoding and decoding; critical revelation. Results: these stages were developed in four culture circles with the participation of six elderly people. The study showed three themes: (1) Expression and feelings, (2) Potentiality and difficulty, (3) Voice care. The circles brought expression of ideas and practices to voice care. The sense of belonging that the group provides could be observed, especially on emotional issues. The elderly empowered themselves to discuss their beliefs regarding voice care, clarified during culture circles, providing subsidies for a greater autonomy in their personal life. Conclusion: the dialog between the participants made the understanding possible on the role of voice, permeating aspects related to the physiology, functionality and emotion in the participants’ perception.


INTRODUCTION
The promotion of health is a process that empowers individuals and the community to work on improving the quality of life, including their greater participation in health processes.In order to achieve a complete physical, mental and social well-being of both individuals and groups, the promotion of health must meet their needs and appropriately modify their environment 1 , and be understood as a promising strategy for coping with population health problems at the individual, community and public policy levels².
Health should be seen as a resource for life, becoming a positive concept involving social and personal means, as well as physical abilities; therefore encompassing a healthy lifestyle as an important factor for overall well-being¹.
The promotion of health aims at improving the conditions of life of each individual, broadens the means to enhance collective and individual health, reduces social, environmental, economic, cultural and political risks and also reduces vulnerability.The actions with the objective of an improvement in the quality of life have fundamental importance in favor of healthy aging³.
The focus on aging with quality of life seeks as its main aspects life care in the care of the elderly and the verification of their performance in daily tasks compared to their functional capacity 4 .
In order to maintain an active aging, it is necessary to have good functional capacity, where there is a socially active life with great possibilities of communication, in which the elderly have the opportunity to express themselves, which will give them greater social interaction with other individuals 5 .
In a study carried out with the elderly, it was observed that social activities performed by the individuals surveyed, such as involvement with friends, the church and the local culture, seem to be protective factors in relation to the decline of mental functions and lack of communication and social involvement, improving their quality of life 6 .
With advancing age, some changes are expected and can be considered as part of the aging process.Among these alterations, speech-language pathology (SLP) disorders, such as voice changes and hearing impairment, among other alterations in the various areas of SLP performance, may compromise the quality of life of the elderly population and their social autonomy 7 .SLP therapy is also present in the promotion of health for healthy and active aging, through prevention and rehabilitation when it is needed 8 .
All those who use communication share different information, ideas, feelings and emotions among themselves, making the act of communicating an activity essential for life in society.The voice, in turn, has a fundamental role in communication, for expressiveness and integration, enabling a greater empowerment of the individual in the community 9 .
Voice is transmitted using spoken language, being peculiar to the subject and varying according to the sex, age and emotional state of the speaker.As a consequence, it is largely responsible for success in human interactions 10 .
In view of the foregoing, the present study aimed to understand the perception of elderly participants in a singing group, with a view to promoting voice health.

METHODS
The ethical aspects that guided this study followed Resolution Number 466/2012 of the National Health Council of the Research Ethics Committee of the Universidade Federal de Santa Catarina, approved according to CAAE: 54780416.2.0000.0121.After clarifying the study, the elderly gave written informed consent and answered a sociodemographic questionnaire prepared by the researchers to characterize the study population.To guarantee the anonymity of the participants, they were denominated by the letters E (when referring to the elderly) followed by a letter of the alphabet.
This was a qualitative study, of the type actionparticipant research.As a methodological reference, the Paulo Freire research itinerary was used, which consists of three dialectical and interconnected moments: thematic research; codification and decoding; critical unveiling through culture circles 11 .The conceptions of health promotion, together with voice health, contributed as a theoretical reference for the critical unveiling of the themes in the culture circles.
The culture circle is a term created by Freire, which represents a dynamic space of learning and exchange of ideas.Participants gather in the dialog process to investigate topics of interest to the group itself 12 .
This study was carried out in the Center of Elderly Studies, linked to the Universidade Federal de Santa Catarina (CES / UFSC).The CES / UFSC was conceived in March 1982 for studies in relation to the elderly community.It is an open university of the elderly where there are workshops and activities aimed at the elderly in the community, with the aim of re-creating, systemizing and socializing knowledge about gerontology 11 .
The research itinerary of Paulo Freire 12 , which outlined the present study, took place in four culture circles, from May to August 2016.For the realization of these circles, CES / UFSC coordination was contacted in order to clarify the purpose of the study and organize the meetings with the elderly.Through a favorable manifestation of the singing group, the elderly were invited for effective participation.
The culture circles were recorded in audio and video, recording the relevant topics related to the demonstrations and expressions of the participants, as well as the organization and development of the next steps of the method applied in the culture circles.During the four meetings, which took place bimonthly and lasted approximately 70 minutes, the stages of thematic research, codification and decoding and critical unveiling were carried out.The meetings were transcribed for later analysis.A total of six elderly people aged 60 or over participated in the study, in addition to the participation of a graduate student in SLP therapy, two SLP therapists and a nurse.The non-attendance in two or more culture circles was adopted as exclusion criterion.
In the stage of the thematic investigation, the survey of generating themes took place, based on the reality of the participants.To help identify the issues, some guiding questions were used: "What is voice for you?" and "How do you understand the act of taking care of your voice?", which fostered reflections, thus generating themes that were recorded with a colored atomic brush on a wall-mounted panel with large letters for everyone to read.Afterwards, themes generated through dialog, coded and decoded in the first culture circles, were then unveiled in the third and fourth meetings that followed, allowing participants to understand the promotion of voice health.Critical unveiling enables the process of action-reflection-action of the participants to jointly seek the transformation of reality 13 .
The themes encoded and decoded by the elderly were written on cards, pasted on panels and later read and discussed in the meetings with all the participants of the group, including the researchers / moderators of the culture circles.As a result, the relevant themes were presented, which reflected the conceptions of voice health promotion, especially during the activities of the singing group.Through a dynamic of clipping and collage of figures, the participants revealed actions that represented the unveiling to promote voice health.
The critical unveiling of the topics investigated, coded and decoded was carried out by the study participants as predicted by Paulo Freire research itinerary, which defines the analytical process under the eyes of the researchers and according to the conceptions of voice health promotion.

RESULTS
The culture circles were carried out at CES / UFSC with the participation of six elderly people, among them five females and one male, with ages between 60 and 70 years old.Among the participants, three had completed post-secondary education, another two had completed high school and one had incomplete higher education.
Initially it was proposed a dynamic of relaxation with presentation of all.This moment favored the insertion of the dialog in the group, establishment of link between participants and mediators of the research, awareness of the people to the theme, besides making the presentation of the study possible.Subsequently in this culture circle, the signing of the free and informed consent form was completed, in addition to filling out the questionnaire to characterize the group.
During the second culture circle, the thematic investigation took place, in which the elderly were asked "What is voice for you?" and "What do you do to take care of your voice?".From the discussion of these questions, the participants enunciated the generative themes that were investigated as three significant topics: (1) "Expression and Feeling", (2) "Potentials and Difficulties"; (3) "Voice Care".These dialogues were carried out throughout the culture circles.
In the third culture circle, the themes that had been investigated were brought into the debate to be codified and decoded.The theme of "Expression and Feeling" (Figure 1) brought the discussion about what the participants understood about voice.In this context numerous opinions emerged, represented in the following comments: "It is the sound emitted by the vocal folds" (EA, EB, EC); "What we speak through our mouth" (ED); "Is everything that makes sound" (ED, EE); "Feels like the sound of the soul" (EF); "The representation of the individual" (EB, EE, EF) and "Expression of feelings" (EA, EB, EF).
from the speech of one of the participants, citing that "We can feel what people are feeling, whether they are happy or sad, through their voice, even on the telephone."(EB), thus showing the relevance of voice in human interaction.
The theme of "Expression and Sentiment" led participants in the culture circles to discuss about the themes of feelings that are present in the lives of the elderly, as well as how individuals speak and what they express through their voice.This was made clear The third research theme on "Potentialities and Difficulties" (Figure 2) raised by the participants reveals how the voice is used in singing.This theme was codified and decoded by the participants from the generating themes raised during the research stage.Through reflections during the culture circles, the group identified that certain themes were related to potentialities and others, to difficulties in promoting their vocal health.The potentialities were codified and decoded aspects related to self-esteem, achievement, flight of problems, pleasure, empowerment of the individual, as well as to the environment and acceptance of the voice.
As difficulties, the aspects about the accompaniment of the score, tension, stress and self-improvement in the singing were debated.
At that point, one of the participants expressed the importance of the support of the group in their personal life, citing that "I found in music an escape for my personal problems, as well as reasons to leave the house and have fun" (EF).This discourse demonstrates the group as an emotional and social support, being a practice that goes beyond the focus on the theme of voice itself, but the general health of the members.breathing for singing, performing vocal exercises, physical exercises, sleep quality, balanced eating and water intake, and others such as the consumption of ginger, alcohol, sprays and lozenges.
The last topic discussed was "Voice Care" (Figure 3), in which the participants brought information about myths and truths related to vocal health.Numerous considerations arose regarding the importance of  In the fourth and last culture circle occurred critical unveiling.Through a dynamic of clipping and collage of figures the participants identified actions and expressions that can help them to promote their vocal health.The collages were several images brought by the researchers and were related to the themes discussed in the previous meetings.These situations were debated among them from the generative themes raised, codified and decoded in previous culture circles.In expressing their own opinions and mediated by the professionals present at the meeting, the topics on care with the voice were discussed and clarified.

DISCUSSION
The vocal health of the elderly deserves attention in SLP, since voice is essential for expressiveness, communication, interaction, socialization and people's quality of life, and in addition, the human aging process implies structural and functional transformations that affect and modify vocal quality 14 .
In this sense, SLP therapy in the elderly aims to attenuate the impact of the vocal aging process and its implications on social integration, communication and quality of life.The actions for the health of the voice of the elderly can take place in an individual or collective manner, in social living spaces of the elderly 15 .
In addition, the practice of singing stands out not only for retarding vocal aging and activating brain regions responsible for processes such as memory, evocation and oral motor coordination, but also for working on emotional aspects, influencing the selfperception of the singer and promoting interpersonal relationships that develop self-confidence and self-esteem 16 .
The elderly groups adopt numerous initiatives for the social interaction and cultural development of the elderly, among them choral singing.Choral singing, in a specific way, enables humanization and socialization due to the group experience that stimulates the relationship with the other and the community in which it is inserted 17 .
Social support can be seen as a collective action that enables human communication and promotes the social inclusion of the elderly.In this context, SLP can act in the aggravations and in the promotion of voice health, providing a better interaction between the participants and the community 18 .
The elderly who participate in group activities are encouraged to remain active by performing a pleasurable activity that contributes to their psychological empowerment, which values their individuality and autonomy.In this perspective, the role of group singing in the development of the quality of life in the elderly is highlighted for health promotion and socialization 19 .It is in this context that the interaction of the individual is observed, thus allowing a greater insertion in the group, giving voice to the elderly person.
One can observe the improvement of the quality of life of the elderly from the moment the individual makes greater use of communication, because in this way they express their ideas and thoughts, becoming more participatory in their environment 15 .
With regard to the practice of vocal exercises, such as vocal warm-up, there is benefit to the individual in the face of better resistance and pneumo-phono-articulatory coordination, preventing fatigue and overload during singing.Another theme brought up by the participants referred to food.In this case, for example, they discussed avoiding the ingestion of spicy foods, which can lead to gastrointestinal and digestive alterations, thus affecting the vocal quality of the individual 20 .
Other reflections brought by the group of the present study refer to the habits that some participants practiced, involving the ingestion of alcohol and ignoring the physiology of the same in the human body.Those involved with singing may have a habit of ingesting alcoholic beverages to sing and achieve greater vocal use during presentations or trials, but drink is an aggressor to the vocal tract 21 .
During culture circles participants revealed that they use lozenges, sprays and ginger for greater vocal comfort.As for the use of lozenges and sprays, the quantity and viscosity of the saliva is altered, such as the anesthetic effect also caused by ginger, which masks the pain felt in the throat, causing a greater misuse of the voice 20 .Some participants showed a better performance during singing from the moment they became aware of respiratory physiology, a topic that was unveiled during the culture circles.The elderly involved with singing showed great concern regarding the respiratory mode, as well as with pneumo-phono-articulatory coordination, body posture and the application of exercises with the objective of improving vocal quality and singing comfort 21 .
It is in this context that the importance is stressed of correlating the care of the voice with the vocal quality in the face of promoting health, when the discussion about the habits and previous knowledge that the individuals and community had, such as those presented and discussed.
Throughout the culture circles it was observed that the participants presented and discussed their cultural beliefs related to the promotion of voice health, in which diverse opinions emerged, and according to their reality, were debated in the group.This activity was made possible through the theoretical and methodological conceptions proposed by Paulo Freire's itinerary.
It was noticed in the culture circles that a great interest of the participants was in discussing the doubts through the themes investigated.They were empowered when they proposed to create a name for the group, this being "Active Maturity", an aspect that focuses on the sense of belonging that they have developed.
In front of the participants' comments, the importance of community participation in group activities that favor greater social interaction and the sense of belonging was denoted by the greater empowerment of the elderly population.Thus, it was possible to understand the need for dialog and participation in the community, involving individuals who share the same interests and needs, bringing with it the construction of a personal and collective sense for health promotion actions.
Empowerment shows itself as a stimulus to subjects over control of their own decisions and choices.Health promotion actions aim to promote the emancipation and autonomy of individuals through the development of personal skills and a better care with their life and health³.
Health care covers key issues for health promotion, such as reception, bond and care organization.Practices are built with experiences and a socially shared process, which involve subjects, communities and populations in general, with needs and determinants of health conditions 22 .
It is in this context that the theme of voice care is emphasized, since it carries with it characteristics of each individual's personality, being a very important factor in communication, social integration and quality of life.In order for the elderly to maintain a healthy and social life, it is important that they have access to vocal health programs that aim to guide and prevent voice changes 15 .
The present study presented some limitations, due to the small number of participants who attended all the proposed cultural circles, and also by the presence of people who had already undergone speech therapy, since they had greater ownership of some topics about voice care, leaving the other participants with apprehension, discouraging their comments.

CONCLUSION
It was concluded that the objective of understanding the perception of the elderly regarding the promotion of vocal health was achieved, since through the Freirean perspective it was possible for the participants to express their feelings and uncertainties in relation to the theme addressed.Based on the topics raised and dialogues carried out in the culture circles, it was discerned that the elderly do not understand the voice only as the production of sound, but as a way of expressing feelings and the possibility of having greater autonomy in their personal life.
The research itinerary of Paulo Freire foresees a relationship of dialog with the participants of the research.It allowed the social reality to be unveiled through the reflections of the participants, leading to new proposals for action on the daily health promotion of the voice of the aging.Thus, debates and enriching reflections on the theme were promoted, clarifying, at the end of the culture circles, the themes elaborated by the different social actors present, as well as the actions carried out in the daily life and at the time of singing, which suggests other studies related to voice health and the application of the Freirean Itinerary be carried out.

Figure 1 .
Figure 1.Codification and decoding of the theme "Expression and Sentiment", raised by the participants during the culture circles

Figure 2 .
Figure 2. Codification and decoding of the theme "Potentialities and Difficulties", raised by the participants during the culture circles

Figure 3 .
Figure 3. Codification and decoding of the topic "Care of the voice", raised by the participants during the culture circles