Occupational voice disorders in teachers and current legislation

Abstracts

Considering voice is the teacher’s work tool and its role in teaching process, this study intend to explore the fact vocal disturbances related to teacher’s work has not been defined as a worker’s health grievance, despite its relevance and legal basis evidences. The group seeks to relate the occupational category’s labor bonds and the communication/notification in case of accidents and/or diseases related to work, besides a reflection over major questions and needs arising from the absence of technical and legal procedures from Health, Labor, Employment and Social Security Ministries in cases of disorders resulting from alterations in teacher’s voice.

Occupational Health; Faculty; Legislation; Health Public Policy

Considerando-se que a voz é o instrumento de trabalho para o professor e de sua importância no processo de trabalho docente, buscou-se neste estudo evidenciar que, apesar do tema ser de grande relevância e da existência de bases legais, o distúrbio vocal relacionado ao trabalho do professor ainda não foi identificado como agravo à Saúde do Trabalhador. Buscou-se relacionar os diferentes vínculos trabalhistas que regem a categoria profissional com as possibilidades de comunicação/notificação em casos de acidentes e/ou doenças relacionados ao trabalho, além de refletir sobre as principais questões e carências decorrentes da ausência de procedimentos técnicos e legais dos Ministérios da Saúde, Trabalho, Emprego e Previdência Social nos casos de transtornos decorrentes de alterações na voz do professor.

Saúde do Trabalhador; Docentes; Legislação; Políticas Públicas de Saúde

INTRODUCTION

Voice disorders can be found among professionals that use their voices as an important work tool in a professional environment. There are a number of factors that can cause voice disorders. There also might be associated occupational factors and risk factors related to the worker him/herself, such as: age; sex, and; allergic, respiratory and hormonal problems¹.

The relationship between voice and labor has been discussed since 1997 with the involvement of representatives of several bodies, such as: CEREST/SP, PUC/SP, Conselho Regional de Fonoaudiologia (Regional Board of Speech Therapy), Sociedade Brasileira de Fonoaudiologia (Brazilian Speech Therapy Society), DESAT/SP, Prefeitura do Município de São Paulo (São Paulo’s Local Government), Hospital do Servidor Municipal, Sindicato dos Radialistas (Radio Broadcasting Union), dos Professores (Teacher’s Union), dos Teleoperadores (Teleoperator’s Union) e dos Atores (Actor’s Union) and INSS (National Institute for Social Security). Several work meetings have taken place in the last few years. The goal was to draft a document which included Occupational Voice Disorders (OVD) in the Manual of Work-Related Diseases². The OVD protocol (OVD)³ was completed and submitted to public consultation by the Ministry of Health in 2011. The publication of this protocol is still pending.

An Occupational Voice Disorder means any kind of dysphonia that is directly related to using one’s voice during work and that limits, compromises or prevents someone from working and/or communicating⁴. There may be histologic lesions in vocal folds arising from its use (IDC 10 J-38, R-49).

A study was conducted throughout Brazil to investigate the prevalence of voice disorders in teachers and non-teachers. The goal was to obtain an epidemiological profile of the voice of teachers in Brazil. The study found out that 66.7% of teachers had experienced hoarseness at some point in their lives; the same occurred with 57.6% of non-teachers. Of all workers who were hoarse when the study was conducted, 41.2% were teachers and 14.8% were not. As for work-related hoarseness in teachers, it totaled 82.2% in teachers and 19.3% in non-teachers. Therefore, such data reflect important indicators of voice disorders in teachers’ performance ⁵.

Another case-control study conducted with teachers of São Paulo’s City Government confirms the association between stress-related factors and diminished work capacity and voice disorders⁶.

Injuries to a teacher’s voice restrict their professional growth. They also often result in a leave of absence and temporary inability to work. This causes significant damage that has implications on health, Social Security and labor.

The fact that Occupational Voice Disorders occur often in teachers, their severity and their social repercussions all contribute to making it a significant Public Health and Labor Health issue, especially considering the large number of workers in this industry in Brazil and worldwide⁷.

Although this condition is extremely relevant for public health, the Ministry of Health (MH) still has not acknowledged it as an Occupational Injury (OI), even though there are legal grounds in Social Security Law.

The aim of this study was to discuss several aspects related to Occupational Voice Disorders in teachers and to identify action taken the Ministry of Health (MH), Ministry of Labor and Employment (MLE) and Ministry of Social Security (MSS).

METHODS

This study was based on a literature review of specialized literature about OVD in teachers. We prioritized articles published in Brazil in the last twelve years, from 1998 to 2011, which are more relevant to the issue under investigation. Search for publications referenced in this study was conducted by combining a number of keywords, as follows: “voice”;; “dysphonia”;; “professors”;; “teachers”;; “worker’s health”;; “legislation”;; “public health policies”;; in addition to their translations into the English language. The first search was conducted in search engines Scirus and Google Scholar. Topics were matched and organized according to subject. After comparing data provided by the search engines, we conducted searches in the following databases: Pubmed, Scielo, Medline and Periódicos CAPES.

We used full-length articles, papers presented at events, bulletins, dissertations and theses, both published nationally and internationally, in addition to specific legislation in this area. As the research progressed, we also consulted important references mentioned in those researched documents.

LITERATURE REVIEW

Contextualizing Occupational Voice Disorders in Teachers and Principles of Legal Grounds

There is a difference between Public School teachers (at the local, state or federal levels) and Private School teachers (at elite or low-cost schools). There are also differences in the types of employment contracts: Public School teachers are statutory (governed by specific labor legislation) or contracted; Private School teachers may work under a contract or not, or they can be temporary or interns⁸. Private School teachers are covered by the National Institute for Social Security (INSS), according to legislation. Furthermore, there are differences in terms of social security coverage, which some have and others do not⁹.

Public School teachers are statutory civil servants who do not fit the abovementioned model. There is a Medical Examination Department that is in charge of pre-employment medical examinations and examining servants in case of a leave of absence (due to an illness, pregnancy, to be with a family member who is ill), readaptation and disability pension, according to the assessment of its physicians. Leaves of absence due to illness can be granted in case of full or partial disability, which may prevent a worker from performing his/her duties on a temporary or permanent basis. This is determined by an expert physician and/or by a panel of physicians, depending on the specifics of each case¹⁰. For civil servants who are governed by specific Statutes and Legislation, there is a specific instrument to record work-related accidents and injuries: Communication of Work-Related Accidents (NAT).

With different administrations, the rules that govern the profession and teacher’s rights also differ. In the public education system, the State sets its own rules in terms of admission requirements, job categories and pay plan, and teacher’s labor and social security rights.

The Ministry of Labor and Employment (MTE) has Regulatory Norms (NRs) on labor health and safety that are related to labor conditions. They provide guidance on occupational issues. However, there is no relationship with the teacher’s work process. NR17 in Annex II is the one that comes closest. It outlines the working conditions of teleoperators. This is the first time that the professional use of one’s voice receives attention and legal coverage with respect to training, including bi-annual training sessions, usage rules, time of use, guidelines on the availability of water and inspection, with mandatory voice and hearing examinations^11,12.

On the other hand, labor and social security legislation offers nothing on symptoms, but rather on work-related diseases that need to be diagnosed and verified as such by an attending physician, undergo the company’s scrutiny and be ratified by INSS’s medical department¹³. It is up to the latter to determine whether an individual is unable to work and to establish a technical connection between the disease and the fact that there is something in the policyholder’s workplace that is causing it.

As for Work-Related Diseases (DRTs), when they are matched with occupational accidents the INSS is in charge of granting a policy holder’s and his/her dependents rights to benefits such as: work-related injury or disease compensation (B91); disease compensation (B31); and injury compensation (B94)¹⁴. It is worth noting that the Brazilian List of DRTs¹⁵ made by the MS and adopted by the MPS (INSS) did not include voice disorders. Dysphonia is included as a symptom of laryngotracheitis; however excessive use of one’s voice in the workplace is not mentioned as a risk factor¹⁶.

According to the National Consensus on Professional Voice¹⁷, the absence of lists or directories of diseases reinforces the subjective aspect of administrative and technical decisions. This situation is made worse by the fact that OVDs are not included in the list of recognized diseases for Brazilian Social Security purposes; there are no diagnostic criteria for OVDs; and there are no criteria to assess inability to work¹⁰. In other words, for the INSS there is no Legislation that recognizes and addresses OVDs.

Communication

A study about teachers in general reports that they miss more days at work because of voice problems. On average teachers lose five days while the general population loses less than one day⁵. This exposes the problem of absenteeism, for instance, which causes economic losses to the country, in addition to social and emotional consequences from interrupting work, both for teachers and students.

On the other hand, although there is a consistent scientific causal relationship between inadequate use of one’s voice and vocal overwork in a few professions and occupations^18,19, in many countries such as Brazil changes arising from this situation are not recognized and work-related illnesses. Some countries restrict themselves to acknowledging the magnitude of the problem at the international level and the possibility of primary prevention through specialized health and workplace safety programs, especially in the private sector²⁰.

Act 8080/90 outlines worker health care and surveillance actions and since 1999 the MS has been attempting to list diseases and work-related causing agents, using several systems and databases to incorporate relevant information for Worker’s Health. Even so, under-reporting and the real magnitude of those diseases are not yet well known. The priority is the Communicable Disease Information System - SINAN/SUS, which is fed not only with communication and investigation of cases of diseases that are on the national list, but also those already defined as risks for workers in the SUS.

This is an important instrument that reveals the reality of healthcare, regardless of where workers are in the labor market and of their employment relationship. It is also extremely relevant for healthcare planning, establishing priorities and assessing the impact of interventions^21,22.

With disease communication it is possible to identify the reasons why workers get sick or die and to combine this data with the type of economic activity so as to intervene in their causes and determinants.

In the case of workers under the Consolidation of Labor Laws (CLT), a different instrument is used to record cases of work-related accidents and occupational diseases: the Communication of Work-Related Accidents (CAT).

The MPS only has data in a more systematic way on work-related accidents and occupational diseases of individuals covered by the Occupational Accident Insurance (SAT) notified through the CAT. This corresponds to approximately 1/3 of the economically active population. For a considerable number of workers, and such is the case of teachers, there is no information, even among workers covered by SAT. Studies have been showing very high levels of under-reporting.

There needs to be consistent and swift information available about the production situation in order to build a worker’s profile and of work-related injuries. This will guide healthcare actions, intervention in different environments and working conditions, in addition to providing support to social control. We have also noticed that such information is infrequent, incomplete and difficult to find. Regulation no 104/GM, published in 2011 within the SUS, provided a list of Public Health diseases, injuries and events whose communication is compulsory in the entire country²³. However, OVDs were not included.

Despite ongoing administrative and technical difficulties arising from lack of legal grounds for recording OVDs, state and local governments can encourage communication by, for instance, making notification an issue of statewide interest and recognizing it as a Public Health issue. In Brazil the only States that have included Dysphonia (R49.0) in SINAN NET as worthy of communication were Rio de Janeiro and Alagoas^24,25and the city of Campinas¹.

CONCLUSIONS

The voice is the most basic work tool and OVDs in teachers are an important voice condition not only because they are directly related to professional activities, but also because of the impact they cause.

It is worth noting that the rules that govern the profession and teacher’s rights are so contrasting that teachers today who suffer from an OVD and who are away from work receive conflicting guidance from the MTE or MPS when they need labor and/or social security support.

Special attention should be given to Public School teachers, who are governed by specific Statutes and Legislation and whose work-related accidents and occupational diseases are reported through a Notification of Work-Related Accidents (NAT), as opposed to a Communication of Work-Related Accidents (CAT), which is already recognized by the MPS.

The conclusion is that for voice disorders in teachers there is no legal definition for a pattern of conduct. This is not only because occupational health and safety legislation (MTE) does not recognize those disorders, but also because there are no criteria for SUS communication. This prevents identifying the real magnitude of the disease. It also prevents the Ministries of Health, Labor and Employment and Social Security and society in general from adopting relevant intervention measures to tackle its causes and determinants.

Our analysis shows that current legislation needs to pay greater attention to the main issues and shortcomings caused by occupational voice disorders in teachers.

ACKNOWLEDGEMENTS

We would like to thank the Fundação de Amparo a Pesquisa do Estado de Alagoas – FAPEAL for their financial support.

REFERÊNCIAS

• ¹
  Ferreira LP, Martz MLW. Distúrbio de Voz Relacionado ao Trabalho: a experiência dos Cerest. BEPA [periódico na internet]. 2010 [acesso em 2011 5 mai]; 7(76):13-9. Disponível em: ftp://ftp.cve.saude.sp.gov.br/doc_tec/outros/bepa7610.pdf.
  » ftp://ftp.cve.saude.sp.gov.br/doc_tec/outros/bepa7610.pdf
• ²
  Ferreira LP, Bernardi APA. Distúrbio de Voz Relacionado ao Trabalho:resgate histórico. Distúrb. Comun. 2011;23(2):233-6.
• ³
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de saúde Ambiental e Saúde do Trabalhador. Distúrbio de Voz Relacionado ao Trabalho. Série A Normas e Manuais Técnicos. [acesso em 2012 5 jan]. Disponível em : http://aborlccf.org.br/imagebank/Protocolo_DVRT.pdf.
  » http://aborlccf.org.br/imagebank/Protocolo_DVRT.pdf
• ⁴
  CEREST-SP: Centro de Referência de Saúde do Trabalhador de São Paulo. SES-SP. Secretaria de Estado de Saúde de São Paulo. Distúrbios da voz relacionados ao trabalho. [citado em 2010 dez 10]. Disponível em: http://www.cve.saude.sp.gov.br/agencia/bepa26_dist.htm.
  » http://www.cve.saude.sp.gov.br/agencia/bepa26_dist.htm
• ⁵
  Behlau M, Zambon F, Guerrieri AC, Roy N. Panorama epidemiológico sobre a voz do professor no Brasil. 17° Congresso Brasileiro de Fonoaudiologia, 1° Congresso Ibero-Americano de Fonoaudiologia; 21 a 24 out 2009, Salvador. São Paulo: Sociedade Brasileira de Fonoaudiologia; 2009.
• ⁶
  Giannini SPP, Latorre MRDO, Ferreira LP - Distúrbio de voz e estresse no trabalho docente: um estudo caso-controle. Cad. Saúde Pública. 2012;[periódico na internet] 29(11):[10p]. [acesso em 2010 jul 22]. Disponível em: http://www.scielo.br/pdf/csp/v28n11/11.pdf
  » http://www.scielo.br/pdf/csp/v28n11/11.pdf
• ⁷
  Schwartz SR, Cohen S, Dailey S, Rosenfeld R, Deutsch E, Gillespie B et. al. Clinical practice guideline: Hoarseness (Dysphonia). Arch. Otolaryngol. Head Neck Surgery. 2009;141(3S2):S1-S31.
• ⁸
  Ferreira LL. Relação entre o trabalho e a saúde de professores na educação básica no Brasil. Fundacentro [relatório online]. 2010. Disponível em: http://www.fundacentro.gov.br/dominios/CTN/anexos/relatoriofinal.pdf
  » http://www.fundacentro.gov.br/dominios/CTN/anexos/relatoriofinal.pdf
• ⁹
  Araújo T, Silvany A, Reis E, Kavalkievicz C. Condições de trabalho e saúde dos professores da rede particular de ensino: Salvador-Bahia. Salvador: Sindicato dos Professores do Estado da Bahia; 1998.
• ¹⁰
  Spitz, C. Para não calar a voz dos nossos professores: um estudo das desordens vocais apresentadas pelos professores da rede pública municipal do Rio de Janeiro. [Dissertação]. Rio de Janeiro, RJ: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Mestrado em Ciências; 2009.
• ¹¹
  Servilha EAM, Leal ROF, Hidaka MTU. Riscos ocupacionais na legislação trabalhista brasileira: destaque para aqueles relativos à saúde e à voz do professor. Rev Soc Bras Fonoaudiol. 2010;15(4):505-13.
• ¹²
  Ferreira LP, Servilha EAM, Masson MLV, Reinaldi MBFM. Políticas públicas e voz do professor: caracterização das leis brasileiras. Rev Soc Bras Fonoaudiol. 2009;14(1):1-7.
• ¹³
  Monteiro AL. Disfonias e Infortunística. In: Anais do I Fórum de Saúde do Trabalhador de Araraquara – Distúrbios de voz relacionados ao trabalho, PUC e CEREST São Paulo [anais online]. 2004. Disponível em: http://www.fonosp.org.br/publicar/arquivos/imprensa/disfonias_e_infortunistica.pdf
  » http://www.fonosp.org.br/publicar/arquivos/imprensa/disfonias_e_infortunistica.pdf
• ¹⁴
  Brasil. Ministério da Previdência Social. Anuário Estatístico da Previdência Social. [acesso em 04 jun 2011]. Disponível em : http://www1.previdencia.gov.br/aeps2006/15_01_01_01.asp.
  » http://www1.previdencia.gov.br/aeps2006/15_01_01_01.asp
• ¹⁵
  Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Legislação em Saúde: Caderno de Legislação em Saúde do Trabalhador.[acesso em 04 jun 2011]. Disponível em: http://www.epsjv.fiocruz.br/beb/textocompleto/009031
  » http://www.epsjv.fiocruz.br/beb/textocompleto/009031
• ¹⁶
  Hidaka MTU, Leal ROF, Servilha EAM. Riscos ocupacionais na legislação trabalhista brasileira: destaque para aqueles relativos à saúde e à voz do professor. Rev Soc Bras Fonoaudiol. 2010;15(4):505-13.
• ¹⁷
  Consenso Nacional sobre Voz Profissional. Rev Bras Otorrinolaringol. 2004;70(6):722.
• ¹⁸
  Vilkman E. Occupational safety and health aspects of voice and speech professions. Folia Phoniatr Logop. 2004;56:220-53.
• ¹⁹
  Pérez Fernandez CA, Preciado López J. Nódulos de cuerdas vocales. Actores de riesgo em los docentes: estúdio de casos e controles. Acta Otorrinolaringol Esp. 2003;54:253-60.
• ²⁰
  Reyes Garcia ME. Morbilidad por laringites nodular crônica profesional em educadores cubanos. Rev. Cuba. Hig. Epidemiol. 2005 [periódico na internet];44(1):[7 p] [acesso em 2010 jul 22]. Disponível em: http://scielo.sld.cu/pdf/hie/v44n1/hie04106.pdf.
  » http://scielo.sld.cu/pdf/hie/v44n1/hie04106.pdf
• ²¹
  CEREST-RJ - Centro de Referência em Saúde do Trabalhador do Estado do Rio de Janeiro e CESTEH/ENSP-FIOCRUZ- Centro de Estudos em Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública Sergio Arouca-Fundação Oswaldo Cruz. Fonoaudiologia na Saúde do Trabalhador. [acesso em 01 fev 2011]. Disponível em: http://www4.ensp.fiocruz.br/biblioteca/dados/txt_191303375.pdf.
  » http://www4.ensp.fiocruz.br/biblioteca/dados/txt_191303375.pdf
• ²²
  CEREST-RJ - Centro de Referência em Saúde do Trabalhador do Estado do Rio de Janeiro e CESTEH/ENSP-FIOCRUZ- Centro de Estudos em Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública Sergio Arouca-Fundação Oswaldo Cruz. Fonoaudiologia na Saúde do Trabalhador [acesso em 01 fev 2011]. Disponível em: http://www4.ensp.fiocruz.br/biblioteca/dados/txt_285211437.pdf.
  » http://www4.ensp.fiocruz.br/biblioteca/dados/txt_285211437.pdf
• ²³
  Brasil. Ministério da Saúde. Portaria nº 104/GM, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. [acesso 02 set 2011]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html.
  » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt0104_25_01_2011.html
• ²⁴
  CEREST-RJ-Centro de Referência em Saúde do Trabalhador do Estado do Rio de Janeiro e CESTEH/ENSP-FIOCRUZ- Centro de Estudos em Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública Sergio Arouca-Fundação Oswaldo Cruz. Fonoaudiologia na Saúde do Trabalhador. [acesso em 01 fev 2011]. Disponível em: http://www5.ensp.fiocruz.br/biblioteca/dados/txt_348320188.pdf.
  » http://www5.ensp.fiocruz.br/biblioteca/dados/txt_348320188.pdf
• ²⁵
  SESAU/AL- Secretaria de Estado da Saúde de Alagoas. DIVEP- Diretoria de Vigilância Epidemiológica. Portaria SES/AL nº 206 de 14 de setembro de 2012. Define o acréscimo, à Lista de Notificação Compulsória, o agravo Disfonia (CID R49.0), como interesse estadual para notificação compulsória no Sistema de Informação de Agravos de Notificação – SINAN. [acesso em 06 jan 2013]. Disponível em: http://www.saude.al.gov.br/sites/default/files/nota_tec._no_14_-_disfonia_-_pg_01_0.pdf.
  » http://www.saude.al.gov.br/sites/default/files/nota_tec._no_14_-_disfonia_-_pg_01_0.pdf

• Funding: Fundação de Amparo a Pesquisa do Estado de Alagoas – FAPEAL. Type of Funding: Doctoral Grant.

Publication Dates

• Publication in this collection
  Mar-Apr 2014

History

• Received
  25 Oct 2012
• Accepted
  23 Mar 2013