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On-line version ISSN 2179-6491
J. Soc. Bras. Fonoaudiol. vol.24 no.3 São Paulo 2012
EVIDENCE-BASED SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY FONOAUDIOLOGIA BASEADA EM EVIDÊNCIAS
Maria da Conceição C. Pessoa de SantanaI; Bárbara Niegia Garcia de GoulartII; Brasilia Maria ChiariIII
IMultidisciplinary Residency in Family Health, Universidade Estadual de Ciências da Saúde de Alagoas - UNCISAL - Maceió (AL), Brazil
IIDepartment of Social and Institutional Psychology, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil
IIIDepartment of Speech-Language Pathology and Audiology, Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil
PURPOSE: To analyze scientific bibliographic production on the practice of occupational health surveillance related to voice disorders in teachers. Search
STRATEGY: The Cochrane Handbook precepts which involves the formulation of the question to be investigated, the location, the studies selection and articles' critical evaluation were followed.
SELECTION CRITERIA: The articles published between 2000 and 2011 were selected in the PubMed, LILACS, MEDLINE database, and the Cochrane Library using the descriptors voice disorders; teachers, occupational health, workers' health surveillance.
DATA ANALYSIS: Texts were analyzed, using a standardized form when the following data were collected: objectives, research design, characteristics of the study group, obtained results and discussion on the practice of surveillance related to voice disorder.
RESULTS: Initially, 141 studies were identified. After reviewing the titles and abstracts, considering inclusion and exclusion criteria, verifying consistency with the topic researched and eliminating the ones which were concurrently in more than one database, 32 articles were effectively analyzed for relating in the findings and/or conclusions to the practice of surveillance related to voice disorders in teachers.
CONCLUSION: The practice of monitoring workers' health was evidenced in this research mainly as the identification of risk factors associated with voice disorders in teachers, aimed at the transformation of the working conditions and the assurance of quality of assistance to these workers as professionals.
Keywords: Voice disorders; Faculty; Occupational health; Surveillance of the workers health; Dysphonia; Occupational risks
Work complements and gives meaning to life and is one of the most important ways to position oneself as an individual, considering that good working condition is a determinant and conditioning factor for good health(1). The interest in investigating the relationship between voice disorders and teaching has grown in recent years. Authors explain teachers' illness by means of changes in work organization and incompatibility between the latter and the actual working conditions(2)..
Work environment surveillance has been included in the Brazilian Unified Health System (SUS) as one of the component operations of the workers' health surveillance. This action has been structured in the centers, nuclei or in the worker's health programs and has been characterized by the presence of multidisciplinary teams, which enable the integration of perspectives from various disciplines as well as those from institutions(3). The harm to human communication has already been widely described. It should evolve into more detailed knowledge of issues related to risk factors to such alterations, besides the impact of these on the subject's life(4)..
This review will certainly contribute to discussions on the relationship between teaching, health-disease process and teacher's voice, which constitute an indicator of the progress necessary to reorient actions, overcoming fragmentation and dichotomies.
To analyze scientific bibliographic production on the practice of occupational health surveillance related to voice disorders in teachers.
The Cochrane Handbook precepts(5) which involved the formulation of the question to be investigated, the location, the studies selection and articles' critical evaluation were followed. The research question that supported the review was the following: ,,What surveillance practices are being directed to voice disorders in teachers in occupational health?".
Following the research question formulation, the bibliographic research on the central topic of this paper was performed in the PubMed, LILACS, MEDLINE database, and the Cochrane Library. The following Boolean operator AND associated descriptors were used: voice disorders; teachers, occupational health, workers' health surveillance
The study included articles published both in English and Portuguese, from 2000 to 2011, available in full version. This allowed a more detailed analysis of surveillance practices in occupational health related to voice disorders in teachers.
For the selected articles, the following inclusion criteria were used: It should contain at least two of the descriptors and the research subject should be the teacher. The full text versions which did not relate to the purpose of the research were excluded.
Only the studies whose abstracts were related to the purpose of the research were considered and selected, following that, the full versions were obtained. The full versions of the potentially relevant articles to the review were analyzed, using a standardized form when the following data were collected: objectives, research design, characteristics of the study group, obtained results and discussion on the practice of surveillance related to voice disorder.
Initially, 141 studies were identified, however after reviewing the titles and abstracts, considering inclusion and exclusion criteria, verifying consistency with the topic researched and eliminating those which were concurrently in more than one database, 32 articles were effectively analyzed for relating in the findings and/or conclusions to the practice of surveillance related to voice disorders in teachers.
Whilst analyzing the selected articles (Chart 1), it was possible to observe researchers' concern, especially from 2003 onwards, about the use of an instrument to investigate the teachers' working conditions. A cross-sectional study(6), for example, with 328 teachers from four schools in São Paulo aimed at validating a self-assessment questionnaire for teachers at all educational levels, including, in addition to the clinical symptoms, work organizational factors. Among the results, the study population's work organization and quality of life were portrayed. The authors reported that the instrument was proven satisfactory in the description and elaboration of parameters in order to implement preventive programs for teachers exposed to risks related to the development of vocal disorders. Other Brazilian researchers have also investigated teacher's voice production conditions(7) and proposed a questionnaire that has been continuously perfected(8) through its use as a research tool in investigations with other teachers from different levels of education.
Many studies have been conducted in order to investigate the prevalence of voice disorders in teachers, in which working conditions are included in the results. A cross-sectional observational study conducted in 2000(9) in eight kindergartens in the city of São Paulo, in which actions of a program were being developed, aimed at verifying the prevalence of self-reported voice alteration among educators in daycare and associated factors. The authors concluded that educators' adequate perception of their voice problems might become an important tool for future work with this population in order to reduce the high prevalence of voice disorders.
Among the studies verified, it is observed that an effort to understand the causes of voice disorders in teachers, in order to prevent such problems and promote their health, has been undertaken especially by speech therapists authors. In recent years, discussions have focused on environmental aspects and those concerning work organization and conditions in the pursuit of broader relations between these, health and quality of life(10-12). A worrying finding is that teachers demonstrate misperceptions of their health-disease process(13). Some authors even concluded that teachers whose work is characterized as active and highly demanding were more affected in the areas of quality of life, requiring, thus, greater investment in health promotion policies(14).
One study(13) had as its focus to evaluate aspects related to teachers' quality of life and seek relationships with vocal health matters in 2002. A sample of 128 high school teachers from four state schools in Rio Claro (SP), Brazil, was studied. Although reasonably satisfied with their voice and quality of life, teachers showed misperceptions of their health-disease process. In their conclusions, the authors mentioned that once speech therapy actions were extended, workshops and voice experience groups would be a social space for possible interventions.
Researchers emphasize that prevention programs are important and should focus on raising professionals' awareness about the problems, early symptoms recognition and guidance on a good vocal hygiene(10). However, the practice of offering training to at-risk populations to prevent voice disorders development does not get the support from definitive evidence on their effectiveness(12). An experimental study(15), developed by means of theoretical and practical program, addressing professional vocal use with 26 female educators from two daycare centers in São Paulo, was aimed at evaluating, over speech therapy intervention program offered, changes in behaviors which the literature considered negative to the voice. The study concluded that the observed changes during the program were interesting, nevertheless, very limited, leading to a reflection on the scope of this type of practice and how broader changes do not rely on small individual changes, which is often recommended.
Studies, however, suggest strategies based on the results obtained, as a cross-sectional cohort study(16) with 451 teachers from 66 schools in Mogi das Cruzes (SP), Brazil, which aimed at determining dysphonia prevalence and evaluating factors and symptoms associated. In the conclusions, it was evident that preventive measures should include reducing the workload and the number of students per class as well as the treatment of concomitant conditions.
It is considered that human work has a dual character: it can be a source of fulfillment, satisfaction and pleasure which structures and shapes the subjects' identity process, but it can also become a pathogen element, becoming harmful to health(17). The legislation proposed by the Occupational Health and Safety (OSH), in the European Union, states that understanding work-related health problems should start from the observation of the interaction between workers, environment and the conditions of their workplace(18). In Occupational Health, the need to have a holistic view of the subject in their relation to work emerges together with the need to consider the political, economic, administrative, logistical, technological, environmental, social, cultural and psychological issues that define the characteristics of work organization and production process which shape social relations in the work contexts in which the worker's health-disease process(19) is developed.
The dimensions of Occupational Health performance are established on three intervention levels: damages, risks and the socio-environmental determinants(20). Based on the review conducted, it was observed that the study of the teachers' working conditions in Brazil is a recent approach in the field of professional activities. Starting in 1999, the surveys conducted by the National Confederation of Education Workers (CNTE) in partnership with the Laboratory of Work Psychology at Universidade de Brasília (UNB-LPT), revealed the Portrait of Education in Brazil, mainly the public education, in three series, establishing a relationship between these categories' working conditions and health(20).
In the Brazilian public health history, the term invigilator conveys the meaning of monitoring in order to control, and thus to prevent the outbreak of new cases, the transmission of the disease to communicants, i.e., it means to watch in order to prevent transmission, to prevent new cases. Etymologically, the term surveillance (vigilância) comes from the Latin word Vigilare, meaning something or someone to be closely watched. Originally, surveillance was aimed at recognizing and intervening in environmental factors, predisposing to the disease and observing the first signs of an infection(17) in potentially sick individuals.
It is unacceptable to talk about quality of work without thinking about the environment quality and working conditions as well, which would be greatly aided by the democratization of social relations in the workplace(21). Thinking about the teacher as a worker implies that the school is seen as an environment with certain structural and organizational features that configure workloads which can be more or less healthy, influencing and determining the health-disease process in the teacher-worker. It is important to monitor the work environment, analyzing the risk factors for the development of diseases in teachers, verifying what actions can be taken to minimize or eliminate such factors(22).
Recurring complaints in the workers' speech are actually common in organizations as a demonstration of dissatisfaction(23). As an isolated fact, however, little is mentioned in studies. In the context of professional voice use, the multiple dimensions of relations established between the teacher and their work are relevant. In the detected studies, self-assessment or self-vocal perception has been highly valued(24). A reflective analysis about Voice Seminars, events which earned importance, voice and tradition over the years, held by Pontifícia Universidade Católica de São Paulo(25) highlighted that there is a significant advancement in society's attention to the problem in question and in offering professional voice health prevention and promotion programs.
A cross-sectional study(26) that included 126 elementary school teachers in municipal schools in Maceió (AL), Brazil, randomly selected, concluded that it is possible to intervene in a direct and simple way in environmental and organizational work factors, which would certainly help reducing the occurrence of work-related pathologies.
Speech-Language Pathology and Audiology, inserted in Occupational Health, has the particularity of being an area that establishes innovative practices in construction, in the pursuit of integral health care and the transformation of the status quo, resulting often in the de-construction of the existing dichotomy between preventive and healing actions and between individual and collective ones. It also seeks to improve and enhance worker's communication, by means of guidance concerning the possibilities of improving environmental conditions and elimination of factors that interfere with communication, promoting a more efficient interaction between the individual and their environment which is seen as essential for one's well-being(27).
Occupational Health Surveillance is, more specifically, the set of actions aimed at knowing the magnitude of accidents and work-related diseases, identifying operational risk factors, establishing prevention and control measures and evaluating health services permanently, seeking the transformation of working conditions and ensuring the quality of health care provided to the worker(28). The sanitary practice that organizes the work processes in health, in the form of operations, to continuously confront problems in a given territory-population is also related to the concept of Occupational Health Surveillance(28). This confrontation requires actions that target the condition and determinants of the issues in a convergent (which includes intersectoral actions), systematic way which has a favorable impact on the quality of life of a population(29). It is important to monitor the work environment, analyzing the risk factors for the development of diseases in teachers, verifying what actions can be taken to minimize or eliminate such factors(30). Moreover, the importance managers give to vocal wellness is paramount.
A qualitative and exploratory study based on semi-structured interviews was developed in 2011. Its aim was to investigate the importance given to the teachers' vocal wellness during graduation by coordinators of the courses in Education in São Paulo. According to the research participants, in most institutions there are no ongoing prevention programs for the teachers' vocal wellness. It was concluded that, although coordinators have emphasized the importance of vocal wellness in the courses curriculum, which they coordinated, this aspect is not questioned(31). This is considered very serious, since studies show that voice disorder represents one of the occupational diagnosis responsible for the largest number of teachers leave from their working activities(32).
The presence of self-reported vocal pathologies is associated with factors that point to the need to develop actions that promote teachers' vocal health and changes in the work structure and organization. This need was identified in an epidemiological-based census of a cross-sectional study conducted with 4,495 primary and secondary primary school teachers in Salvador (BA), northeastern of Brazil, between March and April 2006(33).
It has been noticed, especially in recent years, the authors' concern to verify the association between the presence of self-reported voice disorder and isolated aspects considered important risk factors, such as violence. For instance, in a study, 422 municipal school teachers in São Paulo were selected to fill out a questionnaire containing yes/no questions, which had as its objective to investigate the association between vocal disorder and aspects related to school violence(34). It was concluded that the self-reference to the presence of voice disorder is associated with frequent threat situations towards the teacher, assaults, insults and violence at the school entrance gate or against employees, regardless of the variables experience and time performing the profession.
Another aspect that has been widely investigated in the context of teaching is the psychological one. Studies show stress as a major risk factor related to voice disorders in teachers(35-37).
The interest in investigating the correlation between lifestyle, health problems and voice disorder was also noted, as verified in a study with 51 teachers in a public school in Campinas (SP). Data were analyzed using descriptive statistics and later compared to those provided by teachers who reported voice alteration and those who denied it, in the following variables present in the instrument: health, life habits, leisure and vocal habits. The conclusion was that there was a correlation between lifestyle, health problems and voice disorder in the variables "have already smoked" and "having the last meal 30 minutes before bed"(38).
The objective of identifying risk factors, establishing control and prevention measures and evaluating health services, aimed at transforming the working conditions and assuring the quality of health care to the worker, is not only present in the national literature(39), but also in the international one(40). Studies have identified the groups most likely to develop voice disorders, such as teachers with 40 years of age or older with a family history of dysphonia working over 20 hours a week exposed to chalk dust(39).
A comprehensive consideration about this review is that the practice within the workers' health surveillance scope related to voice disorders in teachers was consistent and crescent over the period studied. The growing contribution of health/prevention promotion of voice disorders in teachers is supported by the increasing number of speech therapy descriptive studies among teachers and the effects of evaluation of vocal health programs. The characterization of teacher's vocal problem is primarily made through descriptions of signs and symptoms and perceptual-auditory voice analysis. The identification of the conditions of voice use at work in certain population samples gave rise to a series of descriptive studies, with a change of the analysis focus from the subject's voice to the teaching environment and organization. With the completion of this review, it was evident that there is a search for the identification of problems to be minimized in favor of teachers' vocal health.
As noted in another review(41), studies constitute support to the development of public policy proposals for the recognition of voice disorder as a work-related disease(42). We highlight the important development of the document Work-related Voice Disorder which aimed at helping voice professionals in general and, therefore, teachers, in prevention, assistance, rehabilitation, notification and benefits payment. However, there is a need for scientific production increasingly effective in providing consolidated data to support such initiatives(41,42).
The literature points to the importance of multidisciplinary interventions in vocal health promotion and prevention in teacher and emphasizes that it is essential to consider the teacher's point of view to develop an intervention program(43). Furthermore, it is noteworthy that the demand or the lack of it for health care is attached to factors related to other dimensions beyond the illness(44)..
It is also important to highlight the study populations' diversity concerning the educational levels. Professors have been contemplated by investigations especially in recent years(45,46).
Through this study, it was found that, increasingly, speech therapists authors seek to perform socio-demographic characterization as well as teachers' environmental and organizational working conditions, showing that teachers work in unfavorable working conditions, which can contribute to the intensive and abusive voice use(47). It was noticed that the identification of vocal alteration process in teachers is contemplating the understanding of the relationship between work and health, according to workers' perspective. The characterization of vocal sickening in teachers currently aims at identifying the intervening factors involved in this process and proposing relevant speech therapy actions in order to preserve the health and quality of life at school(48).
Authors already point to the need for speech therapists to incorporate surveillance structures to their practice, identifying and modifying the risks arising from work activities(49). Furthermore, these professionals can assist in vocal preservation and indicate changes that make work more beneficial(50). They also mention that surveillance should be anticipatory, enabling the delivery of important information for planning actions and ensuring the health care quality to the workers population(49).
The practice of monitoring workers' health was evidenced in this research mainly as identification of risk factors associated with voice disorders in teachers, aimed at the transformation of the working conditions and the assurance of quality of assistance to these workers as professionals. Studies show the importance of prevention and vocal health promotion actions for teachers and emphasize the need for consideration of the voice problems determinant factors in the sense of recognizing that vocal disorder is not determined simply by prolonged or excessive voice use, but that there are other factors contributing to the development of these changes. Based on this research, it is possible to suggest that studies are needed to verify the impact of actions that affect the conditioning and determinant factors of the issues in a convergent, systematic way which will impact teachers' quality of life.
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Correspondence address: Received: 12/20/2011 Work performed at Universidade Estadual de Ciências da Saúde de Alagoas - UNCISAL - Maceió (AL), Brazil, in partnership with Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil, and Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil.
Bárbara Niegia Garcia de Goulart
Universidade Federal do Rio Grande do Sul
R. Ramiro Barcelos, 2600, Santa Cecília
Porto Alegre (RS), Brasil, CEP: 90035-003
Conflict of interests: None
Work performed at Universidade Estadual de Ciências da Saúde de Alagoas - UNCISAL - Maceió (AL), Brazil, in partnership with Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil, and Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil.