Relation between voice disorders and work in a group of Community Health Workers

Purpose: To analyze the relationship between voice disorders and work in a group of Community Health Agents (CHA). Methods: The subjects of this study were 65 CHA working in the city of São Paulo. The instrument used for data collection was an adaptation of the questionnaire named Conditions of Vocal Production – Teachers (CPV-P). The results were keyed in twice and submitted to statistical analysis, in order to verify: the self-reported frequency of voice disorder frequency of present vocal symptoms, the association among the three most frequently reported present symptoms, and environmental and organizational aspects of work. Results: Of the 65 (100%) CHA in the study, 37 (56.9%) self-reported having present or past vocal disorders. The most frequently reported present symptoms were: dry throat, tiredness when speaking, and burning sensation in the throat. There was significant association between: taking work to home, having personal items stolen, police intervention, violence against employees and vocal symptom dry throat, not having enough time to complete all tasks, difficulty in leaving work, inadequate furniture, intense physical strain, objects stolen from the health unit, racism and vocal symptom tiredness when speaking, dust, job dissatisfaction, work stress, building destruction, drug issues, and vocal symptom burning in throat. Conclusion: Based on the obtained results, the initial hypothesis of association between the development of vocal disorders among the subjects and the adversities present in their work environment and organization was confirmed.


INTRODUCTION
The relationship between the living and working conditions of the population is not a recent theme.A research (1) highlights that such relationships are portrayed since antiquity by Egyptian and Greek authors.In a document prepared by the Brazilian Ministry of Health (2) , the determinants of a worker's health are, among other conditioning factors, social, economic, technological and organizational factors.These determinants are responsible for the life conditions and issues related to the environment and organization that present in the work processes.
The object of study and intervention of workers' health is the relationship between work and health/diseases, as opposed to occupational medicine and occupational health (3) .This area is approaching concepts, formulated by the Latin American Social Medicine (4) , concerning social determination of the health-disease process.As a field of practice and knowledge, workers' health relates to public health, in its programmatic aspect, and to collective health, to address aspects related to suffering, illness and death in the social groups concerned with productive processes (5) .
With regard to speech-language therapy, in Brazil, the occurrence of voice disorders in workers is explicit in several studies (6)(7)(8) .In this direction, we present two possible approaches to the practice of speech-language therapy, with workers suffering from voice disorders: the first, which prioritizes individual and biological aspects, in addition to bad vocal habits, and the second, taken as a basis for this research, which, from an expanded conception of the health-disease process, places emphasis on its social determinants, life and work conditions (1) , understands vocal illness beyond the individual and biological aspects, and also considers the social and historical dimensions of work and health-disease.
Studies (7,9,10) reiterate this position by recognizing that vocal illness among workers is the result of multiple factors.Apart from the individual and biological aspects and vocal habits, the adversities of the work environment and organization also act as risk factors for the development of voice disorders.
Workers surveyed in this research were Community Health Agents (CHA), since, as pointed out in a study (11) , their professional activity presents particularities that make them more susceptible to a compromised vocal welfare.It can be presumed that there is an association between the development of voice disorders in the CHAs and adversities present in their work environment and organization.
Among the studies conducted in speech-language therapy with CHAs, most are aimed towards intervention and training, and little is analyzed from the perspective of their health as a worker.
Based on these considerations, this study sought to analyze the relationship between voice disorders and work in a group of CHAs working in São Paulo.Emphasis will be given to aspects related to the work environment and organization, particularly to matters of vocal production.

METHODS
This study was conducted according to all ethical standards and was approved by the Research Ethics Committee of Pontifícia Universidade Católica de São Paulo (CEP-PUC-SP), under protocol no.037/2009, and by the Research Ethics Committee of São Paulo City Department of Health (CEP-SMS-SP), under protocol no.344/09.
The CHAs and their managers were contacted personally, in the Basic Health Units (BHU) in which they work, in order to state the purpose and procedures of the research.The CHAs, who agreed to participate, were given an envelope containing the questionnaire and, as promised, it was sent back sealed after the period of a week, which ensured non-identification of the participants' personal data.
Out of convenience, participant CHAs were selected from five BHUs belonging to the administrative district of Ermelino Matarazzo, eastern region of São Paulo, in the year of 2010, with a total of 77 potential participants confirmed.There was a loss of 12 participants, and the final sample consisted of 65 CHAs.
As a tool for data collection, the questionnaire, Conditions of Vocal Production -Teacher (CPV-P) (8) , was adapted.It consisted of 40 questions divided into four parts: (I) Identification of Basic Health Unit (questions 1-4: full name of BHU, address, zip code and telephone), (II) Identification of the respondent (questions 5-9: name, date of birth, gender, marital status and education), (III) functional status (questions 10-38: aspects of the work environment and organization) and (IV) vocal aspects (questions 39-40: self-reference of voice disorders and vocal symptoms).
Most of the questions were presented on an ordinal scale and requested clarification of the frequency of occurrences (0never, 1 -rarely, 2 -sometimes, 3 -always, 4 -I don't know).
The variables in this study were the self-reference of voice disorders and of vocal symptoms.These variables were analyzed for their association with aspects of work environment and organization.
For each variable analyzed, the following situations were considered: "absence" when the frequencies "never" and "rarely" were marked; "presence" when "sometimes" and "always" were marked; and "I don't know" answers were disregarded from the analysis.
The answers were entered twice in a specific worksheet, and then subjected to statistical analysis (χ2 parametric test) for the verification of the following criteria: self-reported frequency of voice disorder; frequency of vocal symptoms; association between self-reference of voice disorders and vocal symptoms; and association among the three most-cited vocal symptoms and aspects of the work environment and organization.
P-values with level ≤ 5% (0.05) were considered significant.The statistical software used was Stata 8.0.

Characterization of the study population
Of the 65 participants, 100% were female.The mean age was 37.4 years (minimum = 22.5 years, maximum = CoDAS 2013;25(6):548-56 58.7 years; standard deviation (SD)=7.6 years) and the mean time of work as CHA was 3.7 years (minimum = 1 month, maximum=9 years; SD=2.7 years), all of whom worked in teams on the Family Health program (PSF).

Vocal aspects
Regarding the presence of voice disorder, 56.9% (37) of the CHAs self-reported to having it (Figure 1).
When the vocal symptoms were crossed with the selfreference of voice disorder, there was significant association with variables such as hoarseness (p=0.000),loss of voice (p=0.000) and voice failure (p=0.000)(Table 1).
The three voice symptoms most frequently reported by the CHAs (dry throat, vocal fatigue and sore throat) were cross-referenced with the variables related to aspects of work environment and organization (Tables 2 and 3).

DISCUSSION
In the characterization of the study population, one must consider that the sample was composed exclusively by women, which confirms the trend of feminization of the work market among professionals involved in the PSF teams (12) .By focusing on this aspect, it is necessary to include some reflections, mediated by a research study (13) , that women mostly opt for traditionally female fields such as education, health and social welfare, which the author names "occupational female ghettos".
Regarding matters of vocal production, in particular, the literature indicates that women show greater predisposition to the development of voice disorders, mainly due to the genre's laryngeal configurations and hormonal variations (1,14) .
As for vocal aspects, the self-reference of voice disorder among the study population is higher, when compared to the percentages found between telemarketers and sellers  (19-23.8%)and industrial workers (7.1-16.7%),and is approximated to the percentages found among teachers and childcare educators (30-82.8%) (15).The voice symptoms cited by the CHAs surveyed here were similar to those found in a study on the conditions of vocal production in a group of these same workers (11) .These symptoms are related to each other with regard to overuse and/or improper use of the voice, being more frequent among professionals who use their voices extensively in their work activities.
Another point observed was the significant association between self-reference of voice disorders and vocal symptoms such as hoarseness, loss of voice and voice failure.
In this direction, Colton, Casper and Leonard (16) argue that individuals with voice disorders tend to have nine main vocal symptoms, and that these generally do not appear isolated, but combined.In the case of this study, there was no concern in raising the number of vocal symptoms by CHA; these, however, were mentioned by these researchers and are similar to the findings of this study.This finding supports the hypothesis that although the collection of data privileged the self-reference of voice disorder and that workers did not undergo speech evaluation to confirm it, the CHAs surveyed in this study did, in fact, present vocal symptoms that are entitled to special attention.
For the environmental aspects, the significant association between the presence of dust and sore throat can be elucidated by a study (17) that shows that CHAs are permanently exposed to dust and smoke from the streets and cars, in addition to little water intake.This situation predisposes these workers to the drying of the vocal tract, which leads to, among other symptoms, sore throat.
The reference by the CHAs that the cleaning products used in the BHUs do not cause irritation and its significant association with sore throat, possibly confirms the type of activity performed by them, who end up spending more time working on the streets than in their own unit.This fact does not exclude the possibility that contact with cleaning products used in BHUs harms the vocal tract; however, because these workers are most of the time on the streets, this does not seem to be a factor responsible for sore throat.
With regard to the organization of work, there was significant association between not having time to develop all activities and vocal fatigue.Similarly, taking work home indicated a significant association between vocal symptoms, dry throat and vocal fatigue.
Therefore, it is worth considering a study (18) that observed that the CHAs, apart from the activities related to their function, carried out activities to support other workers in the BHU (working at the reception, delivering the records for medical appointments, organizing folders and records, among other activities), which points to a possible overload and accumulation of functions, with the consequent need to take work home, indicating absence of sufficient time to perform all their duties.Thus, activities that should be completed during office hours (visit reports, monthly financial close, planning of activities, etc.) are often finished at home.The study (18) also recognizes the high number of families under the responsibility of each CHA (which generally exceeds the amount recommended by the Department of Health), and the limited number of hours dedicated to home visits.This reality implies that the CHAs need to meet the community's demand at the end of working hours (clarifying doubts, sending messages of the BHU, writing prescriptions and medication, among others), which points to a possible prolonged work time, added to the continuous use of voice.As dialogue is necessary in the CHAs' contact with the population they serve, one can consider the over-determination of these aspects to clarify the presence of dry throat and vocal fatigue among the CHAs surveyed (19) .
The specificity of these workers' activity (20) , should be highlighted, since they live in the area they work in, they are approached by members of the community served by PSF outside work hours for different reasons (questions, directions, appointment scheduling, among others) or in their own homes, on the streets and/or public spaces.Thus, the significant association between the difficulty in leaving the workplace and the presence of vocal fatigue deserves to be pointed out.Therefore, some researchers (17) underlie the difficulty of CHAs to disconnect from work, for being immersed in that community, and because of the population's refusal to accept other professionals in their absence.Thus, it can be inferred that such association is consistent, because the daily use of voice in dialogue with PSF users is necessary.Therefore, excessive use of voice may cause vocal fatigue.
The significant association between the presence of intense physical exertion, inadequate furniture and voice fatigue can be cleared by the findings of a study (17) that describes the long daily walks taken by the CHAs, as a result of home visits, and the weight of backpacks, which sometimes contained a scale for weighing children.In this direction, another study (21) articulates that besides the physical effort, exposure to adverse weather contributes to the wear and physical fatigue of these workers.It is known that physical fatigue can compromise vocal production.Talking for long periods in this condition can cause swelling and inflammation in the vocal cords, often leading to hoarseness with a decreased vocal intensity (22) .Vocal production is a bodily function of high energy expenditure, and its overuse, especially in the presence of physical fatigue, can cause vocal fatigue (23) .
Trindade et al. (17) also highlights the uncomfortable positions that CHAs adopt during their activities, and the need to remain in incorrect positions during home visits, some of the cases have indicated that there were no benches or chairs to accommodate them.Thus, it can be presumed that work performed in the same position and with inadequate furniture for long periods of time tends to stiffen the muscles of the neck and shoulders, which may cause tension and pain, and even hinder vocal production.The excess of muscular tension, especially in the face, neck and shoulder regions, can interfere with the Martines and Chaves (25) emphasize how difficult it is for these workers to deal with aspects relating to time and excessive tasks, besides the difficulty in preserving their family space and time to rest.This reality points to significant occurrence of malaise among CHAs, evidenced by signs and symptoms of suffering, stress, exhaustion, anxiety, depression, fatigue and insomnia, and it thus legitimates the reference of dissatisfaction in the performance of their work in this study's population.
In the field of speech-language therapy, the presence of stress in professional activity has been identified as an important risk for the development of voice disorders among workers (6,10) .Research (26) confirms, when considering the association between voice disorders and work stress among teachers in São Paulo, the presence of stress in professional activity reduces the ability to work and can lead to vocal compromising.
Regarding aspects related to violence, a significant association was found between theft of personal objects, police intervention, violence against staff and dry throat; theft of material from BHUs, expressions of racism and fatigue when speaking; vandalism, drug problems and sore throat.
Given these findings and considering the complexity of this subject, it seems feasible to address these results by means of two central aspects inherent to the activity of CHAs: the obligation to live and work in the same area and the fact that the streets are part of their workspace.
As elucidated in research (27,28) , the CHAs' ongoing contact with the community reveals a range of financial and emotional conditions, among others.Their entry into the family space of the PSF users reveals their exposure to people's privacy.Therefore, these workers come in contact with possible situations of poverty and violence, present in the users' homes.In contrast, a study (29) highlights the CHAs' lack of theoretical and practical information to recognize potential domestic violence situations, to approach families and, if appropriate, to offer them referrals.OK Moreover, verbal and even physical aggressions to which CHAs can be exposed during home visits cannot be excluded (17) .Living and working in the same area does not necessarily imply good relationship with all members of the community.There are those who understand home visits as invasive, especially that of drug users and victims of domestic violence.
Another important aspect concerns local violence.The CHAs, for reasons related to the organization of their work, have the streets as their workspace.Therefore, moving in an open environment without proper protective apparatus of the BHUs and being in direct contact with users during their work hours (and beyond), make them vulnerable to potential situations of violence and aggression (30 Consequently, situations of workplace violence sometimes affect the physical and psychological integrity of workers, and result in the development and/or aggravation of diseases, sleep disorders, fears, etc. (31) .
In the field of speech-language therapy, some researchers (7,9) agree that the impact of violence on work activities may contribute to the development of voice disorders among workers, characterized, among other things, by the presence of vocal symptoms such as dry throat, vocal fatigue and sore throat.
In the midst of this discussion, the linear understanding of vocal compromising is disregarded, and the understanding is that vocal illness among CHAs, as among other workers, cannot be seen as having one single causal relationship, but rather a relationship between the different aspects that predispose them to the development of voice disorders.In this sense, the reductionist manner in which illness among workers is seen as an exclusive result of biological factors should be disregarded and comprehended into, as one author names it (32) , "a new pathological profile" (p.157).Thus, the research study (32) suggests that the way in which workers fall ill is similar to what happens with the general population, for there is no evidence of causality with the diseases classically classified as occupational.
Another question that should be addressed ultimately relates to the use of voice by the CHAs.If, on the one hand, these workers do not depend on a specific refinement in the use of voice (as in the case of actors and singers), or its intense use (as in the case of teachers, who are generally faced with overcrowded and acoustically unsatisfactory classrooms), on the other hand, the use of voice by CHAs is necessary in dialogue with users and other members of the BHUs.Thus, although not considered in literature as "voice professionals", these workers need their voices to work and thus deserve the attention of speech-language therapists, as the results of this research indicate a high self-reference of voice disorders and vocal symptoms by CHAs.
For speech-language therapy, we would like to invite professionals to carry out other studies with larger samples, in order to understand the relationship between the development of voice disorders in CHAs and its association with aspects related to their work environment and organization, in the light of some indicators presented in this study.

CONCLUSION
At the end of this study, the need to recognize that the initial hypothesis of association between the development of voice disorders among those surveyed and the adversities they face in their work environment was confirmed.

Figure 1 .
Figure 1.Percentual distribution (%) of Community Health Agents, according to the self-reference of voice disorders (n=65)

Table 1 .
Numerical (n) and percentual (%) distribution of Community Health Agents, according to the frequency of vocal symptoms and their association with self-reference of voice disorders (n=65) Continue... Voice and work in community health workers CoDAS 2013;25(6):548-56

Table 2 .
Numerical (n) and percentual (%) distribution of Community Health Agents, according to the frequency of vocal symptoms (dry throat, vocal fatigue and sore throat) and its association with environmental aspects (n = 65)