QUALITY OF LIFE RELATED WITH THE VOICE OF TEACHERS: EXPLORATORY SYSTEMATIC REVIEW OF LITERATURE Qualidade de vida relacionada à voz de professores: uma revisão sistemática exploratória da literatura

reading Excluded studies (n=290) Reviews, commentaries, proceedings and editorials (n=27) Does not concern quality of life of teachers (n=250) Repeated (n=12) Thesis (= 1) Reading of complete studies considered potentially relevant (n=25) Excluded studies (n=12) QoL of other professionals, not teachers (n=8) QoL of Education students (n=4) Selected studies for the exploratory systematic review (n=13) Key: QoL = Quality of Life Figure 3 – Inclusion and exclusion process of articles in the exploratory systematic review 298 Ribas TM , Penteado RZ, García-Zapata MTA Rev. CEFAC. 2014 Jan-Fev; 16(1):294-306 Study Subjects Education Level Private or Public School Instrument used Main Findings 1. GRILLO & PENTEADO (2005)* 120 Elementary and Middle School Public School V-RQOL Global Domain– 84,2. Vocal self-assessment: “good” (49.2%). The impact of voice on quality of life was evidenced in work. 2. GILLIVANMURPHY et al (2006)* 20 Elementary, Middle and High School The study does not mention whether it was a public or private school V-RQOL

in quality of life related to the voice of teachers has been evidenced in a study that showed that teacher's worst quality of life aspects involved work conditions, organization, environment and the process of this specific occupation -especially social relationships 5 .Low salaries that are insufficient for daily needs and personal investment, in addition to intense physical and mental energy drain, associated to insufficient sleep and rest are other aspects with a negative impact on the personal wellbeing and the life of teachers, thus contributing to physical and mental stress.Thus, the general health of teachers is harmed by different ailments that may be physical and emotional, with general health and vocal problems and needs that are unresolved, unmet or that require specific actions of promotion of teachers' health.
The studies that focus on voice-related quality of life [3][4][5] contribute to the understanding of the subject's degree of satisfaction in regards to his own health, considering the social and cultural aspects of work that interfere in voice production and has implications in his daily life.
The purpose of this study was to conduct a survey of the studies involving quality of life related to the voice of teachers by performing an exploratory systematic review of the literature in the field of Speech Language Pathology and Audiology.

METHODS
An exploratory systematic review 6 was used as the research strategy.This method is used in order to synthesize the existing scientific evidence on a research problem in the field of health.The procedure was conducted at the Nucleus for Research in Emergent and Re-emergent Agents (NUPEREME) in the period between May and September, 2011.The research problem question was: has quality of life related to the voice of teachers been investigated?
In order to answer this question, research papers were selected from the following data bases: Education Resources Information Center (ERIC), LILACS, PUBMED Central (PMC) and SciELO, on May 5 th , 2011.At a previous stage, the terms to be used in the survey of the publications of the data bases were consulted.Different descriptors were tested, but the best crossing was obtained with the uniterms 'quality of life' and 'voice', and their correspondents in the Portuguese language 'qualidade de vida', 'voz'; that were found in the Virtual Health Library, using DeCs (Health Science Descriptor) and in PubMed, using MeSH (Medical Subject Headings).

Figure 1 -Flowchart of the design of the exploratory systematic review
On all data bases with the exception of PubMed, that permits searches with associations of 'quality of life'[Mesh] and 'voice'[Mesh] (Pubmed), the uniterms were crossed in pairs in order to assure that all papers related to the subject had been included.
Papers written in English, Portuguese and Spanish were accepted.There were no restraints in regards to the period of publication.The selected studies were evaluated by two reviewers, independently, who used standardized forms for analysis 7 , obeying the previously established criteria for inclusion and exclusion (Figure 2) that were a part of Relevance Test I, to which only the papers' abstracts were submitted.The studies considered relevant were subject to Relevance Test II, conducted for the entire paper.
The variables in each study, method characteristics and results were recorded and summarized.The evaluation of these parameters was used for the comparison, when applicable, of the selected studies.
values ranging from 0 to 100, where those closest to zero are worse and the best values are those closer to 100.The total score for healthy voices is 97.1; the social-emotional score for these voices is 99.3 and the physical 98.0.For dysphonic voices, the total score is 71.6, social-emotional is 79.5 and the physical score is 74.9 10 .
The VAS (Voice Care Knowledge Visual Analogue Scale) is a scale that assesses the changes related to voice and is comprised of questions such as "I know how the voice is produced' and the subject should indicate along the line the level where he evaluates himself.Answers are in between 'I completely agree' and "I completely disagree'.It was used only in the study by Gillivan-Murphy et al 11 ; and is not validated in Brazil.
The VOISS -The Voice Symptom Severity Scale is a scale of severity of vocal symptoms that is also composed by three domains: emotional, physical and global 11 .This scale has not been validated in Brazil.
The WHOQoL Brief is a self-reported questionnaire that contains 26 questions that relate to several aspects of daily life.The first question refers to quality of life and the second question to the level of satisfaction with one's own health.The answers are given in scores (1 to 5), where the worst level corresponds to one and the best to 5. The remaining 24 questions are divided into the following domains: physical, psychological, social relations and environment 12 . .
The Voice Activity and Participation Profile (VAPP) is a protocol that is translated and validated for use in Brazil according to the standards of the Scientific Advisory Committee of the Medical Outcomes Trust.It is a self-assessment instrument with 28 questions involving voice quality and emotional impacts, in work and communication (day-to-day and at work).The protocol offers The studies included in this investigation were those concerning quality of life related to the voice of teachers of public and private daycare, elementary, middle and high schools as well as universities, and used different evaluation instruments, such as scales, questionnaires and protocols.
In regard to data analysis, the systematization and description of the characteristics of the studies found in the exploratory review of Speech-Language Pathology and Audiology literature are performed considering the number of studied teachers, the level where they teach, the instruments, results and conclusions in each study.

Description of the instruments used in the studies included in this review
The studies used different instruments, questionnaires, scales and strategies, namely: The Voicerelated Quality of Life questionnaire (V-RQOL); the Voice Symptom Severity Scale (VOISS); the Voice Care Knowledge Visual Analogue scale (VAS); the World Health Organization Quality of life/brief (WHOQOL/Brief); the Voice Activity and Participation Profile (VAPP); the General Health Questionare-12 (GHQ-12); Anamnesis, Speech-Language Pathology Assessment and Focal Groups (Figure 4).
The Voice-Related Quality of Life (V-RQOL) is an international standardized questionnaire and its Brazilian Version (Qualidade de Vida em Voz -QVV) has been translated and adapted by Behlau 8 from the original by Hogikyan and Sethuraman

RESULTS
The entire electronic search yielded 315 publications from: PubMed (n=149), Eric (n= 70), Lilacs (n=63) and SciELO (n=33); 12 were repeated and according to the Relevance Test I 25 studies were eligible; and according to Relevance Test II 13 fulfilled the inclusion criteria for the review (Figure 3).The remaining publications were excluded as they were reviews, letters, theses and studies that did not concern the quality of life of teachers.
Figure 4 shows the characteristics of the 13 included studies, of which 11 were quantitative and 2 qualitative.The data are described below.additional scores: Activity Limitation Score and Participation Restriction 13 .It shows a horizontal line that must be marked (the left extremity represents the best voice quality and the right extremity represents the worst voice quality).
A Focus Group is a qualitative technique for data survey that has been employed in studies in the field of Speech-Language Pathology and Audiology 14 .Groups are formed with 6 to 15 people who have at least one important trace in common for the investigation being held; and the criteria for participant selection are determined by the purpose of each study.The impact of voice on quality of life was evidenced in work.There was significant improvement in all VAS scores in the treatment group as well as the total VoiSS score between the control and treatment groups.During the body Speech-Language Pathology evaluation, the most frequent disorder was tension in 10 (47.61%) teachers; in the vocal evaluation, the most evident aspects were voice modulation in 11 (52.38%)teachers and vocal projection in 10 (47.61%) of them.The relationship between the V-RQOL and the Speech-Language Pathology assessment showed that these teachers adequately evaluated their voices, as well as their impacts on quality of life.guidance decrease vocal symptoms and lead to an improvement of vocal care by teachers.Penteado and Bicudo-Pereira 15 studied 128 High School teachers in 4 public schools of Rio Claro (SP), evaluated using the World Health Organization Quality of life/brief (WHOQOL/brief) and Voice-Related Quality of Life (V-RQOL).In regard to the answers to the V-RQOL, on the vocal self-evaluation question 'How do you evaluate your voice?' the teachers showed satisfaction with their voice quality: 42.2% of the subjects considered their own voices 'good', 15.6% 'very good' and 3.1% 'excellent', while 32% considered in 'reasonable' and 7% 'bad'.The relationship between vocal selfassessment and the domains of the WHOQOL brief showed that the worse the teacher's quality of life, the worse was his/her vocal self-assessment, thus evidencing the hypothesis of the relationship between vocal health and quality of life of teachers.The authors concluded that the teachers, in spite of being satisfied with their voices, showed difficulties in the perception of the health-illness process, of the aspects associated with work, quality of life and health, which are possibly related to vocal health issues.
Jardim, Barreto and Assunção 16 studied 2133 Elementary School teachers from Belo Horizonte, using instruments such as the V-RQOL and the General Health Questionare-12(GHQ-12), in order to seek the presence of the most common mental disorders such as depression and anxiety.They found that less creativity at work and bad relationship with the students were associated to worse quality of life related to voice in the social-emotional and physical domains (90.6 and 79.4 respectively; and total score of 84.2).
The study by Servilha and Roccon 17 shows the investigation on quality of life of 21 university professors, 77% women and 23% men, using the V-RQOL and Speech-Language Pathology evaluation; on the question on vocal self-assessment 'How do you evaluate your voice?' the teachers considered their voices good (42.85%),reasonable (38.09%) and very good and bad, equally (9.52%).The physical domain had a mean score of 78.18 where difficulty in speaking loudly or being heard in noisy environments and having problems at work or in carrying out duties because of their voices stood out.On the social-emotional domain, the mean score was 88.98 and evidenced anxiety or frustration because of their voices.The global domain had a mean score of 82.61.The Speech-Language Pathology assessment considered more adapted voices (61.90%) than voices with disorders (38.09%) that had restrictions in projection and modulation or hoarseness.The comparison The study by Grillo and Penteado 4 , was observational and involved 120 Elementary School teachers in the Ribeirão Preto area, who completed the Voice-Related Quality of Life questionnaire (V-RQOL).On the vocal self-evaluation question 'How do you evaluate your voice?' most teachers (49.2%) considered their voice good in spite of facing difficulties to speak, especially when they are required to speak loudly in noisy environments and of running out of air and feeling the need to breathe many times while speaking.In general, teachers are satisfied with their voices, but several of those who considered their voices good have difficulties speaking, such as speaking loudly in noisy environments and quickly running out of air and feeling the need to constantly breathe when speaking (questions 1 and 2).Time in the occupation was related to question 2 and 5, concerning issues such as lack of air and depression, respectively, so that those with greater time in teaching reported more difficulties regarding rapidly running out of air and the more they feel depressed because of their voices.The impact of voice on quality of life was seen in the difficulties with using one's voice in high intensity, in the lack of speech coordination with breathing, at work and in negative feelings, directly associated to this category's vocal needs.
Gillivan-Murphy et al 11 conducted an intervention study with 20 Elementary and High School teachers who had reported voice disorders, in Ireland.Eleven participated in the control group and nine were part of the group that underwent treatment.The questionnaires used were the Voice-Related Quality of Life (V-RQOL), the Voice Symptom Severity Scale (VOISS) and the Voice Care Knowledge Visual Analogue Scale (VAS).This last instrument was used to assess changes regarding the voice; all instruments were completed before and after intervention.A combined approach was used, involving vocal function exercises and guidance on vocal hygiene for 8 weeks.Before the treatment there was no significant difference between the groups for the V-RQOL, VOISS and VAS.After the intervention, both groups showed improvement in the V-RQOL and in VOISS, although there was significant difference only for the treatment group.There was significant improvement in all VAS scores of the treatment group and of the total VOISS score when comparing control and treatment groups.There was no statistically significant difference on the V-RQOL between the groups.There was a significant difference regarding the knowledge of mechanisms of voice production for the group who underwent intervention.The study suggests that vocal function exercises associated to vocal hygiene reasonable information about vocal care, these are not put into practice, which shows a need for attention towards the factors of quality of life, subjectivity, history, culture, conditions and organization of the work environment of teachers -that interfere in the subjects' choices and communities in regard to their health care.
The qualitative study by Bragion, Foltran and Penteado 21 , involved five Preschool, Elementary, Middle and High School teachers from the city of Piracicaba, with the conduction of a focus group before and after the subjects' participation in a group about voice practices.The following categories were identified in the groups: teaching and impacts on health, quality of work and private life (overwork and social relationships) and work environment.The authors concluded that the experience broadened the perception of the teachers about their voices as they became aware of discomforts, disorders in voice production and have also related health to habits, behaviors as well as environment and work conditions.
Palheta Neto et al 22 in an epidemiological investigation of 120 teachers from the city of Belém in the state of Pará, used a questionnaire to obtain data about: symptoms reported throughout the subjects' professional life (hoarseness) at the time of the interview, time in the teaching career, average number of students per classroom, number of daily work hours and average weekly workload, temperature in the classroom, material used to write (chalk or marker) and vocal care throughout their careers.There was no statistically significant difference in the prevalence of hoarseness in relationship to the use of fans or air conditioning and between the group using chalk and the one using markers.However, there was a significant relationship between the absence of vocal care and hoarseness, symptom presented by half the teachers in the sample (45 teachers did not have vocal care).There was no significant association between hoarseness and daily workload, and there was also not a strong influence of the weekly workload.As far as hoarseness and number of years in the teaching career, 60 teachers had the symptom, of which 39 had been teachers for less than 15 years, while 21 had been working in the field for longer than 15 years.
Choi-Cardim, Behlau and Zambon 23 correlated work conditions, habits and vocal symptoms presented by 411 teachers from the Preschool, Elementary and Middle School Teachers' Union of São Paulo who took part in a Vocal Health Program.Two groups participated in the study: G1 (256 subjects submitted to voice evaluation and guidance) and G2 (155 subjects submitted to voice evaluation, guidance and rehabilitation).The between vocal self-assessment, Speech-Language Pathology Evaluation and quality of life evaluation showed more consensus than divergences.
Gampel, Karsch and Ferreira 18 studied 47 elderly teachers (over 65 years of age: GP-23) and non-teachers (GNP-24); and in comparing the scores of the Voice-Related Quality of Life questionnaire (V-RQOL) of both groups verified the relationship among the scores, chronological age and perception of vocal changes.The authors observed that there was no significant difference between the V-RQOL scores of GP and GNP, and no relationship between the scores and perception of vocal changes.Furthermore, they found that the older the chronological age, the greater the values obtained in the total V-RQOL and the values of the physical domain for both groups.Thus, the older the chronological age, the smaller the impact that voice has on the physical domain.No statistically significant difference was found between the groups.For GP, the questions of the physical domain that were reported as most difficult, from higher to lower, were questions 1, 2 and 7 (difficulty in speaking loudly or being herd in noisy environments, needing to breathe many times while speaking, and having problems at work due to their voices); and in regard to the socialemotional domain, the most problematic issue was question number 4 (being anxious or frustrated because of their voices).For the individuals in GP and GNP who perceived changes in their voices during the ageing process, there was significant difference in the questions referring to: Q2 -quickly running out of air (p=0.02),Q4-feeling anxious over voice (p=0.007),Q5-Being depressed because of voice (p=0.012) and Q9-having to repeat what has already been said (p=0.002).
Fabrício, Kasama and Martinez 19 focused their study on 82 professors at the Medical School of Ribeirão Preto, using the V-RQOL and a questionnaire developed by the authors.It was verified that, in the vocal self-evaluation question 'How do you evaluate your voice?' half of the teachers considered their voices 'excellent' or 'very good', and only 3% considered their voices 'bad'.Voice complaints were verified using scales 'always', 'sometimes', 'never' and 'did not answer', and the most frequent complaints were dry throat, phlegm, cough and hoarseness.
The study by Penteado 20, involved 12 High School teachers of the city of Rio Claro/SP (nine female subjects and three male subjects) in a qualitative study (focus group).Content analysis of the discussions held during the focus group identified 4 theme groups: knowledge and care, concerns and representations, problem identification and ways to cope with them.In spite of having knowledge and of students per class is over 51 for most subjects.As far as voice symptoms, the ones occurring in greater proportion were: sore throat (in 70% of the professors), phlegm and neck pain (in 54% of teachers).Hoarseness was reported in 31% of the subjects.
The study by Ricarte, Bommarito and Chiari 25 investigated 107 High School teachers (86 with complaints and 21 without voice complaints) from a private school in the city of Maceió.The authors used the Voice Activity Participation Profile (28 questions) that encompasses quality of life evaluation and the result of vocal treatments.The protocol offers additional scores: Activity Limitation Score and Participation Restriction Score.The authors found that the teachers with voice complaints feel restricted not only in their work as teachers but also in other daily life activities; and the study showed that the teachers perceive themselves having vocal problems.
The data about the numeric distribution of the instruments for measuring quality of life related to the voice of teachers, according to the 13 studies selected from the bibliography review are shown in table 1.
Tables 2, 3 and 4 show the scores of the domains of the studies that used the V-RQOL, the answers regarding vocal self-assessment and the distribution of the levels of education studied, respectively.authors verified that the groups were similar as far as gender (female), age group (31-40 years), taught more than one different grade, with up to 30 students per classroom, reported presence of noise at work, caring for their voices, using their voices excessively outside the school, did not smoke or consume alcohol.The groups were different regarding their daily workload: most of G1 worked up to 5 hours, while G2 worked between 6-10 hours a day; and having sought the care of an otorhynolaryngologist or Speech-Language Pathologist due to voice disorders: most teachers in G1 had not been to a specialist, while G2 had already sought professional care.The mean number of vocal symptoms in G2 was greater than in G1, which shows that this group attended the vocal health program for being more at risk of having a vocal problem.The authors report that G2 possibly needed rehabilitation for working more hours per day.
In the study by Almeida et al 24 328 professors from four colleges of the north region of the State of São Paulo were investigated.A self-assessment questionnaire developed by the Three-Part Commission for Professional Voice Norms was completed, in order to trace the symptoms of the occupational dysphonic syndrome as well as work organization factors that could interfere in the natural history of occupational voice disorders.The questionnaire was divided into four parts: identification, work organization, clinical symptoms, health and quality of life.In regard to work organization, class time is over 100 minutes; the average number 18 2 V-RQOL associated to another instrument (VOISS; VAS; WHOQOL/Brief; GHQ-12) [11][12][13][14][15][16] 3 V-RQOL + Voice assessment or developed questionnaire [17][18][19] 2 Questionnaire developed for study (identification, work organization, clinical symptoms, habits and quality of life) [22][23][24] 3 VAPP 25 1 Focus Groups

DISCUSSION
The studies that were included in this review have used different analysis criteria and standards, which made the comparison between them more difficult.Some studies lack data about the level of teaching, or if the institutions are private or public or if they are run by the city or state administrations.
When analyzing Figure 4, one may observe that studies on quality of life began being published from 2005 onwards 4 , even in Brazil; approximately one a year, except for 2007 [15][16] and 2010 [18][19][23][24] , when two and four papers, respectively were published. It shuld be noted that, in Brazil, the first publication of a translated version for Portuguese of this instrument was in the book by Behlau 8 , published in 2001; and the global domain varied from 82.61 to 97.5, thus in agreement with the values suggested in literature (97.1 for healthy voices and 71.6 for dysphonic voices) 10 , considering that the greater part of the studied population is composed of teachers without voice complaints, except for the study by Gillivan-Murphy 11 , where the studied group were teachers with complaints such as hoarseness and voice loss, and where there is greater impact on quality of life (65.2).The social-emotional domain varied from 87.3 to 100.0, where the standard score is 99.3 for healthy voices and 79.5 for dysphonic voices.In the same study by Gillivan-Murphy 11 , with teachers with voice complaints, there was no negative impact of the voice on quality of life.The physical domain varied from 74.4 to 95.8, and is thus equivalent to the standard expected for dysphonic individuals (74.9) 10 .
The studies by Penteado and Bicudo-Pereira 15 , Servilha and Roccon 17 and Jardim, Barreto and Assunção 16 showed lower scores in regard to the physical domain of the V-RQOL, which shows that both Elementary teachers and College Professors have problems related to the use of their voices, such as difficulties in speaking loudly in noisy environments; quickly running out of air and needing to breathe many times while speaking; and problems in carrying out their jobs as teachers because of their voices.The physical domain was the one that had the most negative impact on the quality of life of teachers, usually related to the questions referring to using the voice in high intensity, running out of air and needing to breathe many times while speaking; for Elementary, Middle and High School teachers, which reinforces the idea that an accessory in Speech-Language Pathology would benefit the use of voice in teaching.In the social-emotional domain, the impact on quality of life was low, meaning that teachers do not limit their social activities and do not experience feelings of anxiety and depression because of their voices.
Few studies showed results from the isolated question on vocal self-assessment How do you evaluate your voice? 4,15,19(Table 3).Most responses are concentrated on the parameters "good" and "reasonable".The original version of the instrument in Portuguese, published by Behlau 8 contained the isolated question that was later removed from the validated version of the questionnaire.In fact, for the validation process, the vocal self-assessment question was answered through a Likert 5-point scale: bad, reasonable, good, very good and excellent 10 .Later studies that have used the published validated version of the questionnaire no longer used this question, reducing the data for analysis.
that the publication of the validation in Brazil of this instrument occurred in 2006 and 2007 26 .
Figure 4 shows that there are few studies involving private school teachers [21][22][23]25 , possibly because there is easier access to public schools than to private schools which may be due to concerns regarding competition, fear of exposing limitations, difficulties among other reasons. Elmentary and Middle School were the most investigated education levels 4,11,16,[21][22][23] and the least explored were Preschool 11,21,23 and College Education 17,19,24 (table 4).There is a need to find and understand the relationships between voice and quality of life in the different education levels and in different work conditions in both public and private schools in order to search for the factors that interfere and how they may affect the quality of life of teachers.
Figure 4 evidences that the Voice-Related Quality of Life Questionnaire (V-RQOL) was the most widely used instrument in the investigations about the relationship between quality of life and voice of teachers.However, it should be stressed that, in Brazil, there are studies using the V-RQOL from as early as 2003 5 , that are Masters' Dissertations, Doctoral Theses and Undergraduate and Specialization essays that are not published as journal articles and thus have not been considered for analysis in this study.It should be noted that in Brazilian Speech-Language Pathology and Audiology, the main channel for publication and for sharing the research conducted at the Universities is the National Speech-Language Pathology and Audiology Congress and its respective Proceedings.Many investigations are not published in scientific journals and therefore are not included in systematic review studies.
Table 1 shows that the V-RQOL was used in isolation in two studies; and alongside other instruments (VOISS; VAS; WHOQOL-Brief; GHQ-12) in three studies.Other investigations used strategies such as questionnaires developed for the study, the VAPP and focus groups, respectively.The Voice-Related Quality of Life questionnaire was used in a total of seven studies (53.84 %).
The use of the V-RQOL has advantages such as being easy to understand and requires a short amount of time to complete.However, it has only one question related to work.It is important that new studies that aim to use the V-RQOL with teachers do not fail to include other strategies that enable the evaluation of specific aspects and issues of the teaching profession, especially those referring to work conditions and organization.Focus groups may constitute an interesting strategy in this direction.
In table 2, among the studies that have used the V-RQOL, it may be observed that the score in In the analyzed studies, it was verified that the V-RQOL was the most widely used instrument for the teachers; and its physical domain was the one with the most negative impact.The studies that used the vocal self-assessment question found that teachers, in spite of considering their voices good, have difficulties in noticing and valuing vocal symptoms, and do not relate them to the negative aspects of their quality of life.
Thus, the importance of Speech-Language Pathology actions that are constituted as social spaces and health education processes should be stressed, as they have potential to promote awareness and the perception of teachers about their own voices and its eventual changes and disorders, changing the wrong idea that a voice disorder is a natural part of the profession.
There is a need for more studies that relate voice and quality of life of teachers in an organized way and that cover aspects related to teachers' work conditions and organization in different levels of education and schools.
Even though most teachers considered their own voices good in answer to the self-assessment question, previous studies 5 show that teachers have difficulties perceiving and valuing vocal signs and symptoms.According to Servilha and Roccon 17 , when the teacher has a vocal problem, he/she does not notice any negative aspects on his/her quality of life.
Both qualitative studies that conducted focus groups [20][21] reinforced, by the teachers' perceptions, that work conditions influence professional performance, health and the quality of life of teachers.

CONCLUSIONS
There are few published studies concerning quality of life related to the voice of teachers, with unequal distribution and unevenness among education levels (Preschool, Elementary, Middle, High School or College) and types of school (public or private).Furthermore, there is no standard technique or similar criteria among the studies, making the analysis process more difficult.

Figure 2 -
Figure 2 -Reviewed answer sheet for relevance tests I and II 7

instruments used and main findings Study Subjects Education Level Private or Public School Instrument used Main Findings
Mental disorder (50%) and autonomy margin at work were associated to worse quality of life related to voice in the social-emotional domain.Noise in the classroom was associated to worse quality of life related to voice in the physical domain.Work organization, vocal health and mental health are associated to a worse voice-related quality of life.50%) related to lack of vocal care and to work conditions such as less than 15 years of teaching and great number of students per class.
Theme groups approached: Knowledge and caring for the voice/vocal health; concerns and representations regarding the illness-health process; ways of perceiving, identifying and interpreting vocal problems; ways of coping Actions in vocal health should involve aspects on work organization, daily life, subjectivity and quality of life.environment;Perception of voice and its disorders; vocal care/vocal health.Practical actions concerning voice use provide relationships between voice, work and health in the promotion of vocal health.**qualitative studyFigure 4 -Representative Picture of the systematic exploratory review of the studies in regard to the population, Education Level and Type of School (public or private),