Voice impact in the social communication and emotion of teachers before and after speech therapy

Methods: observational study, based on information collected in two stages: secondary data from medical records and questionnaires on line, after rising speech. The participants were 54 teachers, sent by the municipal occupational service with the diagnosis of dysphonia, for the Speech Therapy Clinic of a Teaching hospital. Speech therapy occurred from January 2012 to December 2013. The information of interest were responses to the Voice Activity and Participation Profile, number of vocal symptoms, issues relating to working conditions and living habits. A descriptive and inferential analysis using a statistical program.


INTRODUCTION
The voice problems that affect teachers, experienced in daily speech therapy services, are revealed in significant numbers of prevalent and incident cases that require vocal assistance 1 .
Teachers have shown a higher occurrence of multiple signals and vocal symptoms when compared to other occupational groups, and their problems are related to the use of voice at work 2.3 .Most of them report that they have had limitations on voice functionality, with adverse and negative repercussions on the effectiveness of communication by vocal deviation 4 .
A case-control study found an association between work stress and loss of functional ability early, by teacher´s vocal illness from the municipal education of São Paulo.Health-related aspects showed that they are crucial to the ability in their work and, in this case, the vocal symptom had a preponderant role 5 .
To the World Health Organization (WHO), a healthy work environment is determined by a process of continuous improvement of the protection and promotion of safety, health and well-being of all workers and the sustainability of the work environment, with collaboration of workers and managers 6 .
Thus, the concern for the quality of teacher´s life is growing, according to the occupational challenges that they are submitted to an effective performance in their working day, such as the use of their voices for long periods without adequate rest, loud noise in the school environment and in the classroom, and the maintenance of healthy habits such as proper hydration and nutrition, among others 7 .
Due to susceptibility of numerous interferences in the teacher's voice, the speech therapy is of great importance for maintenance of a good vocal health, which reflect in a better quality of life 8 .
The objective of this study was to compare the impact of voice on quality of teachers´ life, in the beginning and after speech therapy discharge and to identify associated factors.

METHODS
This work is part of a research project approved by the Research Ethics Committee (COEP) of the Federal University of Minas Gerais with the ETIC 482/08 number.The original project consists of a broad study with teachers treated at a school hospital, contemplating the group of teachers that were contacted by telephone, letter and / or email.
A prospective observational study was conducted with teachers, who were sent by the municipal occupational health service with a diagnosis of dysphonia, which made combined traditional voice therapy directly and indirectly 9 , from January 2012 to December 2013 and they were discharged from speech therapy.
The direct speech therapy approach provides a change in the voice operation by using techniques for voice, in order to encourage more effective production.In a complementary way, the indirect approach favors the understanding of vocal use, psychological and environmental factors that can lead to change of voice and develop strategies to minimize such risk factors 10 .
The teachers were selected for the study according to the inclusion and exclusion criteria.Inclusion criteria were: being female, sent by the municipal occupational health service operating in any levels of education, management or teaching coordination, which were discharged from speech therapy during the stated period and they agreed to participate.
Exclusion criteria were: male teachers, given the small number of them in the Speech Therapy Clinic; the teachers who did not respond to the Voice Activity and Participation Profile Protocol (VAPP) at the beginning of vocal therapy, those who left treatment, and who underwent speech therapy in another hospital after discharge from the Speech Therapy Clinic.
Among 140 teachers, 11 were excluded from the study for not having responded to VAPP in the early speech therapy and 13 for lack of telephone contact.For these 13 teachers were sent letters without return.Phone contacts with the 116 teachers eligible for the survey were conducted from January to July 2014, and permits to send the questionnaires were asked to be sent by email, which were sent in the period from March to June 2014.
The information related to the pre-speech therapy period the data were collected from medical records, including the results of VAPP and (s) cycle (s) of teaching performance; and information on the segment of speech therapy discharge, a questionnaire and VAPP were sent online.For the online questionnaire the following questions were selected: age, total working time in school; vocal symptoms, such as cough, dry cough, dry throat, bites, burning, choking, shortness of breath, strange body sensation in the throat, after prolonged use of voice, fatigue after a brief use of voice, laryngeal irritation, laryngeal constriction and pain; noise in the classroom and outside the school and contact with chalk power; microphone use and hydration during the class; constant practice of vocal exercises of vocal warm-up and slowdown, and physical activity associated with vocal use.The data on the impact of voice on quality of life were collected through the VAPP protocol.
<Insert Attachment 1> The VAPP is a questionnaire with strategies for evaluating the impact of voice on quality of life 11 , it is easy to apply and it provides a better description of the degree of functional capacity related to the use of the voice.The higher the results, the greater the difficulty and restriction imposed on the participation of voice activities 12.13 .
It is known that the self-assessment protocols reveal greater quantifying of the perspective of the subject of his speech problem 14 , and are important tools in measuring the results of speech therapy for teachers with behavioral dysphonia 15 .
The scores of VAPP parameters used in this study, applied pre and post speech therapy were: vocal selfperception, the effects of the impact of dysphonia at work, daily and social communication, emotion, and total.Additional scores VAPP protocol: Scoring Limitation on Activities (PLA) and the Restriction Score Participation (PRP) were not analyzed in this study.
For the application of VAPP and the online questionnaire after discharge from speech therapy, the teachers were contacted through phone calls, to invite them to participate.Questionnaires were sent by e-mail, with a minimum segment of four months and a maximum of two years and two months of speech therapy discharge.
Before starting the questionnaire, the participants should be required to read and agree to the IC, according to resolution number 466 of 12/12/2012 of the National Health Council / Ministry of Health.
The information obtained from medical records were stored in Microsoft Office Excel spreadsheets.
The analysis of the data was performed quantitatively through the statistical program IBM -SPSS, version 19.We conducted a descriptive analysis of the data with measures of central tendency and dispersion.In the comparison of median of VAPP parameters pre and post speech therapy was used the Wilcoxon test.The verification of the factors associated to the parameters of social communication and emotion after speech therapy was performed using the nonparametric Mann-Whitney test for independent samples.Considered the confidence level of 95%.

RESULTS
Among 116 teachers, 54 responded to the online questionnaire, representing a response rate equal to 46.6%.
The survey was conducted from the medical records of 54 teachers, aged 24-61 years, average of 41 years (SD = 8.26); and almost two-thirds of them (69%) teach in two shifts and 14 of them (31%) in a shift.The most prevalent teaching cycles were 30 early childhood education (53%) and primary education 20 (35%).
There was statistical difference between the groups of social communication and emotion parameters.There was no difference in relation to the self-awareness parameters, work, daily and total communication.In the comparison of VAPP parameters in pre and after speech therapy discharge, there was a reduction of the median in all aspects investigated.Comparing the number of reported symptoms, pre-speech therapy groups and after speech therapy discharge, there were differences between them.
Almost two thirds of teachers (67%) answered the questionnaire after the interval of four to twelve months speech therapy discharge for voice treatment.
As for working conditions it was found that most teachers realize the presence of sound competition with external noise in school and they have no contact with chalk powder; and 54% mentioned sound competition with noise in the classroom.
According to reference to behavioral factors, one third of them uses microphone.Most of them reported hydration during classes, physical activity associated with the use of voice and vocal exercises, and they perform vocal exercises of warm-up and slowdown frequently.
By correlating the VAPP parameters in which the groups differed -social communication and emotion -with behavioral and occupational aspects after discharge, we observed a statistical difference between the groups regarding the absence of noise generated in the classroom.The other independent variables did not differ between the groups.

DISCUSSION
The study shows that the speech therapy intervention promotes positive impact on the voice of teachers, observed by reducing the number of reported vocal symptoms after speech therapy discharge.There is improvement in aspects of quality of life, verified by the reduction in the limitation of dysphonia in all parameters analyzed, with significant differences for social communication and emotional profile.
We see a similarity scores of vocal self-perception when comparing the pre and post speech therapy, as similar to that found in other studies with teachers 17,20 .This finding may suggest the difficulty of the teacher to recognize his vocal changes, since the found average values are low and correspond to the perception of a slight change of voice.It is known that knowing the perception of the teacher in relation to the vocal and the consequent limitation generated in personal and social life is essential for motivation and adherence to speech therapy 21 .
It is still valid to suppose that, by acting as voice professionals, occupational aspects of the teacher influence the demand for use of voice and are directly related to vocal behavior, in the everyday life and emotion.Thus, the teacher exposed to the worst working conditions are prone to excessive use of voice, and negative vocal behavior, signaled in his voice, for example, by fatigue and hoarseness, among other health problems that cause losses in their daily communication and work 22,23 .
According to behavioral factors, a third of teachers reports the use of microphone after the treatment.The use of sound amplifier, when properly used, suggests benefits by reducing the vocal effort 24 .And the chalk powder is not part of the work by the most teachers studied.It is believed that this finding is related to the predominant role in this study, the teachers in early childhood education cycle.
Nearly all participants claim to hydration and do vocal exercises after discharge from speech therapy.The hydration and the frequency of the vocal exercises of vocal warm-up and slowdown demonstrated beneficial adhesions to speech therapy guidelines 8.12 .However, despite instructions about vocal hygiene, most teachers remains practicing physical activities associated with the use of voice.
The use of voice interferes less in the social communication and excitement of the teachers who perceive less noise at school.As for the external noise at school, and most teachers talked about sound competition, which was also found in another study with teachers 25 .
The study found average noise levels in schools between 68.65 dB (A) and 80.10 dB (A), far above the recommended, and found that the noise intensity is competitive with the voice of the teacher and the student will tend to present difficulties in teaching and learning process, related to the difficulty of understanding the message and keep the attention 26 , and it The results indicate that after the speech therapy discharge, it appears to have maintenance of healthier vocal adjustments, and reduction of the limitation of the vocal problem and the individuals´ desire to participate in daily activities when compared to the initial treatment period.
Despite the long period between the speech therapy discharge and the realization of the second data collection, there is no difference between teachers who were discharged for shorter or longer period than 12 months, for the social communication and emotion parameters, which corroborate other findings 8 .The other parameters were not analyzed in relation to speech therapy discharge time.
The positive impacts of speech therapy in improving quality of life through awareness and maintenance of vocal care were observed in some studies using therapeutic approaches and different research methods.
12. 15-18   .A recent study found that the vocal stability of patients with dysphonia after voice therapy remains for a period of six to 24 months 19 .There are few studies with teachers, who suffer of dysphonia, which analyze the results in long-term of speech therapy on quality of life.
As for the findings of VAPP, it is emphasized that there is a reduction of the limitations and restrictions on the vocal activities in all analyzed parameters, but the only ones that have significant changes, comparing pre and post speech therapy periods, were the social communication and the emotion.Reducing the social communication parameter in this study, post-speech therapy, is similar to that found in other studies with teachers 15.17 .The reduction and significant improvement in all parameters after the speech therapy were observed in other studies 12,15 .
It seems that the lack of difference between the groups pre and post speech therapy in some parameters of this study may be related to the small number of teachers that participated in the research, which reduces the statistical power of the analysis.There is a great variability of results in the analysis of VAPP parameters, verified by high values of standard deviation, indicating a heterogeneity of the studied population in these aspects.This can be explained by subjectivity in the perception of teachers on the use of voice in the various dimensions of life that is independent of the auditory perception aspect of vocal quality.The number of participants also prevented groups of teachers with less speech therapy discharge time variation were compared, it may influence the results.may cause harmful interference to the dynamic quality in the classroom.
The results showed that the perception of noise in the classroom after speech therapy is related to the greatest limitation of the voice to the parameters of social communication and emotional aspects.The noisy places cause the vocal abuse, and the continuous demand of this process can lead to waste on phonation structures and produce, over the time, voice disorders 27 .Noise can also favor stress and it increased psychological stress among teachers 28 .
Cross-sectional study with 682 teachers, held in Spain's schools, with the objective of evaluating the effects of the school environment on vocal health of teachers found an association between noise and acoustics of classrooms with the occurrence of vocal symptoms among teachers 29 .Another study showed that the teacher in working environment with unfavorable acoustics tend to feel less comfortable and most of them at risk of school clearance 30,31 .
The median of social communication and emotion parameters are lower among teachers who reported absence of noise in the classroom.It can be inferred that with speech therapy, enhances the development of specific strategies work management to deal with the students, which reduces the occurrence of vocal abuse and promotes interaction and communication in the classroom between the student and the teacher, making the most pleasurable and satisfying work.
It is believed that the speech therapy, by providing healthy vocal production, is related to the improving of teacher´s quality of life, promoting social, communicative processes and self-confidence, thus reducing median VAPP parameter social and emotional communication, as observed in this study, in line with other authors 15 .
Despite the limitations of the study and the small number of participants and following the losses in the segment of teachers and the variability of speech discharge time, the results show that healthy vocal behaviors are maintained after speech therapy and it should pay special attention to the control of noise in the classroom, within the context of each school.

CONCLUSION
The speech therapy brings positive impact on the voice of teachers in relation to behavioral and occupational factors, reducing the number of reported vocal symptoms.After speech therapy, the scores of social communication and emotion parameters reduced, indicating a lower limit of dysphonia vocal activities, especially in the absence of noise in the classroom.

Table 1 .
Comparison of median parameters protocol profile of participation and vocal activities and symptoms vocal autorrelatatos prespeech therapy and after four twenty-six -month high speech.

Table 2 .
Statement of variable independent and comparison with the median of parameters social communication and after high emotion phonotherapy.