Behavioral Dysphonia and Depression in Elementary School Teachers *Luise Marques da Rocha, †Mara Behlau, and *Luciano Dias de Mattos Souza, *Pelotas, Rio Grande do Sul, and yS~ao Paulo, S~ ao Paulo, Brasil
Summary: Objective/Hypothesis. To verify the relationship between behavioral dysphonia and current depressive episodes in municipal elementary school teachers. We hypothesize that teachers with behavioral dysphonia will be more susceptible to psychiatric disorders. Design. Cross-sectional study, quantitative, conducted across municipal schools in both rural and urban regions of Pelotas. Method. Five-hundred seventy-five teachers from urban and rural areas of the same Brazilian state were included. The full version of the Voice Handicap Index validated into Brazilian Portuguese was used to determine the presence of behavioral dysphonia. A profile of vocal behaviors was also used to quantify the number of phonotraumatic events. In addition, the Mini-International Neuropsychiatric Interview was used to determine current episodes of depression. Data were analyzed via correlative studies using chi-square and Poisson regression analyses. Results. Across all teachers, the prevalence of dysphonia was 33.9% and 55% reported that they had already taken a leave because of their voice. Those teachers with a current depressive episode had a higher rate of dysphonia compared with those without depression (prevalence ratio [PR] 1.66; P < 0.000). Teachers who presented with a risk of serious vocal problems had a prevalence ratio of 2.58, indicating a greater proportion of dysphonia, whereas teachers classified as champions of abuse were five times more likely compared with those teachers with behaved or candidates for voice problems. Conclusions. There is an association between behavioral dysphonia and current depressive episodes in elementary school teachers. Key Words: Dysphonia–Depression–Faculty. INTRODUCTION Teachers are inherently more likely to present with voice problems.1–4 A myriad of factors related to work and voice use contribute to the overall vocal health of this challenging population. The voice is essential for communication, one of the main ways to transfer ideas and thoughts, and for teachers, it is a vital tool of the trade. A seminal study from the United States showed a high incidence of voice disorders in teachers when compared with the general population.5 Similar findings were reported in a recent study of teachers in 27 Brazilian states; 63% of teachers reported that they have had a voice problem compared with 35% of the general population.1 Several risk factors may contribute to the increased likelihood of voice disorders in teachers. These factors include (1) physical factors such as inadequate acoustics and increased class size, (2) chemical factors such as dust and smoke exposure, and (3) ergonomics such as continuous voice use at increased intensity.1,6 Furthermore, increased occupational demands, unsatisfactory teaching environments,7 poor work organization, daily stresses, few opportunities for vocal rest,8 Accepted for publication October 22, 2014. From the *Programa de Pos-Graduac¸~ao em Saude e Comportamento, Universidade Catolica de Pelotas, Pelotas, Rio Grande do Sul, Brasil; and the yPrograma de PosGraduac¸~ao em Dist urbios da Comunicac¸~ao Humana, Universidade Federal de S~ao Paulo, S~ao Paulo, S~ao Paulo, Brasil. Address correspondence and reprint requests to Luciano Dias de Mattos Souza, Programa de P os-Graduac¸~ao em Saude e Comportamento, Universidade Catolica de Pelotas, Rua Gonc¸alves Chaves, 373, sala 418C, Centro, Pelotas, RS 96015-560, Brasil. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-6 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.10.011
and decreased social status and remuneration leading to professional frustration9 may contribute to dysphonia9,10 as well as issues related to overall psychological well-being in teachers11 In this population, dysphonia may lead to absence from work resulting in financial and social losses.13 Vocal complaints in this population are likely related to difficulty in producing natural voice.12 Specifically, altered vocal quality (hoarseness, instability, or as vocal fatigue or effort), difficulties in breathing control, tension, reduced vocal projection, and discomfort during speech have been reported.1,9,10,12,14,15 Absenteeism can be the result of worsening symptoms.1,3,7,16,17 The current literature suggests an emotional component to dysphonia.2,10,14,16 Although emotional issues with regard to voice production and specifically with regard to employment, has been discussed, these aspects have not received adequate attention through a structured approach with teachers from multiple locations. A recent finish study suggested that stress arising from work conditions may increase vocal symptoms in teachers and have a negative influence on emotional aspects of their occupation.3 Similarly, major depressive episodes and generalized anxiety disorders were more prevalent in teachers with vocal disorders.2 A recent review indicated a strong association between functional dysphonia and psychosocial symptoms as those present in depressive episodes.18 Therefore, the aim of the present study was to investigate the relationship between behavioral dysphonia and depression in primary school teachers. METHODS The present study was approved by the Ethics Committee of the Catholic University of Pelotas under the protocol number
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2011/29. The teachers were informed of the study objectives, and all signed a ‘‘Statement of Consent.’’ A cross-sectional quantitative study was performed including municipal schools in both rural and urban area of Pelotas, a city in southern Brazil with more than 330 000 inhabitants; 83% of the population resides in urban areas. The city has 214 educational institutions including state, municipal, federal, and private institutions serving preschool, primary, and secondary children. The present study included municipal elementary schools as they serve the largest number of children (103 schools). The study population included 2194 elementary school teachers (Department of Education of Pelotas-RS); 84.46% taught in urban schools and 15.54% in rural schools. The final study sample was developed via stratified random sampling which involved a raffle of 556 teachers from urban schools and 106 teachers from rural schools. Sample size was calculated based on the magnitude of effect of Voice Handicap Index (VHI)19 (minimum difference of outcome between teachers with and without psychiatric disorder, which was found in a pilot study ¼ 9 points 3 0.3) with a standard deviation of 15.5 points, confidence interval of 95%, and a statistical power of 80%. This analysis confirmed that 551 teachers were necessary. In addition, this sample was inflated by 20% to control confounding factors, losses, and refusals, resulting in a total of 662 teachers invited to participate. Physical education teachers were excluded from the sample as their educational characteristics differ considerably from classroom teachers. However, due to the lack of information regarding the number of physical education teachers in the registry of municipal teachers, a total of 633 teachers were invited to participate in this study. Fifty-eight subjects did not agree to participate or did not respond adequately the instrument and were considered refusals or losses. This led to a final sample of 575 teachers; 31 schools were visited, 18 urban and 13 rural (Fig. 1). The research team included two academics from the ‘‘Centro de Ci^encias da Vida e da Sa ude da Universidade Cat olica de Pelotas’’, who identified teachers and implemented the instru-
FIGURE 1. Flowchart of the study design and data collection.
ments after specific training and supervision by the primary author. In addition, a pilot study was conducted in two schools; one in an urban area (n ¼ 20) and the other in a rural area (n ¼ 22). The aim was to train the investigators in the instruments as well as the logistics of the present study. Structured interviews and a self-administered questionnaire containing questions related to sociodemographic data, environmental, behavioral, and emotional factors, such as voice use, were used. Socioeconomic status was measured via the economic indicator instrument for Brazil, based on the 2000 census–IEN.20 The sample was divided into three equal groups and classified into lower, intermediate, and higher socioeconomic status. The evaluation of alcohol consumption was conducted by using the Cut down - Annoyed - Guilty - Eye opener test (CAGE) questionnaire previously validated by Masur and Monteiro.21 This questionnaire involves four questions to assess alcohol abuse or dependence. To measure current depressive episodes, Module A of the Mini-International Neuropsychiatric Interview (MINI)22 was used. This instrument includes a brief standardized diagnostic interview to assess mood disorders and is intended for use in clinical practice and research to objectively classify subjects according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and International Statistical Classification of Diseases and Related Health Problems 10th Edition (ICD-10) criteria. The MINI 5.0, translated into Portuguese, was used in the present study. This instrument was developed for use in primary care and clinical trials. It consists of independent modules, which reduce the interview duration. All sections begin with questions that explore obligatory criteria for a diagnosis, which allows for diagnosis exclusion in cases of negative responses. To analyze vocal characteristics, the Vocal Behavior Profile adapted by Villela and Behlau (1999)23 was used. This instrument consists of 28 questions to identify situations of abuse, bad vocal use, and adverse conditions to vocal health. Scoring is as follows: 0 points indicates never; one point, rare occurrence; two points, lower frequency; three points, high frequency and four points, constant. Scores were tallied, and subjects are stratified into groups: the ‘‘behaved’’ (up to 15 points), ‘‘the candidate to voice problems’’ (16–30 points), ‘‘serious risk’’ (31–50 points), ‘‘the champion of abuse’’ (51 points or more). Finally, dysphonia was quantified via the VHI, validated in Brazilian Portuguese by Behlau et al.24 This instrument contains 30 questions that describe the vocal experience and the effect of the voice on daily activities. The VHI yields four scores, including one of total handicap (Cronbach’s alpha ¼ 0.888). To calculate the total score, the subscores are combined with a maximum score of 120. To determine dysphonia, the cutoff score of 19 was considered; this score was used based on a previous validation study performed in Brazil to characterize the psychometric proprieties of the instrument.25 None of the participants underwent an otorhinolaryngology evaluation to confirm the presence and the type of dysphonia. We chose to cautiously use behavioral dysphonia to determine the vocal injury. All teachers with an impairment of vocal and/or psychological deficits were referred to treatment.
Luise Marques da Rocha, et al
3
Behavioral Dysphonia and Depression in School Teachers
TABLE 1. Characteristics of Elementary School Teachers of Pelotas (Brazil)
TABLE 1. (Continued )
Variable
Current depressive episode Yes No Suicidal ideation Yes No Dysphonia Yes No Total
Prevalence (%)
Gender Female Male Age (y)* up to 40 41 Scholarity* Secondary school, teaching, and secondary school incomplete College undergraduated Graduated Socioecnonomic status by terciles* Disadvantaged Intermediate Most favored Hours* Up to 20 from 21to 40 >40 Any overtime* Yes No Schools divided per area Urban Rural Teaches up to 4th grade* Yes No Number of students per class* Up to 25 26 Teaching Time (y)* Up to 10 from 11 to 20 >20 Any vocal rest* Yes No Sick leave because of the voice* Yes No Self-reported disease* Yes No Tobacco* No tobacco Ex-smoker Smoker Vocal behavior profile Behaved or candidate to vocal problems Serious risk of vocal problems Champion of vocal abuse
N
91.3 8.7
525 50
50.3 49.7
279 276
7.5
43
41.3 51.2
237 294
33.3 35.0 31.7
173 182 165
21.6 62.7 15.7
124 359 90
21.7 78.3
123 445
75.8 24.2
436 139
66.7 33.3
381 190
75.9 24.1
422 134
47.2 24.9 27.9
269 142 159
32.4 67.6
186 388
15.0 85.0
86 488
71.6 28.4
391 155
73.5 14.6 11.9
413 82 67
10.4
52
40.4 49.2
203 247
Variable
Prevalence (%)
N
18.1 81.9
102 463
4.7 95.3
27 547
33.9 66.1 100
187 365 575
* Valid percentage.
(Continued )
Epi-Info 6.04 (https://wwwn.cdc.gov/epiinfo/html/ei6_ downloads.htm) with double data entry and automatic checking of amplitude and consistency was used for data processing. Statistical analyzes were performed via Stata 9.0 (http://www. stata.com/stata9/) and SPSS 13.0 (http://www-01.ibm.com/ software/analytics/spss/). Univariate analysis was performed by describing the simple frequency, means, and standard deviations of the relevant variables. Subsequently, bivariate analysis was performed using the chi-square test to determine the difference in proportion between dysphonia and the various independent variables. Poisson regression was then used to assess, in a specific hierarchical model, the relationship between dysphonia and the independent variables. Variables that achieved significance (P 0.20) via bivariate analyzes were included in multivariate analysis. Significance levels were maintained at P < 0.05. RESULTS In total, 91.3% of the sample was women and 50.3% were younger than 40 years. Regarding socioeconomic status, 51.2% of the teachers were postgraduate and 35.0% were considered from middle socioeconomic status. With regard to work conditions, most of the teachers reported between 21 and 40 hours of work per week (32.4%). In addition, 78.3%reported they did not work overtime, and 75.8% reported teaching in an urban area. Approximately, 67% of participants reported teaching fourth grade or lower, and 75.9% reported a class size of less than 25 students. Of the total, 47.2% have been teaching for less than 10 years, 67.6% report regular vocal rest, and 85% of the cohort reported missing work due to voice problems. Regarding other aspects of health, 71.6% of the participants reported having a disease, 11.9% reported smoking, and 18.1% had a current depressive episode. With regard to the vocal behavior profile, almost half of the sample was classified into the group of the highest occurrence of vocal abuse, teachers who were called champions of abuse (49.2%), 4.7% presented suicidal ideations, and 33.9% presented with dysphonia based on the cutoff value of the VHI. Only three teachers presented with alcohol abuse/dependence (Table 1).
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TABLE 2. Proportion of Dysphonia Compared With Variables of Interest Variables Number of students per class up to 25 26 Vocal rest Yes No Sick leave because of the voice Yes No Self-reported disease Yes No Vocal behavior profile Behaved or candidate to vocal problems Serious risk of vocal problems Champion of vocal abuse Current depressive episode Yes No Suicidal ideation Yes No
Proportion of Dysphonia P Value 0.108 32.2 40.5 0.099 28.9 36.4 0.003 49.4 31.4 0.006 37.4 24.3 0.000
TABLE 3. Multivariate Analysis to Dysphonia Using Poisson Regression Variables Vocal rest Number of students per class 25 or more Sick leave because of the voice Suicidal ideation Self-reported disease Vocal behavior profile Behaved or candidate to vocal problems Serious risk Champion of abuse Current depressive episode
PR Adjusted (95% CI)
P Value
1.166 (0.886–1.535) 1.251 (0.972–1.609)
0.271 0.081
1.550 (1.194–2.012)
0.001
0.927 (0.651–1.321) 1.127 (0.834–1.523)
0.670 0.433 0.000
Reference 2.58 (0.99–6.73) 5.33 (2.07–13.68) 1.66 (1.31–2.10)
0.053 0.000 0.000
7.8 22.2 50.8 0.000 62.5 27.8 53.8 33
0.047
When we compared the cohort of subjects with dysphonia, characterized by deviation in VHI, with variables such as gender, age, education, socioeconomic status, working hours, work overtime, school area, teaching in the early grades, time teaching, and smoking, no statistical relationships were observed. A small number of students in the classroom and vocal rest between semesters showed a statistically significant trend with dysphonia which warrants further study (Table 2). As shown in Table 2, the percentage of teachers with dysphonia who took a leave related to voice problems was higher than the group of teachers who did not (P < 0.003). Similarly, teachers who self-reported a disease (13.1%) had a higher incidence of dysphonia compared with those who denied any disease (P < 0.006). The percentage of teachers with dysphonia among those defined as ‘‘champions of vocal abuse’’ was significantly higher than in dysphonic teachers considered ‘‘behaved’’ or ‘‘candidates for voice problems,’’ and with those who presented as a ‘‘serious risk of voice problems’’ (P < 0.000). Dysphonia in teachers with current depressive episodes was more than two times higher compared with teachers who were not depressed. Finally, the incidence of dysphonia was significantly higher among teachers with suicidal ideations (P < 0.047). Multivariate analysis (Table 3) indicated that the significance noted for vocal rest was not maintained in the hierarchical model (P ¼ 0.271). Furthermore, suicidal ideation (P ¼ 0.678) and self-reported disease (P ¼ 0.433) were also excluded from the model as these variables did not show a
relationship with dysphonia. The independent variable ‘‘number of students per class’’ showed a trend toward significance with dysphonia (P ¼ 0.081), whereas the variables sick leave because of the voice, vocal behavior profile, and current depressive episode remained in the model because it had a significant association with dysphonia. The proportion of teachers who reported that they took a leave because of the voice was 55% higher than those who did not. The proportion of teachers who presented with a current depressive episode was higher than those without depression (PR, 1.66; P < 0.000). With regard to teachers who presented with a serious risk of voice problems, a prevalence ratio of 2.58 was observed, indicating a greater proportion of dysphonia when compared with teachers classified as ‘‘champions of abuse’’ presented a prevalence of dysphonia five times higher in comparison with teachers labeled as ‘‘behaved’’ or ‘‘candidates to voice problems.’’
DISCUSSION Epidemiologic studies conducted with teachers have previously confirmed an association between health, work, and voice, and specifically with a high prevalence of vocal complaints.2,5,6,9 In addition to the vocal demands that may lead to dysphonia, the literature suggests a close relationship between dysphonia and emotional factors.1,2,4,9 About 61% of teachers had vocal symptoms, in comparison with the prevalence of mental disorders (50%).4 The same study observed a higher prevalence of major depressive episodes in teachers with vocal complaints compared with those without voice issues.2 Brazilian studies, in which teachers were compared with nonteachers, changes arising from voice problems in teachers were increased when compared with nonteachers, and one of these alterations is the manifestation of emotion. Previous research indicates that among the feelings arising from loss of voice is depression.26 A subsequent Brazilian study of 5037 adults in the general population indicated that 9.4% had major depressive disorder, with
Luise Marques da Rocha, et al
Behavioral Dysphonia and Depression in School Teachers
43.1% considered severe. Women had a significantly higher proportion of mood disorders (major depressive disorder, bipolar disorder, and dysthymia) compared with men. Considering that the majority of teachers are women, it has been reported that the incidence of major depressive episodes in teachers are higher than the general population.27 It is important to highlight that the chronicity of vocal problems seems to not differ in relation to the incidence of depression. An American casecontrol study with subjects with spasmodic dysphonia and other vocal problems showed that both groups were equally likely to have a diagnosis of depression or anxiety.28 Similarly, a longitudinal survey performed with future teachers evaluated the first and the last year of training with regard to vocal and mental aspects. This study showed that students who obtained the highest score on the VHI total and in the emotional subscale had a higher risk for depression,29 even if there are some doubts on the importance of the subscales.30 Our data showed a relationship between deviations in this specific score and depression. We also found a high proportion of teachers who have suicidal ideation (4.7%). The characteristics of teacher work activity may contribute to their overall health. Research from Belgium showed that class size may be a risk factor for the voice disorders.31 In the same sense, a Brazilian study showed that more than 28 students in the classroom influenced teachers’ voices negatively.32 On the other hand, a cross-sectional study of elementary school teachers showed that the number of students is significantly higher in the group of teachers with constant and frequent dysphonia than in teachers with possible dysphonia or no dysphonia.33 These data suggest that the greater the number of students in the classroom, the greater the vocal demands which may result in dysphonia. In regard to vocal behaviors, studies have previously suggested how teachers are affected by situations and misconduct. In Brazil, teachers had a twofold increase in the incidence of voice problems interfering with communication compared with individuals from the general population, and furthermore, these data confirmed a higher proportion of poor habits among educators.1 An interesting research showed that teachers keep on performing their duties in spite of a high number of vocal symptoms34 In addition, teachers appear to use less productive strategies in the context of a voice problem compared with the general population with vocal complaints.34,35 These data corroborate with the current data. The current study suggests that the percentage of teachers with dysphonia who missed work because of vocal problems was higher than the group of teachers who did not miss work. Previous studies that compared teachers with other occupations showed that teachers often left the profession because of voice problems. The proportion of teachers who were absent from work because of voice was 16%, and this figure was higher than subjects with other occupations7 In Brazil, one study indicated that teachers missed 4.9 days of work because of voice, whereas other professionals were absent only 0.5 days because of voice problems.1 Similarly, US teachers had three times the rate of absenteeism last year.5 In Brazil, 6.9% of teachers were away from the classroom because of a medical diagnosis of
5
dysphonia.36 Other research suggests that educators who were absent because of voice problems in the last 6 months were 15 times more likely to have missed the last 2 weeks of work for the same reason, suggesting chronicity or recurrence of voice problems.37 This same research also showed that emotional problems were positively related with absenteeism related to voice problems. Studies indicate that depressive disorders and vocal problems in teachers are often responsible for absenteeism.36–39 Paschoalino defined the term, presenteeism, or being present at work even when ill, which may contribute to a cluster of symptoms related to depression.40 Research shows that teachers have limited perception of their voice41,42 and little insight into the onset of the symptoms, typically teaching until the problem worsens causing absence of work. There seems to be a tolerance for the impaired voice; teachers tend to minimize the problem.40,43,44 Thus, there is a greater concern with voice functionality than the vocal quality, which makes us believe that teachers may not consider dysphonia an occupational risk. One limitation of the present study was the cross-sectional design. It is impossible to determine whether teachers experienced an emotional or voice problem first. There are some indications that symptoms of depression occur subsequent to a voice problem.45 Longitudinal studies are necessary to verify the causality between dysphonia and depression. In addition to this limitation, we also did not submit the teachers’ to a laryngological examination. However, the large number of participants and the protocols used for this research make it likely that voice problems were accurately captured in this population. CONCLUSIONS There is an important relationship between dysphonia, vocal behavior, and depression. It is important to highlight the relevance of developing preventive strategies with occupational specificity to minimize vocal and mental symptoms with the ultimate goal of improving teacher health. The importance of a multidisciplinary team to establish concisely the causal link between these symptoms cannot be overstated. Enhanced public health policies for workers, specifically for teachers, must be based on fundamental data. REFERENCES 1. Behlau M, Zambon F, Guerrieri AC, Roy N. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26:665.e9–665.e18. 2. Nerriere E, Vercambre MN, Kovess-Masfety FG, Kovess-Masfety V. Voice disorders and mental health in teachers: a cross-sectional nationwide study. BMC Public Health. 2009;9:1–8. 3. Simberg S, Sala E, Vehmas K, Laine A. Changes in the prevalence of vocal symptoms among teachers during twelve-year period. J Voice. 2005;19: 95–102. Condic¸~oes de trabalho, qualidade de 4. Jardim R, Barreto SM, Assunc¸~ao AA. vida e disfonia entre docentes. Cad Saude Publica. 2007;23. 5. Roy N, Merrill RM, Thibeaults S, Gray SD, Smith EM. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551. 6. Alves IAV, Ferreira LP, Pereira KF. Perfil Vocal de docentes do ensino publico e privado da cidade de Jataı´ - Goias. Biol Health J. 2010;4.
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Summary: Objective/Hypothesis. To verify the relationship between behavioral dysphonia and current depressive episodes in municipal elementary school teachers. We hypothesize that teachers with behavioral dysphonia will be more susceptible to psychiatric disorders. Design. Cross-sectional study, quantitative, conducted across municipal schools in both rural and urban regions of Pelotas. Method. Five-hundred seventy-five teachers from urban and rural areas of the same Brazilian state were included. The full version of the Voice Handicap Index validated into Brazilian Portuguese was used to determine the presence of behavioral dysphonia. A profile of vocal behaviors was also used to quantify the number of phonotraumatic events. In addition, the Mini-International Neuropsychiatric Interview was used to determine current episodes of depression. Data were analyzed via correlative studies using chi-square and Poisson regression analyses. Results. Across all teachers, the prevalence of dysphonia was 33.9% and 55% reported that they had already taken a leave because of their voice. Those teachers with a current depressive episode had a higher rate of dysphonia compared with those without depression (prevalence ratio [PR] 1.66; P < 0.000). Teachers who presented with a risk of serious vocal problems had a prevalence ratio of 2.58, indicating a greater proportion of dysphonia, whereas teachers classified as champions of abuse were five times more likely compared with those teachers with behaved or candidates for voice problems. Conclusions. There is an association between behavioral dysphonia and current depressive episodes in elementary school teachers. Key Words: Dysphonia–Depression–Faculty. INTRODUCTION Teachers are inherently more likely to present with voice problems.1–4 A myriad of factors related to work and voice use contribute to the overall vocal health of this challenging population. The voice is essential for communication, one of the main ways to transfer ideas and thoughts, and for teachers, it is a vital tool of the trade. A seminal study from the United States showed a high incidence of voice disorders in teachers when compared with the general population.5 Similar findings were reported in a recent study of teachers in 27 Brazilian states; 63% of teachers reported that they have had a voice problem compared with 35% of the general population.1 Several risk factors may contribute to the increased likelihood of voice disorders in teachers. These factors include (1) physical factors such as inadequate acoustics and increased class size, (2) chemical factors such as dust and smoke exposure, and (3) ergonomics such as continuous voice use at increased intensity.1,6 Furthermore, increased occupational demands, unsatisfactory teaching environments,7 poor work organization, daily stresses, few opportunities for vocal rest,8 Accepted for publication October 22, 2014. From the *Programa de Pos-Graduac¸~ao em Saude e Comportamento, Universidade Catolica de Pelotas, Pelotas, Rio Grande do Sul, Brasil; and the yPrograma de PosGraduac¸~ao em Dist urbios da Comunicac¸~ao Humana, Universidade Federal de S~ao Paulo, S~ao Paulo, S~ao Paulo, Brasil. Address correspondence and reprint requests to Luciano Dias de Mattos Souza, Programa de P os-Graduac¸~ao em Saude e Comportamento, Universidade Catolica de Pelotas, Rua Gonc¸alves Chaves, 373, sala 418C, Centro, Pelotas, RS 96015-560, Brasil. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-6 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.10.011
and decreased social status and remuneration leading to professional frustration9 may contribute to dysphonia9,10 as well as issues related to overall psychological well-being in teachers11 In this population, dysphonia may lead to absence from work resulting in financial and social losses.13 Vocal complaints in this population are likely related to difficulty in producing natural voice.12 Specifically, altered vocal quality (hoarseness, instability, or as vocal fatigue or effort), difficulties in breathing control, tension, reduced vocal projection, and discomfort during speech have been reported.1,9,10,12,14,15 Absenteeism can be the result of worsening symptoms.1,3,7,16,17 The current literature suggests an emotional component to dysphonia.2,10,14,16 Although emotional issues with regard to voice production and specifically with regard to employment, has been discussed, these aspects have not received adequate attention through a structured approach with teachers from multiple locations. A recent finish study suggested that stress arising from work conditions may increase vocal symptoms in teachers and have a negative influence on emotional aspects of their occupation.3 Similarly, major depressive episodes and generalized anxiety disorders were more prevalent in teachers with vocal disorders.2 A recent review indicated a strong association between functional dysphonia and psychosocial symptoms as those present in depressive episodes.18 Therefore, the aim of the present study was to investigate the relationship between behavioral dysphonia and depression in primary school teachers. METHODS The present study was approved by the Ethics Committee of the Catholic University of Pelotas under the protocol number
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2011/29. The teachers were informed of the study objectives, and all signed a ‘‘Statement of Consent.’’ A cross-sectional quantitative study was performed including municipal schools in both rural and urban area of Pelotas, a city in southern Brazil with more than 330 000 inhabitants; 83% of the population resides in urban areas. The city has 214 educational institutions including state, municipal, federal, and private institutions serving preschool, primary, and secondary children. The present study included municipal elementary schools as they serve the largest number of children (103 schools). The study population included 2194 elementary school teachers (Department of Education of Pelotas-RS); 84.46% taught in urban schools and 15.54% in rural schools. The final study sample was developed via stratified random sampling which involved a raffle of 556 teachers from urban schools and 106 teachers from rural schools. Sample size was calculated based on the magnitude of effect of Voice Handicap Index (VHI)19 (minimum difference of outcome between teachers with and without psychiatric disorder, which was found in a pilot study ¼ 9 points 3 0.3) with a standard deviation of 15.5 points, confidence interval of 95%, and a statistical power of 80%. This analysis confirmed that 551 teachers were necessary. In addition, this sample was inflated by 20% to control confounding factors, losses, and refusals, resulting in a total of 662 teachers invited to participate. Physical education teachers were excluded from the sample as their educational characteristics differ considerably from classroom teachers. However, due to the lack of information regarding the number of physical education teachers in the registry of municipal teachers, a total of 633 teachers were invited to participate in this study. Fifty-eight subjects did not agree to participate or did not respond adequately the instrument and were considered refusals or losses. This led to a final sample of 575 teachers; 31 schools were visited, 18 urban and 13 rural (Fig. 1). The research team included two academics from the ‘‘Centro de Ci^encias da Vida e da Sa ude da Universidade Cat olica de Pelotas’’, who identified teachers and implemented the instru-
FIGURE 1. Flowchart of the study design and data collection.
ments after specific training and supervision by the primary author. In addition, a pilot study was conducted in two schools; one in an urban area (n ¼ 20) and the other in a rural area (n ¼ 22). The aim was to train the investigators in the instruments as well as the logistics of the present study. Structured interviews and a self-administered questionnaire containing questions related to sociodemographic data, environmental, behavioral, and emotional factors, such as voice use, were used. Socioeconomic status was measured via the economic indicator instrument for Brazil, based on the 2000 census–IEN.20 The sample was divided into three equal groups and classified into lower, intermediate, and higher socioeconomic status. The evaluation of alcohol consumption was conducted by using the Cut down - Annoyed - Guilty - Eye opener test (CAGE) questionnaire previously validated by Masur and Monteiro.21 This questionnaire involves four questions to assess alcohol abuse or dependence. To measure current depressive episodes, Module A of the Mini-International Neuropsychiatric Interview (MINI)22 was used. This instrument includes a brief standardized diagnostic interview to assess mood disorders and is intended for use in clinical practice and research to objectively classify subjects according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and International Statistical Classification of Diseases and Related Health Problems 10th Edition (ICD-10) criteria. The MINI 5.0, translated into Portuguese, was used in the present study. This instrument was developed for use in primary care and clinical trials. It consists of independent modules, which reduce the interview duration. All sections begin with questions that explore obligatory criteria for a diagnosis, which allows for diagnosis exclusion in cases of negative responses. To analyze vocal characteristics, the Vocal Behavior Profile adapted by Villela and Behlau (1999)23 was used. This instrument consists of 28 questions to identify situations of abuse, bad vocal use, and adverse conditions to vocal health. Scoring is as follows: 0 points indicates never; one point, rare occurrence; two points, lower frequency; three points, high frequency and four points, constant. Scores were tallied, and subjects are stratified into groups: the ‘‘behaved’’ (up to 15 points), ‘‘the candidate to voice problems’’ (16–30 points), ‘‘serious risk’’ (31–50 points), ‘‘the champion of abuse’’ (51 points or more). Finally, dysphonia was quantified via the VHI, validated in Brazilian Portuguese by Behlau et al.24 This instrument contains 30 questions that describe the vocal experience and the effect of the voice on daily activities. The VHI yields four scores, including one of total handicap (Cronbach’s alpha ¼ 0.888). To calculate the total score, the subscores are combined with a maximum score of 120. To determine dysphonia, the cutoff score of 19 was considered; this score was used based on a previous validation study performed in Brazil to characterize the psychometric proprieties of the instrument.25 None of the participants underwent an otorhinolaryngology evaluation to confirm the presence and the type of dysphonia. We chose to cautiously use behavioral dysphonia to determine the vocal injury. All teachers with an impairment of vocal and/or psychological deficits were referred to treatment.
Luise Marques da Rocha, et al
3
Behavioral Dysphonia and Depression in School Teachers
TABLE 1. Characteristics of Elementary School Teachers of Pelotas (Brazil)
TABLE 1. (Continued )
Variable
Current depressive episode Yes No Suicidal ideation Yes No Dysphonia Yes No Total
Prevalence (%)
Gender Female Male Age (y)* up to 40 41 Scholarity* Secondary school, teaching, and secondary school incomplete College undergraduated Graduated Socioecnonomic status by terciles* Disadvantaged Intermediate Most favored Hours* Up to 20 from 21to 40 >40 Any overtime* Yes No Schools divided per area Urban Rural Teaches up to 4th grade* Yes No Number of students per class* Up to 25 26 Teaching Time (y)* Up to 10 from 11 to 20 >20 Any vocal rest* Yes No Sick leave because of the voice* Yes No Self-reported disease* Yes No Tobacco* No tobacco Ex-smoker Smoker Vocal behavior profile Behaved or candidate to vocal problems Serious risk of vocal problems Champion of vocal abuse
N
91.3 8.7
525 50
50.3 49.7
279 276
7.5
43
41.3 51.2
237 294
33.3 35.0 31.7
173 182 165
21.6 62.7 15.7
124 359 90
21.7 78.3
123 445
75.8 24.2
436 139
66.7 33.3
381 190
75.9 24.1
422 134
47.2 24.9 27.9
269 142 159
32.4 67.6
186 388
15.0 85.0
86 488
71.6 28.4
391 155
73.5 14.6 11.9
413 82 67
10.4
52
40.4 49.2
203 247
Variable
Prevalence (%)
N
18.1 81.9
102 463
4.7 95.3
27 547
33.9 66.1 100
187 365 575
* Valid percentage.
(Continued )
Epi-Info 6.04 (https://wwwn.cdc.gov/epiinfo/html/ei6_ downloads.htm) with double data entry and automatic checking of amplitude and consistency was used for data processing. Statistical analyzes were performed via Stata 9.0 (http://www. stata.com/stata9/) and SPSS 13.0 (http://www-01.ibm.com/ software/analytics/spss/). Univariate analysis was performed by describing the simple frequency, means, and standard deviations of the relevant variables. Subsequently, bivariate analysis was performed using the chi-square test to determine the difference in proportion between dysphonia and the various independent variables. Poisson regression was then used to assess, in a specific hierarchical model, the relationship between dysphonia and the independent variables. Variables that achieved significance (P 0.20) via bivariate analyzes were included in multivariate analysis. Significance levels were maintained at P < 0.05. RESULTS In total, 91.3% of the sample was women and 50.3% were younger than 40 years. Regarding socioeconomic status, 51.2% of the teachers were postgraduate and 35.0% were considered from middle socioeconomic status. With regard to work conditions, most of the teachers reported between 21 and 40 hours of work per week (32.4%). In addition, 78.3%reported they did not work overtime, and 75.8% reported teaching in an urban area. Approximately, 67% of participants reported teaching fourth grade or lower, and 75.9% reported a class size of less than 25 students. Of the total, 47.2% have been teaching for less than 10 years, 67.6% report regular vocal rest, and 85% of the cohort reported missing work due to voice problems. Regarding other aspects of health, 71.6% of the participants reported having a disease, 11.9% reported smoking, and 18.1% had a current depressive episode. With regard to the vocal behavior profile, almost half of the sample was classified into the group of the highest occurrence of vocal abuse, teachers who were called champions of abuse (49.2%), 4.7% presented suicidal ideations, and 33.9% presented with dysphonia based on the cutoff value of the VHI. Only three teachers presented with alcohol abuse/dependence (Table 1).
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TABLE 2. Proportion of Dysphonia Compared With Variables of Interest Variables Number of students per class up to 25 26 Vocal rest Yes No Sick leave because of the voice Yes No Self-reported disease Yes No Vocal behavior profile Behaved or candidate to vocal problems Serious risk of vocal problems Champion of vocal abuse Current depressive episode Yes No Suicidal ideation Yes No
Proportion of Dysphonia P Value 0.108 32.2 40.5 0.099 28.9 36.4 0.003 49.4 31.4 0.006 37.4 24.3 0.000
TABLE 3. Multivariate Analysis to Dysphonia Using Poisson Regression Variables Vocal rest Number of students per class 25 or more Sick leave because of the voice Suicidal ideation Self-reported disease Vocal behavior profile Behaved or candidate to vocal problems Serious risk Champion of abuse Current depressive episode
PR Adjusted (95% CI)
P Value
1.166 (0.886–1.535) 1.251 (0.972–1.609)
0.271 0.081
1.550 (1.194–2.012)
0.001
0.927 (0.651–1.321) 1.127 (0.834–1.523)
0.670 0.433 0.000
Reference 2.58 (0.99–6.73) 5.33 (2.07–13.68) 1.66 (1.31–2.10)
0.053 0.000 0.000
7.8 22.2 50.8 0.000 62.5 27.8 53.8 33
0.047
When we compared the cohort of subjects with dysphonia, characterized by deviation in VHI, with variables such as gender, age, education, socioeconomic status, working hours, work overtime, school area, teaching in the early grades, time teaching, and smoking, no statistical relationships were observed. A small number of students in the classroom and vocal rest between semesters showed a statistically significant trend with dysphonia which warrants further study (Table 2). As shown in Table 2, the percentage of teachers with dysphonia who took a leave related to voice problems was higher than the group of teachers who did not (P < 0.003). Similarly, teachers who self-reported a disease (13.1%) had a higher incidence of dysphonia compared with those who denied any disease (P < 0.006). The percentage of teachers with dysphonia among those defined as ‘‘champions of vocal abuse’’ was significantly higher than in dysphonic teachers considered ‘‘behaved’’ or ‘‘candidates for voice problems,’’ and with those who presented as a ‘‘serious risk of voice problems’’ (P < 0.000). Dysphonia in teachers with current depressive episodes was more than two times higher compared with teachers who were not depressed. Finally, the incidence of dysphonia was significantly higher among teachers with suicidal ideations (P < 0.047). Multivariate analysis (Table 3) indicated that the significance noted for vocal rest was not maintained in the hierarchical model (P ¼ 0.271). Furthermore, suicidal ideation (P ¼ 0.678) and self-reported disease (P ¼ 0.433) were also excluded from the model as these variables did not show a
relationship with dysphonia. The independent variable ‘‘number of students per class’’ showed a trend toward significance with dysphonia (P ¼ 0.081), whereas the variables sick leave because of the voice, vocal behavior profile, and current depressive episode remained in the model because it had a significant association with dysphonia. The proportion of teachers who reported that they took a leave because of the voice was 55% higher than those who did not. The proportion of teachers who presented with a current depressive episode was higher than those without depression (PR, 1.66; P < 0.000). With regard to teachers who presented with a serious risk of voice problems, a prevalence ratio of 2.58 was observed, indicating a greater proportion of dysphonia when compared with teachers classified as ‘‘champions of abuse’’ presented a prevalence of dysphonia five times higher in comparison with teachers labeled as ‘‘behaved’’ or ‘‘candidates to voice problems.’’
DISCUSSION Epidemiologic studies conducted with teachers have previously confirmed an association between health, work, and voice, and specifically with a high prevalence of vocal complaints.2,5,6,9 In addition to the vocal demands that may lead to dysphonia, the literature suggests a close relationship between dysphonia and emotional factors.1,2,4,9 About 61% of teachers had vocal symptoms, in comparison with the prevalence of mental disorders (50%).4 The same study observed a higher prevalence of major depressive episodes in teachers with vocal complaints compared with those without voice issues.2 Brazilian studies, in which teachers were compared with nonteachers, changes arising from voice problems in teachers were increased when compared with nonteachers, and one of these alterations is the manifestation of emotion. Previous research indicates that among the feelings arising from loss of voice is depression.26 A subsequent Brazilian study of 5037 adults in the general population indicated that 9.4% had major depressive disorder, with
Luise Marques da Rocha, et al
Behavioral Dysphonia and Depression in School Teachers
43.1% considered severe. Women had a significantly higher proportion of mood disorders (major depressive disorder, bipolar disorder, and dysthymia) compared with men. Considering that the majority of teachers are women, it has been reported that the incidence of major depressive episodes in teachers are higher than the general population.27 It is important to highlight that the chronicity of vocal problems seems to not differ in relation to the incidence of depression. An American casecontrol study with subjects with spasmodic dysphonia and other vocal problems showed that both groups were equally likely to have a diagnosis of depression or anxiety.28 Similarly, a longitudinal survey performed with future teachers evaluated the first and the last year of training with regard to vocal and mental aspects. This study showed that students who obtained the highest score on the VHI total and in the emotional subscale had a higher risk for depression,29 even if there are some doubts on the importance of the subscales.30 Our data showed a relationship between deviations in this specific score and depression. We also found a high proportion of teachers who have suicidal ideation (4.7%). The characteristics of teacher work activity may contribute to their overall health. Research from Belgium showed that class size may be a risk factor for the voice disorders.31 In the same sense, a Brazilian study showed that more than 28 students in the classroom influenced teachers’ voices negatively.32 On the other hand, a cross-sectional study of elementary school teachers showed that the number of students is significantly higher in the group of teachers with constant and frequent dysphonia than in teachers with possible dysphonia or no dysphonia.33 These data suggest that the greater the number of students in the classroom, the greater the vocal demands which may result in dysphonia. In regard to vocal behaviors, studies have previously suggested how teachers are affected by situations and misconduct. In Brazil, teachers had a twofold increase in the incidence of voice problems interfering with communication compared with individuals from the general population, and furthermore, these data confirmed a higher proportion of poor habits among educators.1 An interesting research showed that teachers keep on performing their duties in spite of a high number of vocal symptoms34 In addition, teachers appear to use less productive strategies in the context of a voice problem compared with the general population with vocal complaints.34,35 These data corroborate with the current data. The current study suggests that the percentage of teachers with dysphonia who missed work because of vocal problems was higher than the group of teachers who did not miss work. Previous studies that compared teachers with other occupations showed that teachers often left the profession because of voice problems. The proportion of teachers who were absent from work because of voice was 16%, and this figure was higher than subjects with other occupations7 In Brazil, one study indicated that teachers missed 4.9 days of work because of voice, whereas other professionals were absent only 0.5 days because of voice problems.1 Similarly, US teachers had three times the rate of absenteeism last year.5 In Brazil, 6.9% of teachers were away from the classroom because of a medical diagnosis of
5
dysphonia.36 Other research suggests that educators who were absent because of voice problems in the last 6 months were 15 times more likely to have missed the last 2 weeks of work for the same reason, suggesting chronicity or recurrence of voice problems.37 This same research also showed that emotional problems were positively related with absenteeism related to voice problems. Studies indicate that depressive disorders and vocal problems in teachers are often responsible for absenteeism.36–39 Paschoalino defined the term, presenteeism, or being present at work even when ill, which may contribute to a cluster of symptoms related to depression.40 Research shows that teachers have limited perception of their voice41,42 and little insight into the onset of the symptoms, typically teaching until the problem worsens causing absence of work. There seems to be a tolerance for the impaired voice; teachers tend to minimize the problem.40,43,44 Thus, there is a greater concern with voice functionality than the vocal quality, which makes us believe that teachers may not consider dysphonia an occupational risk. One limitation of the present study was the cross-sectional design. It is impossible to determine whether teachers experienced an emotional or voice problem first. There are some indications that symptoms of depression occur subsequent to a voice problem.45 Longitudinal studies are necessary to verify the causality between dysphonia and depression. In addition to this limitation, we also did not submit the teachers’ to a laryngological examination. However, the large number of participants and the protocols used for this research make it likely that voice problems were accurately captured in this population. CONCLUSIONS There is an important relationship between dysphonia, vocal behavior, and depression. It is important to highlight the relevance of developing preventive strategies with occupational specificity to minimize vocal and mental symptoms with the ultimate goal of improving teacher health. The importance of a multidisciplinary team to establish concisely the causal link between these symptoms cannot be overstated. Enhanced public health policies for workers, specifically for teachers, must be based on fundamental data. REFERENCES 1. Behlau M, Zambon F, Guerrieri AC, Roy N. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26:665.e9–665.e18. 2. Nerriere E, Vercambre MN, Kovess-Masfety FG, Kovess-Masfety V. Voice disorders and mental health in teachers: a cross-sectional nationwide study. BMC Public Health. 2009;9:1–8. 3. Simberg S, Sala E, Vehmas K, Laine A. Changes in the prevalence of vocal symptoms among teachers during twelve-year period. J Voice. 2005;19: 95–102. Condic¸~oes de trabalho, qualidade de 4. Jardim R, Barreto SM, Assunc¸~ao AA. vida e disfonia entre docentes. Cad Saude Publica. 2007;23. 5. Roy N, Merrill RM, Thibeaults S, Gray SD, Smith EM. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551. 6. Alves IAV, Ferreira LP, Pereira KF. Perfil Vocal de docentes do ensino publico e privado da cidade de Jataı´ - Goias. Biol Health J. 2010;4.
6 7. Smith E, Lemke J, Taylor M, Kirchener HL, Hoffman H. Frequency of voice problems among teachers and other occupations. J Voice. 1998;12: 480–488. 8. Reis EJFB, Carvalho FM, Araujo TM, Porto LA, Silvany Neto AM. Trabalho e dist urbios psı´quicos em professores. Cad Saude Publica. 2005; 21:1480–1490. 9. Behlau M. organizadora. Voz: o livro do Especialista. Rio de Janeiro: Revinter; 2005:2. 10. Amorim SNMC. Disturbio vocal e estresse: os efeitos do trabalho na saude de professores/as do ensino fundamental de Goi^ania [dissertac¸~ao-mestrado]. Universidade Catolica de Goias; 2006. Available at: http://www. cpgss.ucg.br/ArquivosUpload/2/file/MCAS/S^amia%20Neves%20M%20de %20C%20Amorim.pdf. 11. Gianinni SPP, Latorre MRDO, Ferreira LP. Disturbio de voz e estresse no trabalho docente: um estudo caso-controle. Cad de Saude P ublica. 2012; 28:2115–2124. 12. Behlau M, Pontes P. Avaliac¸~ao e Tratamento das Disfonias. S~ao Paulo: Lovil; 1995. 13. Willians NR. Occupational groups at risk of voice disorders: a review of the literature. Occup Med (lond). 2003;53:456–460. 14. Centro de Refer^encia em Saude do Trabalhador. Coordenadoria de Controle de Doenc¸as, Secretaria de Estado da Saude de S~ao Paulo (CEREST, CCD, SES-SP). Boletim Epidemiologico Paulista - Informe Mensal Sobre Agravo a Sa ude P ublica. 2006. 15. Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract discomfort in teachers: its relationship to self-reported voice disorders. J Voice. 2013;27: 473–480. 16. Alvear RMB, Martinez-Arquero G, Baron FJ, Hernandez-Mendo A. An interdisciplinary approach to teachers’ voice disorders and psychosocial working conditions. Folia Phoniatr Logop. 2010;64:24–34. 17. Gassull C, Casanova C, Botey Q, Amador M. The impact of the reactivity to stress in teachers with voice problems. Folia Phoniatr Logop. 2010;62: 35–39. 18. Deary V, Miller T. Reconsidering the role of psychosocial factors in functional dysphonia. Curr Opin Otolaryngol Head Neck Surg. 2011;19: 150–154. 19. Jacobson BH, Johnson A, Grywalski C, et al. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6: 66–70. 20. Barros AJD, Victora CG. Indicador econ^omico para o Brasil baseado no censo demografico de 2000. Rev Saude Publica. 2005;39:523–529. 21. Masur J, Monteiro M. Validation of the CAGE alcoholism screening test in Brazilian Psychiatry inpatient hospital setting. Braz J Med Biol Res. 1983; 16:215–218. 22. American Psychiatric Association. Diagnostical and Statistical Manual of Mental Disorders. DSM- IV-TR. 4th ed. Porto Alegre: Artmed; 2004. 23. Behlau M, Pontes P. Higiene vocal: cuidando da voz. 2nd ed. Rio de Janeiro: Revinter; 1999. 24. Behlau M, Alves Dos Santos L de M, Oliveira G. Cross-cultural adaptation and validation of the voice handicap index into Brazilian Portuguese. J Voice. 2011;25:354–359. 25. Behlau M, Couto Junior EB, Paulinelli BR, Santos LMA, Oliveira G, Moreti F, Madazio G - Efici^encia e Valores de Corte de Protocolos de Autoavaliac¸~ao, Sociedade Brasileira de Fonoaudiologia - SBFa. 21 Congresso Brasileiro de Fonoaudiologia e 2 Ibero – Americano de Fonoaudio-
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