Hoarseness and Risk Factors in University Teachers Gustavo Polacow Korn, Antonio Augusto de Lima Pontes, Denise Abranches, and Paulo Augusto de Lima Pontes, S~ ao Paulo, Brazil
Summary: Purpose. To characterize the presence of hoarseness and the risk factors in male and female university teachers in private institutions in the city of S~ao Paulo, Brazil. Study Design. Cross-sectional survey. Methods. Voice self-evaluation forms prepared by the Brazilian Ministry of Labor were administered to 846 university teachers in a private institution in the city of S~ao Paulo, Brazil. Results. Prevalence of hoarseness in the sample is 39.6%. Percentage of hoarseness is higher in females (51.8%) than in males (32.6%). Comparing hoarseness and time of teaching, it was observed that the percentage of hoarseness is lower in a time shorter or equal to 1 year, and it is higher in a time between 10 and 20 years. Percentage of hoarseness is lower in the maximum workload of one to three class hours per day compared with the other workloads. Percentage of hoarseness is lower when the maximum number of students per classroom is less than 30 than when it is between 101 and 150 students. Other factors like in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life are related to the presence of hoarseness. Conclusion. University teachers show high percentage of hoarseness. Factors, such as time of teaching, females, work organization, workplace, in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life, are related to the presence of hoarseness in this group. Key Words: Teachers–Dysphonia–Risk factors. INTRODUCTION The term ‘‘professional voice users’’ was defined in the Brazilian Consensus of Professional Voice in 2004 as the oral communication used by people who depend on their voice to perform their working activities.1 Approximately, one-third of today’s known professions use the voice to varying degrees.2 Among the professionals who use the voice, teachers, representing more than four million workers in Brazil,3 are the focus of most studies about the professional voice.4 Among the professionals who use the voice, teachers are most likely to develop dysphonia.5,6 Moreover, only one-third of teachers with vocal complaints seek professional assistance.7–9 Teachers have recently been the subject of several studies on the professional voice. Such studies warn of the adverse effects of voice problems on work performance,10,11 suggesting that teaching has a high risk of work-related vocal problems.10,12 In addition, the number of voice complaints is higher in female teachers than in male teachers.8 Behlau et al,13 in an epidemiological study in Brazil, compared vocal symptoms in 1651 teachers of elementary and high schools with 1614 nonteachers. They made the following observations: (1) there was a vocal complaint incidence of 11.6% in teachers and 7.5% in nonteachers, (2) 63% of teachers and 35.8% of nonteachers had vocal problems at some point in life, (3) there was a higher number of vocal symptoms seen in current teachers (average of 3.7) and previous teachers (average of 3.6) compared with nonteachers (1.7 and
Accepted for publication September 8, 2014. From the Department of Otolaryngology, Head and Neck Surgery of Federal, University of S~ao Paulo, S~ao Paulo, Brazil. Address correspondence and reprint requests to Gustavo Polacow Korn, Av. Brigadeiro Faria Lima, 1811 cj 907-908, Jardim Paulistano, S~ao Paulo, SP 01452-001, Brazil. E-mail: [email protected] Journal of Voice, Vol. 29, No. 4, pp. 518.e21-518.e28 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.09.008
2.3), (4) the voice contributed to limitations in the work of 29.9% of teachers and 5.4% of nonteachers, and (5) teachers had higher numbers of absenteeism in the last year and had considered more job changes than nonteachers. The researchers concluded that working at school as a teacher has a high occupational risk for vocal problems. In 2010, de Almeida and Pontes14 introduced the concept of occupational dysphonic syndrome (ODS) by considering the multitude of factors that can cause dysphonia in professional voice use and the numerous symptoms of dysphonia. This range of factors and symptoms explains the discrepancies found in the literature. Regarding the symptoms of ODS, the modification of voice quality that is typically referred to as hoarseness is the symptom most noticed by voice professionals, although this symptom may present with different characteristics, such as roughness, harshness, and breathiness, among others. Thus, in the present study, we will consider this symptom to be an identifying parameter of ODS in university teachers. Several studies include teachers from different segments of school,7,8,10–13 but thus far, we have not found a study specifically addressing university teachers that has used a self-evaluation survey. Thus, it is of interest to use a voice self-evaluation survey, such as that designed by the Brazilian Ministry of Labor, for an epidemiological profile of voice complaints and risk factors in university teachers.15 The objective of this research is to characterize the presence of hoarseness and the risk factors in male and female university teachers in private institutions in the city of S~ao Paulo, Brazil.
METHODS This cross-sectional study was reviewed by the Ethics Committee in Research of the Universidade Federal de of S~ao Paulo (UNIFESP) and was authorized by the institution Universidade Paulista (UNIP), from which the data were collected.
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FIGURE 1. Hoarseness by the time of teaching and the respective P values.
Voice self-evaluation forms, prepared by the Brazilian Ministry of Labor, were completed by 846 university teachers, regardless of type, from a private institution in the city of S~ao Paulo during a 1-month period in 2007. The response rate was 86%. The variables related to hoarseness in teaching that were analyzed were selected from the self-evaluation forms and grouped as follows: Identification variables: age, gender, and time of teaching. Work organization variables: number of institutions, maximum workload during the week, class length, time between classes, maximum number of students per classroom, other professional activities, use of voice in other professional activities, and professional activity that consumes the most time. Workplace variables: noise in the classrooms, air pollution, stress and anxiety because of the activity, and water supply in the institution. Voice care variables: medication for the throat or voice, seeking medical advice because of vocal symptoms, and degree of difficulty in teaching. Habits and style/quality of life outside the institution variables: use of voice, stress and anxiety, drinking water/ hydration, diet, body weight, smoking, alcohol consumption, use of other drugs, continuous-use medication, sports activity, and health care. Differences in hoarseness rates for each variable were considered. Statistical analyses were performed using the SPSS, version 13.0, statistical package for Windows. Student t test was used to compare hoarseness rates for the numeric variables, the chi-square test was used to compare hoarseness for the categorical variables, and Fisher exact or likelihood ratio test was used when necessary. A significance level of 5% (P < 0.05) was used.
RESULTS The incidence of hoarseness in the sample of 846 university teachers is 39.6% (54.6% of the teachers did not have hoarseness, and 5.8% did not answer this question). Identification variables The percentage of hoarseness is higher in females (51.8%) than in males (32.6%). No statistically significant difference in age was observed between patients with and without hoarseness; the age averages and standard deviations were 41.5 (9.4) and 42.5 (9.7), respectively. Additionally, age was analyzed as a qualitative variable by grouping participants into two groups, those who were of 60 years or younger than 60 years and those older than 60 years. Again, no statistically significant difference was observed between patients with or without hoarseness; the percentage of hoarseness in each age group corresponds to 42.6% and 37.8%, respectively. The percentage of hoarseness is lower for those teachers who have spent 1 year or less teaching and higher for those who have taught between 10 and 20 years (Figure 1). Work organization variables The percentage of hoarseness is lower for those teachers with a maximum workload of one to three class hours per day compared with the other workloads (four to six class hours per day, six to eight class hours per day, and more than eight class hours per day) (Figure 2). The percentage of hoarseness is lower for those teachers with a maximum number of students per classroom of less than 30 compared with teachers with a maximum number between 101 and 150 students (Figure 3). No statistically significant differences were observed in the rate of hoarseness for the variables ‘‘number of institutions where you teach,’’ ‘‘duration of the most frequent classes,’’ ‘‘minutes of break,’’ and ‘‘use of the voice in other professional activities’’ (Table 1).
FIGURE 2. Hoarseness by maximum workload during the workweek and the respective P values.
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FIGURE 3. Hoarseness by maximum number of students per classroom and the respective P values.
The percentage of hoarseness is lower for teachers who are involved in other activities besides teaching compared with those who are involved in no other activities. The percentage of hoarse-
ness is higher among those whose professional activity that consumes most of their time was teaching, compared with those who had other activities consume most of their time (Table 1).
TABLE 1. Comparison of the Variables of Work Organization as to Hoarseness Hoarseness
Yes
Number of institutions where you teach 1—One 156 (38.6) 2—Two 127 (45.8) 3—Three 36 (42.4) 4—More than three 16 (57.1) Total 335 (42.2) Duration of the most frequent classes in the workday daily work Less than 40 min 1 (100) 40 min 10 (43.5) 50 min 173 (43.3) 60 min 13 (33.3) 100 min 69 (39.2) More than 100 min 68 (43.9) Total 334 (42.1) Minute of class breaks granted usually Less than 20 310 (41.9) 20–30 23 (46) More than 30 2 (33.3) Total 335 (42.1) Other professional activities besides teaching Yes 217 (39.2) No 117 (48.5) Total 334 (42) Use of the voice in the other professional activities besides teaching 1—The voice is the work tool 0 (0) 2—The voice is important to work 169 (40.1) 3—The voice is secondary to work 41 (34.7) Total 210 (38.9) Professional activity that takes most of the time Professor 213 (47.3) Professor/other 11 (45.8) Other 102 (33.9) Total 326 (42.1) Professor 3 professor/other Professor 3 other Professor/other 3 other Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test.
No
Total
P Value
248 (61.4) 150 (54.2) 49 (57.6) 12 (42.9) 459 (57.8)
404 (100) 277 (100) 85 (100) 28 (100) 794 (100)
0.102*
0 (0) 13 (56.5) 227 (56.8) 26 (66.7) 107 (60.8) 87 (56.1) 460 (57.9)
1 (100) 23 (100) 400 (100) 39 (100) 176 (100) 155 (100) 794 (100)
0.602*
429 (58.1) 27 (54) 4 (66.7) 460 (57.9)
739 (100) 50 (100) 6 (100) 795 (100)
0.775**
337 (60.8) 124 (51.5) 461 (58)
554 (100) 241 (100) 795 (100)
0.017*
1 (100) 252 (59.9) 77 (65.3) 330 (61.1)
1 (100) 421 (100) 118 (100) 540 (100)
0.345**
237 (52.7) 13 (54.2) 199 (66.1) 449 (57.9)
450 (100) 24 (100) 301 (100) 775 (100)
0.001*
1.000* 0.001* 1.000*
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FIGURE 4. Hoarseness by workplace in terms of noise and sound competition and the respective P values.
Workplace variables The percentage of hoarseness is higher among those who work in an uncomfortably or intensely noisy environment compared with those who work in a silent and suitable environment (Figure 4). The percentage of hoarseness is higher among those who work in a moderately or heavily polluted, hot, cold, stuffy, or windy environment than among those who work in a clean, cool, and airy environment or a slightly polluted, hot, cold, stuffy, or windy environment (Figure 5). The percentage of hoarseness is higher among those who work in a moderately or very tense and stressful environment than among those who work in a calm environment (Figure 6). The percentage of hoarseness is higher among those who do not have water available and easily accessible than among those who do have water available and easily accessible (Figure 7). Voice care variables The percentage of hoarseness is higher among those who generally take some care of or medication for the throat or the voice than among those who did not take these actions (Table 2). The percentage of hoarseness is higher among those who seek medical advice because of hoarseness than among those who do not seek medical advice (Table 2). The percentage of hoarseness is higher among those who experience difficulty teaching because of vocal problems (mild, moderate, or severe) than among those who do not experience any difficulty. In addition, among those who experience
difficulty teaching because of vocal problems, the percentage of hoarseness is higher among those with minimal difficulty than among those with moderate or significant difficulty (Table 2). Habits and style/quality of life variables In terms of voice quality inside and/or outside the workplace, the percentage of hoarseness is higher among chattering or impulsive people than among introverts (Table 3). The percentage of hoarseness is higher among those moderately or very stressed and anxious compared with among those who are calm (Table 3). No statistically significant differences were observed in the rate of hoarseness for the variables ‘‘water/hydration,’’ ‘‘diet,’’ ‘‘body weight,’’ ‘‘smoking,’’ ‘‘alcohol consumption,’’ ‘‘use of other drugs,’’ ‘‘continuous-use medication,’’ ‘‘sports activity,’’ and ‘‘health care’’ (Tables 3 and 4).
DISCUSSION The term ‘‘occupational dysphonic syndrome’’ was coined in 2010 by de Almeida and Pontes14 and describes functional dysphonia in the professional voice. There are five symptoms of ODS: (1) hoarseness, (2) pain or irritation in the throat, (3) neck pain, (4) foreign body sensation, and (5) throat cleaning. In the same year, de Almeida et al16 observed that the rate of incidence of symptoms related to ODS in a group of university teachers ranged from 31% to 54%. The present study focused on the hoarseness symptom.
FIGURE 5. Hoarseness by workplace in terms of air pollution and the respective P values.
FIGURE 6. Hoarseness by workplace in terms of stress and anxiety and the respective P values.
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FIGURE 7. Hoarseness for provision of water at ease and easily accessible.
Cantor Cutiva et al,5 in a systematic review, found significant variety in the prevalence of voice disorders and mentioned the following three causes for this finding: the use of generic terms in publications, such as ‘‘vocal complaints’’ and ‘‘vocal symptoms,’’ and the period in which the sample was obtained because a lengthy period leads to a greater number of issues. We propose to assess each of the symptoms of ODS; the additional symptoms and their associated risk factors will be discussed in future publications. Thus, we focused the present study on the specific symptom of hoarseness, and a sample was obtained during a 1month period. Our study was based on a self-evaluation survey and was not an objective evaluation method, such as documentation through a laryngoscopy or a voice laboratory; this selfevaluation survey thus involves the interpretation of individual factors. To reduce the variability because of individual interpretations of the self-evaluation survey, we worked with a group that was as culturally, socially, and regionally homogeneous as
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possible. Our sample included teachers who had undergone graduate education and who were subject to the same work shifts in a single institution under the same environmental conditions in the same city. In the same review, we observe studies comparing elementary education to high school and high school to kindergarten. Interestingly, however, university teachers have not been the subject of previous studies, which limits any comparison between our results and the literature. Moreover, the articles mentioned in the discussion did not use the term hoarseness, which also limits comparisons. We stress the importance of university teachers as a cohort to be studied because they may represent a high level of social and cultural uniformity. We observed an association between the presence of hoarseness and the length of teaching time. However, in previous studies with teachers from kindergarten, elementary school, and high school, no statistical significance was observed for this variable.7,12 There were more females than males in the present study, which is consistent with the study of Russell et al,8 which included teachers from kindergarten, primary, secondary, and area schools. We observed a higher percentage of hoarseness for those teachers with a workload longer than four class hours per day. We assume that, because of financial issues in our country, many teachers also engage in other professional activities, and we found that the percentage of hoarseness in teachers who engage in other professional activities is lower than that of teachers without other professional activities. This finding may be explained by these other activities requiring less frequent use of the voice. Similarly, we observed an association between hoarseness in professionals who work
TABLE 2. Comparison of the Variables of Voice Care as to Hoarseness Hoarseness
Yes
Some usual care or medication for the throat or the voice 1—No 228 (39.7) 2—Yes 107 (49.8) Total 335 (42.4) Seek medical advice because of some of the symptoms previously asked 1—Yes 108 (73.5) 2—No 224 (37.3) Total 332 (44.4) Degree of difficulty in teaching because of vocal issues 1—None—no difficulty, full use of the voice 121 (27.2) 2—Mild—minimal disruption or limitation in the use of the voice 142 (54.4) 3—Moderate—some disruption or limitation in the use of the voice 69 (79.3) 4—Intense—major disruption or limitation in the use of the voice 3 (75) Total 335 (42) 1—None 3 2—mild 1—None 3 3—moderate 1—None 3 4—intense 2—Mild 3 3—moderate 2—Mild 3 4—intense 3—Moderate 3 4—intense Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test. ***Fisher exact test.
P Value
No
Total
347 (60.3) 108 (50.2) 455 (57.6)
575 (100) 215 (100) 790 (100)
0.013*
39 (26.5) 377 (62.7) 416 (55.6)
147 (100) 601 (100) 748 (100)
0.000*
324 (72.8) 119 (45.6) 18 (20.7) 1 (25) 462 (58)
445 (100) 261 (100) 87 (100) 4 (100) 797 (100)
0.000**
0.000* 0.000* 0.049*** 0.000* 0.049*** 1.000***
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Hoarseness and Risk Factors
TABLE 3. Comparison of the Variables of Style/Quality of Life as to Hoarseness Hoarseness In terms of stress and anxiety, you consider yourself as being 1—Calm 2—Slightly stressed and anxious 3—Moderately stressed and anxious 4—Very stressed and anxious Total 1—Calm 3 2—little stressed 1—Calm 3 3—moderately stressed 1—Calm 3 4—very stressed 2—Little stressed 3 3—moderately stressed 2—Little stressed 3 4—very stressed 3—Moderately stressed 3 4—very stressed In terms of water/hydration, you consider yourself as being a person who 1—Drinks a few liquids (forgets or does not feel thirsty, and urinates less than three times daily) 2—Drinks moderately (1–2 L a day) 3—Drinks a lot (more than 2 L a day) 4—Drinks excessively (the need to urinate is frequent and it bothers you) Total In terms of food, you consider yourself as being a person who 1—Eats little (fastens or eats less than three meals a day) 2—Eats moderately (eats three meals a day) 3—Eats a lot (does not control gluttony and realizes that abuses a bit) 4—Eats excessively (feels the stomach full and/or that is losing control) Total In terms of body weight, you qualify as being 1—Lean (underweight) 2—In the ideal weight 3—Slightly overweight 4—Obese (very overweight) Total
Yes
No
Total
P Value
68 (34) 141 (41.5) 94 (49) 32 (50.8) 335 (42.1)
132 (66) 199 (58.5) 98 (51) 31 (49.2) 460 (57.9)
200 (100) 340 (100) 192 (100) 63 (100) 795 (100)
0.011*
0.618* 0.024* 0.049* 0.684* 1.000* 1.000* 60 (42)
83 (58)
143 (100)
0.881**
185 (42.1) 87 (41.6) 3 (60) 335 (42.1)
254 (57.9) 122 (58.4) 2 (40) 461 (57.9)
439 (100) 209 (100) 5 (100) 796 (100)
50 (46.3) 234 (40.8) 48 (46.6) 2 (22.2) 334 (42.1)
58 (53.7) 339 (59.2) 55 (53.4) 7 (77.8) 459 (57.9)
108 (100) 573 (100) 103 (100) 9 (100) 793 (100)
0.325*
11 (36.7) 134 (44.2) 172 (42.5) 17 (29.8) 334 (42)
19 (63.3) 169 (55.8) 233 (57.5) 40 (70.2) 461 (58)
30 (100) 303 (100) 405 (100) 57 (100) 795 (100)
0.215*
Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test.
primarily as a teacher. That is, the greater the dedication to teaching, the higher the chance of hoarseness. We observed an association between hoarseness and the environment in terms of noise and sound competition, and air pollution, as well as an association between hoarseness and stress and anxiety. We agree with Cantor Cutiva et al5 on the need for an objective assessment in the workplace to determine the necessary interventions to improve the environment. Rantala et al,17 studying ergonomic factors in elementary school teachers, observed a correlation between risk factors and scores on vocal symptom questionnaires, and the factor with the strongest correlation was stress. Likewise, Ilom€aki et al18 observed correlations between vocal complaints and air quality, noise, and stress in female primary school teachers. Ahlander et al19 administered a questionnaire to various schools in Sweden and observed correlations between vocal complaints and noise and air quality in the classroom. The finding of an association between water availability and a lower percentage of hoarseness corroborates the
importance that the otolaryngologists place on adequate hydration. We found an association between hoarseness and the presence of some care or medication for the throat or voice as well as an association between hoarseness and the seeking of medical advice. We can infer that professors who exhibit hoarseness are more likely to seek care and treatment for this vocal complaint. However, the percentage of patients with hoarseness seeking medical advice is low (32.5%), a value that is similar to the percentage of elementary teachers (32.6%) who sought medical care in the study by Da Costa et al.7 In the study by Roy et al,10 the percentage of teachers from the elementary and secondary schools who sought medical advice because of vocal complaints was only 14.3%. Thus, our study, and others, demonstrates a low demand for medical advice; the reason for this low demand requires investigation, in addition to a proper orientation for the professor who is under voice care. The degree of difficulty in teaching because of vocal issues is also associated with the percentage of hoarseness.
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TABLE 4. Comparison of the Variables of Live Style as to Hoarseness Hoarseness
Yes
Cigarettes (tobacco) 1—Yes 46 (42.2) 2—No 167 (40.6) 3—Former smoker 63 (45) Total 276 (41.8) Alcohol 1—Yes 92 (38.3) 2—No 229 (43.1) Total 321 (41.6) Other drugs 1—No 304 (41.5) 2—Yes 3 (50) Total 307 (41.6) Continuous-use medication 1—No 236 (42.5) 2—Yes 91 (40.8) Total 327 (42) Practicing sports activity 1—No 168 (45.7) 2—Yes 166 (39.5) Total 334 (42.4) In terms of health care, you consider yourself as being 1—Absent minded 60 (40) 2—Controlled/cautious 236 (42.4) 3—Concerned 35 (47.3) 4—Alarmed 1 (25) Total 332 (42.3)
P Value
No
Total
63 (57.8) 244 (59.4) 77 (55) 384 (58.2)
109 (100) 411 (100) 140 (100) 660 (100)
0.661*
148 (61.7) 302 (56.9) 450 (58.4)
240 (100) 531 (100) 771 (100)
0.242*
428 (58.5) 3 (50) 431 (58.4)
732 (100) 6 (100) 738 (100)
0.697***
319 (57.5) 132 (59.2) 451 (58)
555 (100) 223 (100) 778 (100)
0.720*
200 (54.3) 254 (60.5) 454 (57.6)
368 (100) 420 (100) 788 (100)
0.096*
90 (60) 320 (57.6) 39 (52.7) 3 (75) 452 (57.7)
150 (100) 556 (100) 74 (100) 4 (100) 784 (100)
0.659**
*Chi-square test. **Likelihood ratio test. ***Fisher exact test.
With regard to the habits and style/quality of life inside and/ or outside the workplace, we observed that hoarseness is associated with a greater use of the voice. In addition, tense and anxious professors showed a higher percentage of hoarseness. These findings justify giving care and guidance to university teachers, not only in the workplace but also in any environment. Ohlsson et al,20 through questionnaires, observed that 17% (150) of teachers in the first days of university education had vocal problems. Thus, we note the need for voice care in relation to voice and attention to the risk factors for hoarseness as early as possible. Limitations in this study include the fact that the sample came from a single institution, so these data cannot be generalized to university professors from around the country. Future directions with this line of research include the characterization of the other symptoms of the ODS (pain or irritation in the throat, neck pain, foreign body sensation, and throat cleaning) in university teachers using the same risk factors in the same private institution. CONCLUSION University teachers show high percentage of hoarseness. Factors, such as time of teaching, females, work organization,
workplace, in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life, are related to the presence of hoarseness in this group. REFERENCES 1. Brazilian Society of Otorhinolaryngology; Brazilian Academy of Laryngology and Voice. Voice and work: a matter of health and worker’s rights. 3th National Consensus on Professional Voice; August 13-14, 2004; Rio de Janeiro. 2. Vilkman E. Occupational safety and health aspects of voice and speech professions. Folia Phoniatr Logop. 2004;56:220–253. 3. Instituto Nacional de Estudos e Pesquisas Educacionais Anı´sio Teixeira. Sinopses Estatı´sticas da Educac¸~ao Basica 2009[Internet]. Brası´lia, DF: Instituto Nacional de Estudos e Pesquisas Educacionais; c2011; 2009. Available at: http://portal.inep.gov.br/basica-censo-escolar-sinopse-sinopse. Updated December 20, 2010. Accessed July 17, 2014. 4. Dragone ML, Ferreira LP, Giannini SP, Sim~oes-Zenari M, Vieira VP, Behlau M. Teachers’ voice: a review of 15 years of SLP contribution [Portuguese]. Rev Soc Bras Fonoaudiol. 2010;15:289–296. 5. Cantor Cutiva LC, Vogel I, Burdorf A. Voice disorders in teachers and their associations with work-related factors: a systematic review. J Commun Disord. 2013;46:143–155. 6. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. 1997;11:254–259.
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7. Da Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 8. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467–479. 9. Thomas G, Kooijman PG, Cremers CW, de Jong FI. A comparative study of voice complaints and risk factors for voice complaints in female student teachers and practicing teachers early in their career. Eur Arch Otorhinolaryngol. 2006;263:370–380. 10. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res. 2004;47:281–293. 11. Van Houtte E, Claeys S, Wuyts F, Van Lierde K. The impact of voice disorders among teachers: vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-related absenteeism. J Voice. 2011;25:570–575. 12. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of teachers’ voice problems. J Voice. 1997;11:81–87. 13. 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. 14. de Almeida SI, Pontes P. Dysphonic occupational syndrome: new aspects of this nosological entity [Portuguese]. Arq Int Otorrinolaringol. 2010;14:346–350.
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15. Ministry of Labor and Employment (Brazil). Labor Office in the State Sao Paulo SDT 1 North/SP. Occupational dysphonia program in teachers. S~ao Paulo, Brazil: Labor Office in the State of Sao Paulo, Security Section and Health Worker; 2003. 16. de Almeida SI, Pontes P, Bussacos MA, Neves L, Zambon F. Vocal self assessment questionnaire: epidemiological control tool of the occupational dysphonic syndrome in professors [Portuguese]. Arq Int Otorrinolaringol. 2010;14:316–321. 17. Rantala LM, Hakala SJ, Holmqvist S, Sala E. Connections between voice ergonomic risk factors and voice symptoms, voice handicap, and respiratory tract diseases. J Voice. 2012;26:819.e13–819.e20. 18. Ilom€aki I, Leppanen K, Kleemola L, Tyrmi J, Laukkanen AM, Vilkman E. Relationships between self-evaluations of voice and working conditions, background factors, and phoniatric findings in female teachers. Logoped Phoniatr Vocol. 2009;34:20–31. 19. Ahlander VL, Rydell R, Lofqvist A. Speaker’s comfort in teaching environments: voice problems in Swedish teaching staff. J Voice. 2011;25: 430–440. 20. Ohlsson AC, Andersson EM, Sodersten M, Simberg S, Barregard L. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629–634.
Summary: Purpose. To characterize the presence of hoarseness and the risk factors in male and female university teachers in private institutions in the city of S~ao Paulo, Brazil. Study Design. Cross-sectional survey. Methods. Voice self-evaluation forms prepared by the Brazilian Ministry of Labor were administered to 846 university teachers in a private institution in the city of S~ao Paulo, Brazil. Results. Prevalence of hoarseness in the sample is 39.6%. Percentage of hoarseness is higher in females (51.8%) than in males (32.6%). Comparing hoarseness and time of teaching, it was observed that the percentage of hoarseness is lower in a time shorter or equal to 1 year, and it is higher in a time between 10 and 20 years. Percentage of hoarseness is lower in the maximum workload of one to three class hours per day compared with the other workloads. Percentage of hoarseness is lower when the maximum number of students per classroom is less than 30 than when it is between 101 and 150 students. Other factors like in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life are related to the presence of hoarseness. Conclusion. University teachers show high percentage of hoarseness. Factors, such as time of teaching, females, work organization, workplace, in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life, are related to the presence of hoarseness in this group. Key Words: Teachers–Dysphonia–Risk factors. INTRODUCTION The term ‘‘professional voice users’’ was defined in the Brazilian Consensus of Professional Voice in 2004 as the oral communication used by people who depend on their voice to perform their working activities.1 Approximately, one-third of today’s known professions use the voice to varying degrees.2 Among the professionals who use the voice, teachers, representing more than four million workers in Brazil,3 are the focus of most studies about the professional voice.4 Among the professionals who use the voice, teachers are most likely to develop dysphonia.5,6 Moreover, only one-third of teachers with vocal complaints seek professional assistance.7–9 Teachers have recently been the subject of several studies on the professional voice. Such studies warn of the adverse effects of voice problems on work performance,10,11 suggesting that teaching has a high risk of work-related vocal problems.10,12 In addition, the number of voice complaints is higher in female teachers than in male teachers.8 Behlau et al,13 in an epidemiological study in Brazil, compared vocal symptoms in 1651 teachers of elementary and high schools with 1614 nonteachers. They made the following observations: (1) there was a vocal complaint incidence of 11.6% in teachers and 7.5% in nonteachers, (2) 63% of teachers and 35.8% of nonteachers had vocal problems at some point in life, (3) there was a higher number of vocal symptoms seen in current teachers (average of 3.7) and previous teachers (average of 3.6) compared with nonteachers (1.7 and
Accepted for publication September 8, 2014. From the Department of Otolaryngology, Head and Neck Surgery of Federal, University of S~ao Paulo, S~ao Paulo, Brazil. Address correspondence and reprint requests to Gustavo Polacow Korn, Av. Brigadeiro Faria Lima, 1811 cj 907-908, Jardim Paulistano, S~ao Paulo, SP 01452-001, Brazil. E-mail: [email protected] Journal of Voice, Vol. 29, No. 4, pp. 518.e21-518.e28 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.09.008
2.3), (4) the voice contributed to limitations in the work of 29.9% of teachers and 5.4% of nonteachers, and (5) teachers had higher numbers of absenteeism in the last year and had considered more job changes than nonteachers. The researchers concluded that working at school as a teacher has a high occupational risk for vocal problems. In 2010, de Almeida and Pontes14 introduced the concept of occupational dysphonic syndrome (ODS) by considering the multitude of factors that can cause dysphonia in professional voice use and the numerous symptoms of dysphonia. This range of factors and symptoms explains the discrepancies found in the literature. Regarding the symptoms of ODS, the modification of voice quality that is typically referred to as hoarseness is the symptom most noticed by voice professionals, although this symptom may present with different characteristics, such as roughness, harshness, and breathiness, among others. Thus, in the present study, we will consider this symptom to be an identifying parameter of ODS in university teachers. Several studies include teachers from different segments of school,7,8,10–13 but thus far, we have not found a study specifically addressing university teachers that has used a self-evaluation survey. Thus, it is of interest to use a voice self-evaluation survey, such as that designed by the Brazilian Ministry of Labor, for an epidemiological profile of voice complaints and risk factors in university teachers.15 The objective of this research is to characterize the presence of hoarseness and the risk factors in male and female university teachers in private institutions in the city of S~ao Paulo, Brazil.
METHODS This cross-sectional study was reviewed by the Ethics Committee in Research of the Universidade Federal de of S~ao Paulo (UNIFESP) and was authorized by the institution Universidade Paulista (UNIP), from which the data were collected.
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FIGURE 1. Hoarseness by the time of teaching and the respective P values.
Voice self-evaluation forms, prepared by the Brazilian Ministry of Labor, were completed by 846 university teachers, regardless of type, from a private institution in the city of S~ao Paulo during a 1-month period in 2007. The response rate was 86%. The variables related to hoarseness in teaching that were analyzed were selected from the self-evaluation forms and grouped as follows: Identification variables: age, gender, and time of teaching. Work organization variables: number of institutions, maximum workload during the week, class length, time between classes, maximum number of students per classroom, other professional activities, use of voice in other professional activities, and professional activity that consumes the most time. Workplace variables: noise in the classrooms, air pollution, stress and anxiety because of the activity, and water supply in the institution. Voice care variables: medication for the throat or voice, seeking medical advice because of vocal symptoms, and degree of difficulty in teaching. Habits and style/quality of life outside the institution variables: use of voice, stress and anxiety, drinking water/ hydration, diet, body weight, smoking, alcohol consumption, use of other drugs, continuous-use medication, sports activity, and health care. Differences in hoarseness rates for each variable were considered. Statistical analyses were performed using the SPSS, version 13.0, statistical package for Windows. Student t test was used to compare hoarseness rates for the numeric variables, the chi-square test was used to compare hoarseness for the categorical variables, and Fisher exact or likelihood ratio test was used when necessary. A significance level of 5% (P < 0.05) was used.
RESULTS The incidence of hoarseness in the sample of 846 university teachers is 39.6% (54.6% of the teachers did not have hoarseness, and 5.8% did not answer this question). Identification variables The percentage of hoarseness is higher in females (51.8%) than in males (32.6%). No statistically significant difference in age was observed between patients with and without hoarseness; the age averages and standard deviations were 41.5 (9.4) and 42.5 (9.7), respectively. Additionally, age was analyzed as a qualitative variable by grouping participants into two groups, those who were of 60 years or younger than 60 years and those older than 60 years. Again, no statistically significant difference was observed between patients with or without hoarseness; the percentage of hoarseness in each age group corresponds to 42.6% and 37.8%, respectively. The percentage of hoarseness is lower for those teachers who have spent 1 year or less teaching and higher for those who have taught between 10 and 20 years (Figure 1). Work organization variables The percentage of hoarseness is lower for those teachers with a maximum workload of one to three class hours per day compared with the other workloads (four to six class hours per day, six to eight class hours per day, and more than eight class hours per day) (Figure 2). The percentage of hoarseness is lower for those teachers with a maximum number of students per classroom of less than 30 compared with teachers with a maximum number between 101 and 150 students (Figure 3). No statistically significant differences were observed in the rate of hoarseness for the variables ‘‘number of institutions where you teach,’’ ‘‘duration of the most frequent classes,’’ ‘‘minutes of break,’’ and ‘‘use of the voice in other professional activities’’ (Table 1).
FIGURE 2. Hoarseness by maximum workload during the workweek and the respective P values.
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FIGURE 3. Hoarseness by maximum number of students per classroom and the respective P values.
The percentage of hoarseness is lower for teachers who are involved in other activities besides teaching compared with those who are involved in no other activities. The percentage of hoarse-
ness is higher among those whose professional activity that consumes most of their time was teaching, compared with those who had other activities consume most of their time (Table 1).
TABLE 1. Comparison of the Variables of Work Organization as to Hoarseness Hoarseness
Yes
Number of institutions where you teach 1—One 156 (38.6) 2—Two 127 (45.8) 3—Three 36 (42.4) 4—More than three 16 (57.1) Total 335 (42.2) Duration of the most frequent classes in the workday daily work Less than 40 min 1 (100) 40 min 10 (43.5) 50 min 173 (43.3) 60 min 13 (33.3) 100 min 69 (39.2) More than 100 min 68 (43.9) Total 334 (42.1) Minute of class breaks granted usually Less than 20 310 (41.9) 20–30 23 (46) More than 30 2 (33.3) Total 335 (42.1) Other professional activities besides teaching Yes 217 (39.2) No 117 (48.5) Total 334 (42) Use of the voice in the other professional activities besides teaching 1—The voice is the work tool 0 (0) 2—The voice is important to work 169 (40.1) 3—The voice is secondary to work 41 (34.7) Total 210 (38.9) Professional activity that takes most of the time Professor 213 (47.3) Professor/other 11 (45.8) Other 102 (33.9) Total 326 (42.1) Professor 3 professor/other Professor 3 other Professor/other 3 other Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test.
No
Total
P Value
248 (61.4) 150 (54.2) 49 (57.6) 12 (42.9) 459 (57.8)
404 (100) 277 (100) 85 (100) 28 (100) 794 (100)
0.102*
0 (0) 13 (56.5) 227 (56.8) 26 (66.7) 107 (60.8) 87 (56.1) 460 (57.9)
1 (100) 23 (100) 400 (100) 39 (100) 176 (100) 155 (100) 794 (100)
0.602*
429 (58.1) 27 (54) 4 (66.7) 460 (57.9)
739 (100) 50 (100) 6 (100) 795 (100)
0.775**
337 (60.8) 124 (51.5) 461 (58)
554 (100) 241 (100) 795 (100)
0.017*
1 (100) 252 (59.9) 77 (65.3) 330 (61.1)
1 (100) 421 (100) 118 (100) 540 (100)
0.345**
237 (52.7) 13 (54.2) 199 (66.1) 449 (57.9)
450 (100) 24 (100) 301 (100) 775 (100)
0.001*
1.000* 0.001* 1.000*
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518.e24
FIGURE 4. Hoarseness by workplace in terms of noise and sound competition and the respective P values.
Workplace variables The percentage of hoarseness is higher among those who work in an uncomfortably or intensely noisy environment compared with those who work in a silent and suitable environment (Figure 4). The percentage of hoarseness is higher among those who work in a moderately or heavily polluted, hot, cold, stuffy, or windy environment than among those who work in a clean, cool, and airy environment or a slightly polluted, hot, cold, stuffy, or windy environment (Figure 5). The percentage of hoarseness is higher among those who work in a moderately or very tense and stressful environment than among those who work in a calm environment (Figure 6). The percentage of hoarseness is higher among those who do not have water available and easily accessible than among those who do have water available and easily accessible (Figure 7). Voice care variables The percentage of hoarseness is higher among those who generally take some care of or medication for the throat or the voice than among those who did not take these actions (Table 2). The percentage of hoarseness is higher among those who seek medical advice because of hoarseness than among those who do not seek medical advice (Table 2). The percentage of hoarseness is higher among those who experience difficulty teaching because of vocal problems (mild, moderate, or severe) than among those who do not experience any difficulty. In addition, among those who experience
difficulty teaching because of vocal problems, the percentage of hoarseness is higher among those with minimal difficulty than among those with moderate or significant difficulty (Table 2). Habits and style/quality of life variables In terms of voice quality inside and/or outside the workplace, the percentage of hoarseness is higher among chattering or impulsive people than among introverts (Table 3). The percentage of hoarseness is higher among those moderately or very stressed and anxious compared with among those who are calm (Table 3). No statistically significant differences were observed in the rate of hoarseness for the variables ‘‘water/hydration,’’ ‘‘diet,’’ ‘‘body weight,’’ ‘‘smoking,’’ ‘‘alcohol consumption,’’ ‘‘use of other drugs,’’ ‘‘continuous-use medication,’’ ‘‘sports activity,’’ and ‘‘health care’’ (Tables 3 and 4).
DISCUSSION The term ‘‘occupational dysphonic syndrome’’ was coined in 2010 by de Almeida and Pontes14 and describes functional dysphonia in the professional voice. There are five symptoms of ODS: (1) hoarseness, (2) pain or irritation in the throat, (3) neck pain, (4) foreign body sensation, and (5) throat cleaning. In the same year, de Almeida et al16 observed that the rate of incidence of symptoms related to ODS in a group of university teachers ranged from 31% to 54%. The present study focused on the hoarseness symptom.
FIGURE 5. Hoarseness by workplace in terms of air pollution and the respective P values.
FIGURE 6. Hoarseness by workplace in terms of stress and anxiety and the respective P values.
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FIGURE 7. Hoarseness for provision of water at ease and easily accessible.
Cantor Cutiva et al,5 in a systematic review, found significant variety in the prevalence of voice disorders and mentioned the following three causes for this finding: the use of generic terms in publications, such as ‘‘vocal complaints’’ and ‘‘vocal symptoms,’’ and the period in which the sample was obtained because a lengthy period leads to a greater number of issues. We propose to assess each of the symptoms of ODS; the additional symptoms and their associated risk factors will be discussed in future publications. Thus, we focused the present study on the specific symptom of hoarseness, and a sample was obtained during a 1month period. Our study was based on a self-evaluation survey and was not an objective evaluation method, such as documentation through a laryngoscopy or a voice laboratory; this selfevaluation survey thus involves the interpretation of individual factors. To reduce the variability because of individual interpretations of the self-evaluation survey, we worked with a group that was as culturally, socially, and regionally homogeneous as
Journal of Voice, Vol. 29, No. 4, 2015
possible. Our sample included teachers who had undergone graduate education and who were subject to the same work shifts in a single institution under the same environmental conditions in the same city. In the same review, we observe studies comparing elementary education to high school and high school to kindergarten. Interestingly, however, university teachers have not been the subject of previous studies, which limits any comparison between our results and the literature. Moreover, the articles mentioned in the discussion did not use the term hoarseness, which also limits comparisons. We stress the importance of university teachers as a cohort to be studied because they may represent a high level of social and cultural uniformity. We observed an association between the presence of hoarseness and the length of teaching time. However, in previous studies with teachers from kindergarten, elementary school, and high school, no statistical significance was observed for this variable.7,12 There were more females than males in the present study, which is consistent with the study of Russell et al,8 which included teachers from kindergarten, primary, secondary, and area schools. We observed a higher percentage of hoarseness for those teachers with a workload longer than four class hours per day. We assume that, because of financial issues in our country, many teachers also engage in other professional activities, and we found that the percentage of hoarseness in teachers who engage in other professional activities is lower than that of teachers without other professional activities. This finding may be explained by these other activities requiring less frequent use of the voice. Similarly, we observed an association between hoarseness in professionals who work
TABLE 2. Comparison of the Variables of Voice Care as to Hoarseness Hoarseness
Yes
Some usual care or medication for the throat or the voice 1—No 228 (39.7) 2—Yes 107 (49.8) Total 335 (42.4) Seek medical advice because of some of the symptoms previously asked 1—Yes 108 (73.5) 2—No 224 (37.3) Total 332 (44.4) Degree of difficulty in teaching because of vocal issues 1—None—no difficulty, full use of the voice 121 (27.2) 2—Mild—minimal disruption or limitation in the use of the voice 142 (54.4) 3—Moderate—some disruption or limitation in the use of the voice 69 (79.3) 4—Intense—major disruption or limitation in the use of the voice 3 (75) Total 335 (42) 1—None 3 2—mild 1—None 3 3—moderate 1—None 3 4—intense 2—Mild 3 3—moderate 2—Mild 3 4—intense 3—Moderate 3 4—intense Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test. ***Fisher exact test.
P Value
No
Total
347 (60.3) 108 (50.2) 455 (57.6)
575 (100) 215 (100) 790 (100)
0.013*
39 (26.5) 377 (62.7) 416 (55.6)
147 (100) 601 (100) 748 (100)
0.000*
324 (72.8) 119 (45.6) 18 (20.7) 1 (25) 462 (58)
445 (100) 261 (100) 87 (100) 4 (100) 797 (100)
0.000**
0.000* 0.000* 0.049*** 0.000* 0.049*** 1.000***
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518.e26
Hoarseness and Risk Factors
TABLE 3. Comparison of the Variables of Style/Quality of Life as to Hoarseness Hoarseness In terms of stress and anxiety, you consider yourself as being 1—Calm 2—Slightly stressed and anxious 3—Moderately stressed and anxious 4—Very stressed and anxious Total 1—Calm 3 2—little stressed 1—Calm 3 3—moderately stressed 1—Calm 3 4—very stressed 2—Little stressed 3 3—moderately stressed 2—Little stressed 3 4—very stressed 3—Moderately stressed 3 4—very stressed In terms of water/hydration, you consider yourself as being a person who 1—Drinks a few liquids (forgets or does not feel thirsty, and urinates less than three times daily) 2—Drinks moderately (1–2 L a day) 3—Drinks a lot (more than 2 L a day) 4—Drinks excessively (the need to urinate is frequent and it bothers you) Total In terms of food, you consider yourself as being a person who 1—Eats little (fastens or eats less than three meals a day) 2—Eats moderately (eats three meals a day) 3—Eats a lot (does not control gluttony and realizes that abuses a bit) 4—Eats excessively (feels the stomach full and/or that is losing control) Total In terms of body weight, you qualify as being 1—Lean (underweight) 2—In the ideal weight 3—Slightly overweight 4—Obese (very overweight) Total
Yes
No
Total
P Value
68 (34) 141 (41.5) 94 (49) 32 (50.8) 335 (42.1)
132 (66) 199 (58.5) 98 (51) 31 (49.2) 460 (57.9)
200 (100) 340 (100) 192 (100) 63 (100) 795 (100)
0.011*
0.618* 0.024* 0.049* 0.684* 1.000* 1.000* 60 (42)
83 (58)
143 (100)
0.881**
185 (42.1) 87 (41.6) 3 (60) 335 (42.1)
254 (57.9) 122 (58.4) 2 (40) 461 (57.9)
439 (100) 209 (100) 5 (100) 796 (100)
50 (46.3) 234 (40.8) 48 (46.6) 2 (22.2) 334 (42.1)
58 (53.7) 339 (59.2) 55 (53.4) 7 (77.8) 459 (57.9)
108 (100) 573 (100) 103 (100) 9 (100) 793 (100)
0.325*
11 (36.7) 134 (44.2) 172 (42.5) 17 (29.8) 334 (42)
19 (63.3) 169 (55.8) 233 (57.5) 40 (70.2) 461 (58)
30 (100) 303 (100) 405 (100) 57 (100) 795 (100)
0.215*
Notes: Significant values in bold. *Chi-square test. **Likelihood ratio test.
primarily as a teacher. That is, the greater the dedication to teaching, the higher the chance of hoarseness. We observed an association between hoarseness and the environment in terms of noise and sound competition, and air pollution, as well as an association between hoarseness and stress and anxiety. We agree with Cantor Cutiva et al5 on the need for an objective assessment in the workplace to determine the necessary interventions to improve the environment. Rantala et al,17 studying ergonomic factors in elementary school teachers, observed a correlation between risk factors and scores on vocal symptom questionnaires, and the factor with the strongest correlation was stress. Likewise, Ilom€aki et al18 observed correlations between vocal complaints and air quality, noise, and stress in female primary school teachers. Ahlander et al19 administered a questionnaire to various schools in Sweden and observed correlations between vocal complaints and noise and air quality in the classroom. The finding of an association between water availability and a lower percentage of hoarseness corroborates the
importance that the otolaryngologists place on adequate hydration. We found an association between hoarseness and the presence of some care or medication for the throat or voice as well as an association between hoarseness and the seeking of medical advice. We can infer that professors who exhibit hoarseness are more likely to seek care and treatment for this vocal complaint. However, the percentage of patients with hoarseness seeking medical advice is low (32.5%), a value that is similar to the percentage of elementary teachers (32.6%) who sought medical care in the study by Da Costa et al.7 In the study by Roy et al,10 the percentage of teachers from the elementary and secondary schools who sought medical advice because of vocal complaints was only 14.3%. Thus, our study, and others, demonstrates a low demand for medical advice; the reason for this low demand requires investigation, in addition to a proper orientation for the professor who is under voice care. The degree of difficulty in teaching because of vocal issues is also associated with the percentage of hoarseness.
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TABLE 4. Comparison of the Variables of Live Style as to Hoarseness Hoarseness
Yes
Cigarettes (tobacco) 1—Yes 46 (42.2) 2—No 167 (40.6) 3—Former smoker 63 (45) Total 276 (41.8) Alcohol 1—Yes 92 (38.3) 2—No 229 (43.1) Total 321 (41.6) Other drugs 1—No 304 (41.5) 2—Yes 3 (50) Total 307 (41.6) Continuous-use medication 1—No 236 (42.5) 2—Yes 91 (40.8) Total 327 (42) Practicing sports activity 1—No 168 (45.7) 2—Yes 166 (39.5) Total 334 (42.4) In terms of health care, you consider yourself as being 1—Absent minded 60 (40) 2—Controlled/cautious 236 (42.4) 3—Concerned 35 (47.3) 4—Alarmed 1 (25) Total 332 (42.3)
P Value
No
Total
63 (57.8) 244 (59.4) 77 (55) 384 (58.2)
109 (100) 411 (100) 140 (100) 660 (100)
0.661*
148 (61.7) 302 (56.9) 450 (58.4)
240 (100) 531 (100) 771 (100)
0.242*
428 (58.5) 3 (50) 431 (58.4)
732 (100) 6 (100) 738 (100)
0.697***
319 (57.5) 132 (59.2) 451 (58)
555 (100) 223 (100) 778 (100)
0.720*
200 (54.3) 254 (60.5) 454 (57.6)
368 (100) 420 (100) 788 (100)
0.096*
90 (60) 320 (57.6) 39 (52.7) 3 (75) 452 (57.7)
150 (100) 556 (100) 74 (100) 4 (100) 784 (100)
0.659**
*Chi-square test. **Likelihood ratio test. ***Fisher exact test.
With regard to the habits and style/quality of life inside and/ or outside the workplace, we observed that hoarseness is associated with a greater use of the voice. In addition, tense and anxious professors showed a higher percentage of hoarseness. These findings justify giving care and guidance to university teachers, not only in the workplace but also in any environment. Ohlsson et al,20 through questionnaires, observed that 17% (150) of teachers in the first days of university education had vocal problems. Thus, we note the need for voice care in relation to voice and attention to the risk factors for hoarseness as early as possible. Limitations in this study include the fact that the sample came from a single institution, so these data cannot be generalized to university professors from around the country. Future directions with this line of research include the characterization of the other symptoms of the ODS (pain or irritation in the throat, neck pain, foreign body sensation, and throat cleaning) in university teachers using the same risk factors in the same private institution. CONCLUSION University teachers show high percentage of hoarseness. Factors, such as time of teaching, females, work organization,
workplace, in terms of noise and sound competition, air pollution, and in terms of causing stress and anxiety, besides habits and style/quality of life, are related to the presence of hoarseness in this group. REFERENCES 1. Brazilian Society of Otorhinolaryngology; Brazilian Academy of Laryngology and Voice. Voice and work: a matter of health and worker’s rights. 3th National Consensus on Professional Voice; August 13-14, 2004; Rio de Janeiro. 2. Vilkman E. Occupational safety and health aspects of voice and speech professions. Folia Phoniatr Logop. 2004;56:220–253. 3. Instituto Nacional de Estudos e Pesquisas Educacionais Anı´sio Teixeira. Sinopses Estatı´sticas da Educac¸~ao Basica 2009[Internet]. Brası´lia, DF: Instituto Nacional de Estudos e Pesquisas Educacionais; c2011; 2009. Available at: http://portal.inep.gov.br/basica-censo-escolar-sinopse-sinopse. Updated December 20, 2010. Accessed July 17, 2014. 4. Dragone ML, Ferreira LP, Giannini SP, Sim~oes-Zenari M, Vieira VP, Behlau M. Teachers’ voice: a review of 15 years of SLP contribution [Portuguese]. Rev Soc Bras Fonoaudiol. 2010;15:289–296. 5. Cantor Cutiva LC, Vogel I, Burdorf A. Voice disorders in teachers and their associations with work-related factors: a systematic review. J Commun Disord. 2013;46:143–155. 6. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. 1997;11:254–259.
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7. Da Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 8. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467–479. 9. Thomas G, Kooijman PG, Cremers CW, de Jong FI. A comparative study of voice complaints and risk factors for voice complaints in female student teachers and practicing teachers early in their career. Eur Arch Otorhinolaryngol. 2006;263:370–380. 10. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res. 2004;47:281–293. 11. Van Houtte E, Claeys S, Wuyts F, Van Lierde K. The impact of voice disorders among teachers: vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-related absenteeism. J Voice. 2011;25:570–575. 12. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of teachers’ voice problems. J Voice. 1997;11:81–87. 13. 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. 14. de Almeida SI, Pontes P. Dysphonic occupational syndrome: new aspects of this nosological entity [Portuguese]. Arq Int Otorrinolaringol. 2010;14:346–350.
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15. Ministry of Labor and Employment (Brazil). Labor Office in the State Sao Paulo SDT 1 North/SP. Occupational dysphonia program in teachers. S~ao Paulo, Brazil: Labor Office in the State of Sao Paulo, Security Section and Health Worker; 2003. 16. de Almeida SI, Pontes P, Bussacos MA, Neves L, Zambon F. Vocal self assessment questionnaire: epidemiological control tool of the occupational dysphonic syndrome in professors [Portuguese]. Arq Int Otorrinolaringol. 2010;14:316–321. 17. Rantala LM, Hakala SJ, Holmqvist S, Sala E. Connections between voice ergonomic risk factors and voice symptoms, voice handicap, and respiratory tract diseases. J Voice. 2012;26:819.e13–819.e20. 18. Ilom€aki I, Leppanen K, Kleemola L, Tyrmi J, Laukkanen AM, Vilkman E. Relationships between self-evaluations of voice and working conditions, background factors, and phoniatric findings in female teachers. Logoped Phoniatr Vocol. 2009;34:20–31. 19. Ahlander VL, Rydell R, Lofqvist A. Speaker’s comfort in teaching environments: voice problems in Swedish teaching staff. J Voice. 2011;25: 430–440. 20. Ohlsson AC, Andersson EM, Sodersten M, Simberg S, Barregard L. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629–634.
