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Risk Factors for Recurrent Perceived Voice Disorders in Elementary School Teachers—A Longitudinal Study
ARTICLE IN PRESS
Risk Factors for Recurrent Perceived Voice Disorders in Elementary School Teachers—A Longitudinal Study *Luise Marques da Rocha, †Mara Behlau, and *Luciano Dias de Mattos Souza, *Pelotas, and yS~ao Paulo, Brazil Summary: Objective. To identify the progression of voice disorders and their risk factors in teachers. Design. Longitudinal quantitative study conducted in municipal schools. Method. Of the 575 teachers who participated in the baseline study, 469 were re-evaluated after 3 years of the initial study. Out of these, 152 reported having a voice disorder at baseline and participated in the re-evaluation. Voice disorders were diagnosed with the Voice Handicap Index (VHI) and teachers were considered positive for voice disorders when the total score was above 19. Symptoms of common mental disorder were measured with the SRQ-20 scale (Self-Reporting Questionnaire, 20 items), with a cut-off value of 8 points. A bivariate analysis was performed using Poisson regression to verify the differences in the proportion of teachers who continued presenting a voice disorder among the different categories of the independent variables in the study. Results. A total of 69.1% of the teachers reported having a voice disorder after 3 years. High prevalence of acute common mental disorder symptoms was a predictor for a recurring perceived voice disorder. The risk of having a voice disorder was 30% higher for teachers who presented a common mental disorder 3 years after. Conclusions. Teachers who had both a voice disorder and symptoms of common mental disorder were more likely to maintain the voice disorder. Key Words: Longitudinal study−Teacher’s voices−Voice disorders.
INTRODUCTION Professionals who use their voice to work are the most affected by concerns about their own voice. Within this group, teachers are at the highest risk of developing voice problems since they are exposed to many risk factors.1-3 Ultimately, voice problems limit their professional performance1-3 and may lead to a voice disorder. Psychiatric disorders as well as voice disorders cause absence and/or leaving in teachers.1,5-13 Voice changes have diverse etiologies.14,15 Their effects alter the teacher's voice and lead to emotional, social, and functional restrictions. Verbal communication becomes limited. Negative consequences on the teacher’s career and quality of life may ensue.2,5,15-17 Previous research has shown that it is mainly in preschools and elementary schools5 that teachers are exposed factors that lead to voice disorder. These factors may result from chemical, physical, or biological exposure.5,18 A teacher’s working conditions often include intense vocal demands and unfavorable work environment.19 These issues are worsened by a lack of knowledge and training in public speaking, inadequate working environment, daily pressure, few breaks, low pay, lack of financial and social recognition, and professional frustration.9 Previous investigations of teachers’ voices have tried to identify responsible factors contributing to their voice Accepted for publication August 28, 2019. From the *Programa de P os Gradua¸c ~ao em Sa ude e Comportamento da Universidade Cat olica de Pelotas, Pelotas, Rio Grande do Sul, Brazil; and the yPrograma de P os Gradua¸c ~ ao em Dist urbios da Comunica¸c ~ao Humana da Universidade Federal de S~ao Paulo, S~ ao Paulo, S~ ao Paulo, Brazil. Address correspondence and reprint requests to Luciano Dias de Mattos Souza, Programa de P os Gradua¸c ~ ao em Sa ude e Comportamento da Universidade Cat olica de Pelotas, Rua Gon¸c alves Chaves 373, Sala 418C, Pelotas, Rio Grande do Sul 96015-560, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.08.030
disorders. However, it is still not possible to conclusively determine the relationship between voice disorders and teaching, as voice disorders have a multifactorial etiology.1,14,15 Studies show that teachers with vocal problems are likely to develop emotional problems that often put their careers at risk.6,18,20 In Brazil, epidemiological studies of teachers’ voices indicate that between 54% and 79% of teachers report voice problems.7,8,10 Recent studies indicate that the relationship between voice disorders and emotional factors has become more evident.7,10,14,17 Recurrence of a voice disorder may lead to chronicity, causing, in turn, several other biological, physical, or emotional changes.1,2,6,8,10,17,21-23 Having an episode of vocal impairment can lead to consequences that are not perceived by the individual, especially teachers. Teachers are often unaware of professional help availability.24,25 Therefore, there is a high incidence of voice disorders among teachers.19 Once a voice disorder becomes chronic, teachers may be removed from the classroom and may even be forced to consider changing their occupation.6 A study of self-reported acute and chronic voice disorders in 226 teachers found that 38.9% reported no voice disorders, 35.4% reported an acute disorder, and 25.7% reported a chronic disorder.26 Schwartz et al27 concluded that one of the most common symptoms of a voice disorder is hoarseness. Hoarseness affects nearly one-third of the general population at some point in their lives. If hoarseness persists for more than 3 consecutive or even nonconsecutive months, but for a long time or in a recurring fashion, it can be defined as a chronic event, with greater occurrence in voice professionals.27 There is a lack of longitudinal studies of teachers’ voice disorders in the literature. There are also inconsistencies about what the risk factors are for the recurrence of voice disorders. Therefore, the purpose of this study was to evaluate risk
ARTICLE IN PRESS 2 factors for the presence of voice disorders over a 3-year period in teachers, focusing on the relationship between voice disorders and self-reporting of a mental disorder. METHOD The Committee of Ethics and Research of the Universidade Cat olica de Pelotas (protocols # 2011/29 and 18713613.6.0000.5339) approved this research. An observational longitudinal study was conducted. Sampling design was made through a reassessment of teachers who participated in the first research study.4 Initially, between August and December 2011, 633 teachers were invited to participate, 575 being interviewed.28 Later, between August and December 2014, the same teachers were contacted for a reassessment. The second assessment included 469 teachers (81.56%). Among the 106 teachers who did not participate, 60 were not found, 15 refused to participate, 11 were on leave of absence due to health issues or lacked interest, 10 were retired, 5 were exonerated, 4 found another profession, and 1 was excluded. After the second evaluation, statistical power was calculated, taking into consideration the proportion of teachers who still reported voice disorders and teachers who reported improvement. The confidence interval was 95% and statistical power was 59.9%. The research team consisted of two professors, graduate students, and two volunteers, all of them from the Center of Life and Health Sciences of the Universidade Cat olica de Pelotas (UCPel) that identified the teachers for the study. A self-report questionnaire was used for information gathering. It contained questions referring to sociodemographic, environmental, behavioral, emotional, and voice characteristics of the teachers. Socioeconomic status was measured using the Economic Indicator for Brazilians (IEN), based on the demographic census of 2000.29 The sample was divided in tertiles and classified in three groups: low, intermediate, and high socioeconomic conditions. A self-assessment of voice disorders was obtained from the Voice Handicap Index (VHI),30 validated for Brazilian Portuguese by Behlau et al.31 Results were considered positive for voice disorders when the total score was above 19.32 Finally, the Self-Reporting Questionnaire that has 20 items (SRQ-20) was administered to screen for psychiatric disorder symptomatology, such as anxiety, mood, and somatoform symptoms. The SRQ is a questionnaire that was originally developed by the World Health Organization in 1994 for the purpose of screening for common mental disorders (CMD) in primary care settings.33 However, it does not replace a diagnostic instrument. This instrument has been validated for the Brazilian population by Mari and Williams.33 In the present study, participants with a score of 8 or higher are considered positive for common psychiatric disorders.34 Teachers were informed about research objectives and signed a term of informed consent. Participants who
Journal of Voice, Vol. &&, No. &&, 2019
exhibited voice and/or psychological symptoms were referred for treatment at the Reference Center on Worker’s Health (CEREST Macrosul), bound to the Municipal Health Secretary of Pelotas. Data were processed using the EpiData program. In order to ensure accuracy, data were entered twice. The automatic verification of information consistency was conducted with the EpiData software and some mistakes were corrected. Statistical analyses were done with the Stata 9.0 and SPSS 21.0 programs. During the second assessment, 29 participants did not answer some VHI items. Lost information was substituted with the sample’s mean value for each item. A univariate analysis was performed using the description of the variables’ simple frequencies, average, and standard deviations. Following the univariate analysis, a bivariate analysis was conducted, using the Poisson regression, to verify the difference in the incidence of voice disorders within the different categories of the independent variables. The Poisson regression was also used to evaluate the risk of recurrence of perceived voice disorders in a hierarchical model composed of two variables (teaching time and high CMD symptoms).35 Results were P ≤ 0.20 in the bivariate analyzes and, therefore, these two variables were included in the multivariate analysis. The significance levels were maintained at P < 0.05. RESULTS Table 1 includes sociodemographic and socioeconomic status, work conditions, voice disorder, and presence of common mental disorder symptomology. The sample of participants who presented a voice disorder during the first stage of the research and after 3 years in the re-evaluation was composed of 152 teachers. Among these, 69.1% (n = 105) had a recurrent perceived vocal disorder. Most of them were teachers (94.7%), over the age of 40 (60%), graduated high school (52.3%), had a higher socioeconomic status (35.1%), had a weekly teaching time between 21 and 40 hours (61.7%), were teaching from the fifth grade up (66.2%), and had more than 25 students in the classroom (79.1%). Among these participants, most of them had been teaching from 11 to 20 years, 78.1% reported quitting teaching due to voice disorders, 28.8% reported an important disease (rhinitis, laryngitis, gastroesophageal reflux, hormonal disorder), and 41.4% reported symptoms of common mental disorders. Table 2 shows that gender, age, educational level, socioeconomic level, workload, elementary school teaching up to the fourth grade, number of students per class, voice, and self-reported diseases had no association with the recurrence of the perceived voice disorder. However, teaching time and the presence of common mental disorder symptoms proved to be significant. The adjusted analysis (Table 3) shows that teaching (up to 10 years, between 11 and 20 years, more than 20 years) has no relation with the recurrence of perceived vocal disorders. The presence of reported common mental disorder
ARTICLE IN PRESS Luise Marques da Rocha, et al
TABLE 1. Characteristics of Elementary School Teachers of Pelotas (Brazil) Who Showed Indications of a Voice Disorder in 2011 and Were Reassessed in 2014 Variable
3
Voice Disorders in Elementary School Teachers
%
Gender Female 94.7 Male 5.3 Age (y)* Up to 40 40.0 41 or more 60.0 Schooling* Secondary school, teaching 9.3 and secondary school incomplete Secondary school, teaching and 38.4 secondary school incomplete Postgraduate 52.3 Socioeconomic status* Disadvantaged 31.6 Intermediate 33.3 Most favored 35.1 Workload (hours)* Up to 20 18.1 From 21 to 40 61.7 More than 40 20.1 Initial grades (lectures up to fourth grade) Yes 33.8 No 66.2 Number of students in class* Up to 25 students 79.1 26 or more students 20.9 Time teaching (y)* Up to 10 32.2 From 11 to 20 38.3 More than 20 29.5 Leave due to voice* Yes 78.1 No 21.9 Self-reported illness* Yes 28.8 No 71.2 High symptoms of common mental disorder* Yes 41.4 No 58.6 Total 100
TABLE 2. Factors Associated With Perceived Voice Disorder Recurring in Elementary School Teachers of Pelotas (Brazil) Through Poisson Regression
n 144 8 60 90 14 58 79 36 38 40 27 92 30 51 100 110 29 48 57 44 118 33 42 104 63 89 152
* Valid percentages.
Variable
Perceived Voice Disorder RR (IC 95%)
Age Female Reference Male 1.17 (0.84 a 1.63) Age (y) Up to 40 Reference 41 or more 1.08 (0.86 a 1.34) Schooling Secondary school, Reference teaching and secondary school incomplete College undergraduate 1.09 (0.71 a 1.68) Postgraduate 1.08 (0.71 a 1.22) Socioeconomic status Disadvantaged Reference Intermediate 0.93 (0.68 a 1.27) Most favored 0.92 (0.69 a 1.40) Workload (h) Up to 20 Reference From 20 to 40 0.95 (0.71 a 1.26) More than 40 1.06 (0.76 a 1.47) Initial grades (lectures up to fourth grade) Yes 0.97 (0.77 a 1.21) No Reference Number of students per class Up to 25 Reference 26 or more 0.86 (0.66 a 1.12) Time teaching (y) Up to 10 Reference From 11 to 20 0.99 (0.76 a 1.32) More than 20 1.23 (0.97 a 1.55) Leave due to voice Yes 1.06 (0.84 a 1.33) No Reference Self-reported illness Yes 0.93 (0.75 a 1.17) No Reference High symptoms of common mental disorder Yes 1.30 (1.00 a 1.71) No Reference
P Value
0.349
0.486
0.662 0.583
0.563 0.883
0.734 0.702
0.812
0.282
0.986 0.093
0.579
0.575
0.049
IC, confidence interval; RR, relative risk.
symptoms, however, is shown to be significant, since the percentage of teachers who reported having a voice problem is 30% higher if they also reported a common mental disorder (P < 0.059). DISCUSSION This research sought to identify risk factors that contribute to the perception of a recurrent vocal disorder. Results show that teachers who have acute symptoms of common mental disorders have a tendency to experience
voice problems. This is the first longitudinal study that investigated the prevalence of a recurring voice disorder in teachers. Cross-sectional studies have repeatedly shown the alarming situation of teachers’ voices worldwide.6-8,14,17,18 This study shows that teachers who reported having a voice disorder and acute symptoms of a common mental disorder tend to have a persisting voice disorders for 3 years.
ARTICLE IN PRESS 4
Journal of Voice, Vol. &&, No. &&, 2019
TABLE 3. Risk Factors of Perceived Voice Disorder Recurring in Elementary School Teachers of Pelotas (Brazil) Through Poisson Regression Relative Risk for Voice Disorder
Confidence Interval 95%
Time teaching (y) Up to 10 0.99 0.75 a 1.31 From 11 to 20 1.20 0.95 a 1.51 More than 20 Reference High symptoms of common mental disorder Yes 1.31 0.99 a 1.73 No Reference
P Value 0.955 0.126
0.058
Acute symptoms of common mental disorders are likely to prolong voice disorders. A cross-sectional study conducted in 2012 showed a close association between voice problems and mental disorders.20 Other studies have also highlighted the relation between vocal disorders and mental health, and described the associated factors; the designs of these studies, however, do not allow their authors to conclude on the cause effect.1,4,7,11,14 Prior to this study, only two longitudinal studies analyzed the relation between voice disorders and mental disorders.36,37 Neither of these studies found any recurrence of voice disorders with associated factors. Specifically, Moy et al did not provide results associated with voice health36 while Meulenbroek et al concluded that factors of psychosomatic well-being could play an important role in teachers’ voice disorders.37 Based on previous studies and the results of this study, we observed that the dysfunctions that affect teachers with self-described mental disorders may compromise adequate teaching. Although teachers with vocal complaints use various strategies for dealing with their voice problems, previous studies have shown that the use of these strategies did not lead to better outcomes for their voice problems.37,38-41 Thus, it is important to highlight that perceived voice limitations must be further studied in teachers who report having a common mental disorder. It is important to point out the limitations in this study. There was a loss of 106 teachers. In addition, we did not assess if participants underwent mental health treatment between evaluations. In addition, our data rely solely on self-assessment instruments. These instruments represent the viewpoint of the individual who lives with or without a voice problem; it does not include any clinical evaluation data or psychological/speech assessment. Nevertheless, they do represent a reliable measure to identify participants who present higher risk for vocal damage or impairment, even though neither the VHI nor the SRQ have diagnostic value. Individuals identified with voice or mental symptoms in such questionnaires should be better evaluated with more accurate assessments tools. Finally, we did not follow these
teachers during the 3-year period. Thus, they may have resolved their initial voice disorder at some point and developed a voice disorder prior to the second assessment period 3 years later. Based on the results of this study, further research should seek to understand the specific behaviors that increase the occurrence of mental and vocal disorders in this population, as well as evaluate preventative measures for teachers. CONCLUSION Teachers who suffer from a voice disorder and acute common mental disorder symptoms tend to have persisting voice disorders. These may be referred to as recurring or chronic voice disorders. REFERENCES 1. Smith E, Lemke J, Taylor M, et al. Frequency of voice problems among teachers and other occupations. J Voice. 1998;12:480–488. 2. Gassull C, Casanova C, Botey Q, et al. The impact of the reactivity to stress in teachers with voice problems. J Folia Phoniatrica et Logopaedica. 2010;62:35–39. 3. De Medeiros AM, Assun¸c ~ao AA, Barreto SM. Absenteeism due to voice disorders in female teachers: a public health problem. Int Arch Occup Environ Health. 2012;85:853–864. 4. Houtte EV, Claeys S, Wuyls F, et al. Voice disorders in teachers: occupational risk factors and psycho-emotional factors. Logoped Phoniatr Vocol. 2012;37:107–116. 5. Gianinni SPP, Latorre MRDO, Ferreira LP. Dist urbio de voz e estresse no trabalho docente: um estudo caso-controle. Cad de Saude Publica. 2012;28:2115–2124. 6. Behlau M, Zambon F, Guerrieri AC, et al. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26. 665.e9-18. 7. Amorim SNMC. Dist urbio vocal e estresse: os efeitos do trabalho na sa ude de professores/as do ensino fundamental de Goi^ania [disserta¸c ~ao-mestrado]. Universidade Catolica de Goias. 2006;1:1–121. 8. Guimar~aes I. Os problemas de voz nos professores: preval^encia, causas, efeitos e formas de preven¸c ~ao. Revista Portuguesa de Saude Publica. 2004;22:33–41. 9. Behlau M. Organizadora. Voz: o livro do Especialista. 2. Rio de Janeiro: Revinter; 2005. 10. Centro de Refer^encia em Sa ude do Trabalhador, Coordenadoria de controle de doen¸c as, Secretaria de Estado da sa ude de S~ao Paulo (CEREST, CCD, SES-SP). Boletim epidemiol ogico paulista - informe mensal sobre agravo a sa ude p ublica2006; (26). 11. Martins MGT. Sintomas de estress em professores brasileiros. Revista Lusofona de Educa¸c ~ao. 2007;10:109–128. 12. Emsley R, Emsley L, Seedat S. Occupational disability on psychiatric grounds in South African school-teachers. Afr J Psychiatry. 2009;12:223–226. 13. Behlau M, Pontes P. Avalia¸c ~ao e tratamento das disfonias. S~ao Paulo: Lovil; 1995. 14. Nerriere E, Vercambre MN, Gilbert F, et al. Voice disorders and mental health in teachers: a cross-sectional nationwide study. J BMC Public Health. 2009;9:1–8. 15. Simberg S, Sala E, Vehmas K, et al. Changes in the prevalence of vocal symptoms among teachers during twelve-year period. J Voice. 2005;19:95–102. 16. Behlau M, Park K. Perda da voz em professores e n~ao professores. Revista Sociedade Brasileira de Fonoaudiologia. 2009;14:463–469. 17. Alvear RMB, Martinez-Arquero G, Bar on FJ, et al. An interdisciplinary approach to teachers’ voice disorders and psychosocial working conditions. J Folia Phoniatrica et Logopaedica. 2010;64:24–34.
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Voice Disorders in Elementary School Teachers
18. Roy N, Merrill RM, Thibeault S, et al. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47:542–552. 19. Giannini SP, Latorre Mdo R, Fischer FM, et al. Teacher’s voice disorders and loss of work ability: a case-control study. J Voice. 2015;29:209–217. https://doi.org/10.1016/j.jvoice.2014.06.004. Epub 2014 Dec 9. 20. Rocha LM, Souza LDM. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. 21. De Ceballos AGC. Apoio social e fatores associados com a disfonia em professores. Salvador: Tese [Doutorado em Sa ude Coletiva] - Instituto Sa ude Coletiva da UFBA; 2009. 22. Giannini SPP. Dist urbio de voz relacionado ao trabalho docente: um estudo caso-controle. S~ao Paulo: Tese [Doutorado em Sa ude P ublica]. Faculdade de Sa ude P ublica da USP; 2010. 23. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med. 2008;58:74–76. 24. Da Costa V, Prada E, Roberts A, et al. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 25. e Seligmann-Silva E. Uma hist oria de “crise de nervos”: sa ude mental e trabalho. (org.). In: Rocha, Rigotto, Buschinelli, eds. Isto e trabalho de gente? Vida, doen¸c a e trabalho no Brasil. S~ao Paulo: Vozes; 1993:609–635. 26. Rossi-Barbosa LA, Barbosa MR, Morais RM, et al. Self-reported acute and chronic voice disorders in teachers. J Voice. 2015. Available from: http://dx.doi.org/10.1016/j.jvoice.2015.08.003. 27. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3S2): S1–S31. 28. Rocha LM, Souza LDM. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. 29. Barros AJD, Victora CG. Indicador econ^ omico para o Brasil baseado no censo demogr afico de 2000. Revista de Saude Publica. 2005;39:523– 529. 30. 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.
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31. Behlau M, Oliveira G, Santos LMA, et al. Valida¸c ~ao no Brasil de protocolos de auto-avalia¸c ~ao do impacto de uma disfonia.Barueri-SP. Revista Pro-fono de Atualiza¸c ~ao Científica. 2009;21:326–332. 32. Behlau M, Madazio G, Moreti F, et al. Efficiency and cutoff values of self-assessment instruments on the impact of voice problem. J Voice. 2015. Published Online: July 11. 33. Mari JJ, Williams P. A validity study of a psychiatric screening questionnaire (SRQ-20) in primary care in the city of S~ao Paulo. Br J Psychiatry. 1986;148:23–26. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/3955316. 34. Gon¸c alves DM, Stein AT, Kapczinski F. Avalia¸c ~ao de desempenho do self-reporting questionnaire como instrumento de rastreamentopsiquiatrico: um estudo comparativo com o structured clinical interview for DSM-IV-TR. Cad Saude Publica Rio de Janeiro. 2008;24:380–390. 35. Barros AJ, Hirakata VN. Alternatives for regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. 36. Moy FM, Hoe VC, Hairi NN, et al. Cohort study on clustering of lifestyle risk factors and understanding its association with stress on health and wellbeing among school teachers in Malaysia (CLUSTer)—a study protocol. BMC Public Health. 2014;14:611. 37. Meulenbroek LFP, de Jong FICRS. Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study. Folia phoniatr Logop. 2010;62:47–54. 38. Epstein R, Hirani SP, Stygall J, et al. How do individuals cope with voice disorders? Introducing the Voice Disability Coping Questionnaire. J Voice. 2008;23:209–217. 39. McHugh-Munier C, Scherer KR, Lehmann W, et al. Coping strategies, personality, and voice quality in patients with vocal fold nodules and polyps. J Voice. 1997;11:452–461. 40. Van Opstal MJMC. A systematic, holistic and integrative process of self-control for voicing with optimal coping effects in teachers. 1. A process of awareness an expert’s opinion. Folia Phoniatr Logop. 2010;62:61–70. 41. Meulenbroek LF, Thomas G, Kooijman PG, et al. Biopsychosocial impact of the voice in relation to the psychological features in female student teachers. J Psychosom Res. 2010;68:379–384.
Risk Factors for Recurrent Perceived Voice Disorders in Elementary School Teachers—A Longitudinal Study *Luise Marques da Rocha, †Mara Behlau, and *Luciano Dias de Mattos Souza, *Pelotas, and yS~ao Paulo, Brazil Summary: Objective. To identify the progression of voice disorders and their risk factors in teachers. Design. Longitudinal quantitative study conducted in municipal schools. Method. Of the 575 teachers who participated in the baseline study, 469 were re-evaluated after 3 years of the initial study. Out of these, 152 reported having a voice disorder at baseline and participated in the re-evaluation. Voice disorders were diagnosed with the Voice Handicap Index (VHI) and teachers were considered positive for voice disorders when the total score was above 19. Symptoms of common mental disorder were measured with the SRQ-20 scale (Self-Reporting Questionnaire, 20 items), with a cut-off value of 8 points. A bivariate analysis was performed using Poisson regression to verify the differences in the proportion of teachers who continued presenting a voice disorder among the different categories of the independent variables in the study. Results. A total of 69.1% of the teachers reported having a voice disorder after 3 years. High prevalence of acute common mental disorder symptoms was a predictor for a recurring perceived voice disorder. The risk of having a voice disorder was 30% higher for teachers who presented a common mental disorder 3 years after. Conclusions. Teachers who had both a voice disorder and symptoms of common mental disorder were more likely to maintain the voice disorder. Key Words: Longitudinal study−Teacher’s voices−Voice disorders.
INTRODUCTION Professionals who use their voice to work are the most affected by concerns about their own voice. Within this group, teachers are at the highest risk of developing voice problems since they are exposed to many risk factors.1-3 Ultimately, voice problems limit their professional performance1-3 and may lead to a voice disorder. Psychiatric disorders as well as voice disorders cause absence and/or leaving in teachers.1,5-13 Voice changes have diverse etiologies.14,15 Their effects alter the teacher's voice and lead to emotional, social, and functional restrictions. Verbal communication becomes limited. Negative consequences on the teacher’s career and quality of life may ensue.2,5,15-17 Previous research has shown that it is mainly in preschools and elementary schools5 that teachers are exposed factors that lead to voice disorder. These factors may result from chemical, physical, or biological exposure.5,18 A teacher’s working conditions often include intense vocal demands and unfavorable work environment.19 These issues are worsened by a lack of knowledge and training in public speaking, inadequate working environment, daily pressure, few breaks, low pay, lack of financial and social recognition, and professional frustration.9 Previous investigations of teachers’ voices have tried to identify responsible factors contributing to their voice Accepted for publication August 28, 2019. From the *Programa de P os Gradua¸c ~ao em Sa ude e Comportamento da Universidade Cat olica de Pelotas, Pelotas, Rio Grande do Sul, Brazil; and the yPrograma de P os Gradua¸c ~ ao em Dist urbios da Comunica¸c ~ao Humana da Universidade Federal de S~ao Paulo, S~ ao Paulo, S~ ao Paulo, Brazil. Address correspondence and reprint requests to Luciano Dias de Mattos Souza, Programa de P os Gradua¸c ~ ao em Sa ude e Comportamento da Universidade Cat olica de Pelotas, Rua Gon¸c alves Chaves 373, Sala 418C, Pelotas, Rio Grande do Sul 96015-560, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.08.030
disorders. However, it is still not possible to conclusively determine the relationship between voice disorders and teaching, as voice disorders have a multifactorial etiology.1,14,15 Studies show that teachers with vocal problems are likely to develop emotional problems that often put their careers at risk.6,18,20 In Brazil, epidemiological studies of teachers’ voices indicate that between 54% and 79% of teachers report voice problems.7,8,10 Recent studies indicate that the relationship between voice disorders and emotional factors has become more evident.7,10,14,17 Recurrence of a voice disorder may lead to chronicity, causing, in turn, several other biological, physical, or emotional changes.1,2,6,8,10,17,21-23 Having an episode of vocal impairment can lead to consequences that are not perceived by the individual, especially teachers. Teachers are often unaware of professional help availability.24,25 Therefore, there is a high incidence of voice disorders among teachers.19 Once a voice disorder becomes chronic, teachers may be removed from the classroom and may even be forced to consider changing their occupation.6 A study of self-reported acute and chronic voice disorders in 226 teachers found that 38.9% reported no voice disorders, 35.4% reported an acute disorder, and 25.7% reported a chronic disorder.26 Schwartz et al27 concluded that one of the most common symptoms of a voice disorder is hoarseness. Hoarseness affects nearly one-third of the general population at some point in their lives. If hoarseness persists for more than 3 consecutive or even nonconsecutive months, but for a long time or in a recurring fashion, it can be defined as a chronic event, with greater occurrence in voice professionals.27 There is a lack of longitudinal studies of teachers’ voice disorders in the literature. There are also inconsistencies about what the risk factors are for the recurrence of voice disorders. Therefore, the purpose of this study was to evaluate risk
ARTICLE IN PRESS 2 factors for the presence of voice disorders over a 3-year period in teachers, focusing on the relationship between voice disorders and self-reporting of a mental disorder. METHOD The Committee of Ethics and Research of the Universidade Cat olica de Pelotas (protocols # 2011/29 and 18713613.6.0000.5339) approved this research. An observational longitudinal study was conducted. Sampling design was made through a reassessment of teachers who participated in the first research study.4 Initially, between August and December 2011, 633 teachers were invited to participate, 575 being interviewed.28 Later, between August and December 2014, the same teachers were contacted for a reassessment. The second assessment included 469 teachers (81.56%). Among the 106 teachers who did not participate, 60 were not found, 15 refused to participate, 11 were on leave of absence due to health issues or lacked interest, 10 were retired, 5 were exonerated, 4 found another profession, and 1 was excluded. After the second evaluation, statistical power was calculated, taking into consideration the proportion of teachers who still reported voice disorders and teachers who reported improvement. The confidence interval was 95% and statistical power was 59.9%. The research team consisted of two professors, graduate students, and two volunteers, all of them from the Center of Life and Health Sciences of the Universidade Cat olica de Pelotas (UCPel) that identified the teachers for the study. A self-report questionnaire was used for information gathering. It contained questions referring to sociodemographic, environmental, behavioral, emotional, and voice characteristics of the teachers. Socioeconomic status was measured using the Economic Indicator for Brazilians (IEN), based on the demographic census of 2000.29 The sample was divided in tertiles and classified in three groups: low, intermediate, and high socioeconomic conditions. A self-assessment of voice disorders was obtained from the Voice Handicap Index (VHI),30 validated for Brazilian Portuguese by Behlau et al.31 Results were considered positive for voice disorders when the total score was above 19.32 Finally, the Self-Reporting Questionnaire that has 20 items (SRQ-20) was administered to screen for psychiatric disorder symptomatology, such as anxiety, mood, and somatoform symptoms. The SRQ is a questionnaire that was originally developed by the World Health Organization in 1994 for the purpose of screening for common mental disorders (CMD) in primary care settings.33 However, it does not replace a diagnostic instrument. This instrument has been validated for the Brazilian population by Mari and Williams.33 In the present study, participants with a score of 8 or higher are considered positive for common psychiatric disorders.34 Teachers were informed about research objectives and signed a term of informed consent. Participants who
Journal of Voice, Vol. &&, No. &&, 2019
exhibited voice and/or psychological symptoms were referred for treatment at the Reference Center on Worker’s Health (CEREST Macrosul), bound to the Municipal Health Secretary of Pelotas. Data were processed using the EpiData program. In order to ensure accuracy, data were entered twice. The automatic verification of information consistency was conducted with the EpiData software and some mistakes were corrected. Statistical analyses were done with the Stata 9.0 and SPSS 21.0 programs. During the second assessment, 29 participants did not answer some VHI items. Lost information was substituted with the sample’s mean value for each item. A univariate analysis was performed using the description of the variables’ simple frequencies, average, and standard deviations. Following the univariate analysis, a bivariate analysis was conducted, using the Poisson regression, to verify the difference in the incidence of voice disorders within the different categories of the independent variables. The Poisson regression was also used to evaluate the risk of recurrence of perceived voice disorders in a hierarchical model composed of two variables (teaching time and high CMD symptoms).35 Results were P ≤ 0.20 in the bivariate analyzes and, therefore, these two variables were included in the multivariate analysis. The significance levels were maintained at P < 0.05. RESULTS Table 1 includes sociodemographic and socioeconomic status, work conditions, voice disorder, and presence of common mental disorder symptomology. The sample of participants who presented a voice disorder during the first stage of the research and after 3 years in the re-evaluation was composed of 152 teachers. Among these, 69.1% (n = 105) had a recurrent perceived vocal disorder. Most of them were teachers (94.7%), over the age of 40 (60%), graduated high school (52.3%), had a higher socioeconomic status (35.1%), had a weekly teaching time between 21 and 40 hours (61.7%), were teaching from the fifth grade up (66.2%), and had more than 25 students in the classroom (79.1%). Among these participants, most of them had been teaching from 11 to 20 years, 78.1% reported quitting teaching due to voice disorders, 28.8% reported an important disease (rhinitis, laryngitis, gastroesophageal reflux, hormonal disorder), and 41.4% reported symptoms of common mental disorders. Table 2 shows that gender, age, educational level, socioeconomic level, workload, elementary school teaching up to the fourth grade, number of students per class, voice, and self-reported diseases had no association with the recurrence of the perceived voice disorder. However, teaching time and the presence of common mental disorder symptoms proved to be significant. The adjusted analysis (Table 3) shows that teaching (up to 10 years, between 11 and 20 years, more than 20 years) has no relation with the recurrence of perceived vocal disorders. The presence of reported common mental disorder
ARTICLE IN PRESS Luise Marques da Rocha, et al
TABLE 1. Characteristics of Elementary School Teachers of Pelotas (Brazil) Who Showed Indications of a Voice Disorder in 2011 and Were Reassessed in 2014 Variable
3
Voice Disorders in Elementary School Teachers
%
Gender Female 94.7 Male 5.3 Age (y)* Up to 40 40.0 41 or more 60.0 Schooling* Secondary school, teaching 9.3 and secondary school incomplete Secondary school, teaching and 38.4 secondary school incomplete Postgraduate 52.3 Socioeconomic status* Disadvantaged 31.6 Intermediate 33.3 Most favored 35.1 Workload (hours)* Up to 20 18.1 From 21 to 40 61.7 More than 40 20.1 Initial grades (lectures up to fourth grade) Yes 33.8 No 66.2 Number of students in class* Up to 25 students 79.1 26 or more students 20.9 Time teaching (y)* Up to 10 32.2 From 11 to 20 38.3 More than 20 29.5 Leave due to voice* Yes 78.1 No 21.9 Self-reported illness* Yes 28.8 No 71.2 High symptoms of common mental disorder* Yes 41.4 No 58.6 Total 100
TABLE 2. Factors Associated With Perceived Voice Disorder Recurring in Elementary School Teachers of Pelotas (Brazil) Through Poisson Regression
n 144 8 60 90 14 58 79 36 38 40 27 92 30 51 100 110 29 48 57 44 118 33 42 104 63 89 152
* Valid percentages.
Variable
Perceived Voice Disorder RR (IC 95%)
Age Female Reference Male 1.17 (0.84 a 1.63) Age (y) Up to 40 Reference 41 or more 1.08 (0.86 a 1.34) Schooling Secondary school, Reference teaching and secondary school incomplete College undergraduate 1.09 (0.71 a 1.68) Postgraduate 1.08 (0.71 a 1.22) Socioeconomic status Disadvantaged Reference Intermediate 0.93 (0.68 a 1.27) Most favored 0.92 (0.69 a 1.40) Workload (h) Up to 20 Reference From 20 to 40 0.95 (0.71 a 1.26) More than 40 1.06 (0.76 a 1.47) Initial grades (lectures up to fourth grade) Yes 0.97 (0.77 a 1.21) No Reference Number of students per class Up to 25 Reference 26 or more 0.86 (0.66 a 1.12) Time teaching (y) Up to 10 Reference From 11 to 20 0.99 (0.76 a 1.32) More than 20 1.23 (0.97 a 1.55) Leave due to voice Yes 1.06 (0.84 a 1.33) No Reference Self-reported illness Yes 0.93 (0.75 a 1.17) No Reference High symptoms of common mental disorder Yes 1.30 (1.00 a 1.71) No Reference
P Value
0.349
0.486
0.662 0.583
0.563 0.883
0.734 0.702
0.812
0.282
0.986 0.093
0.579
0.575
0.049
IC, confidence interval; RR, relative risk.
symptoms, however, is shown to be significant, since the percentage of teachers who reported having a voice problem is 30% higher if they also reported a common mental disorder (P < 0.059). DISCUSSION This research sought to identify risk factors that contribute to the perception of a recurrent vocal disorder. Results show that teachers who have acute symptoms of common mental disorders have a tendency to experience
voice problems. This is the first longitudinal study that investigated the prevalence of a recurring voice disorder in teachers. Cross-sectional studies have repeatedly shown the alarming situation of teachers’ voices worldwide.6-8,14,17,18 This study shows that teachers who reported having a voice disorder and acute symptoms of a common mental disorder tend to have a persisting voice disorders for 3 years.
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Journal of Voice, Vol. &&, No. &&, 2019
TABLE 3. Risk Factors of Perceived Voice Disorder Recurring in Elementary School Teachers of Pelotas (Brazil) Through Poisson Regression Relative Risk for Voice Disorder
Confidence Interval 95%
Time teaching (y) Up to 10 0.99 0.75 a 1.31 From 11 to 20 1.20 0.95 a 1.51 More than 20 Reference High symptoms of common mental disorder Yes 1.31 0.99 a 1.73 No Reference
P Value 0.955 0.126
0.058
Acute symptoms of common mental disorders are likely to prolong voice disorders. A cross-sectional study conducted in 2012 showed a close association between voice problems and mental disorders.20 Other studies have also highlighted the relation between vocal disorders and mental health, and described the associated factors; the designs of these studies, however, do not allow their authors to conclude on the cause effect.1,4,7,11,14 Prior to this study, only two longitudinal studies analyzed the relation between voice disorders and mental disorders.36,37 Neither of these studies found any recurrence of voice disorders with associated factors. Specifically, Moy et al did not provide results associated with voice health36 while Meulenbroek et al concluded that factors of psychosomatic well-being could play an important role in teachers’ voice disorders.37 Based on previous studies and the results of this study, we observed that the dysfunctions that affect teachers with self-described mental disorders may compromise adequate teaching. Although teachers with vocal complaints use various strategies for dealing with their voice problems, previous studies have shown that the use of these strategies did not lead to better outcomes for their voice problems.37,38-41 Thus, it is important to highlight that perceived voice limitations must be further studied in teachers who report having a common mental disorder. It is important to point out the limitations in this study. There was a loss of 106 teachers. In addition, we did not assess if participants underwent mental health treatment between evaluations. In addition, our data rely solely on self-assessment instruments. These instruments represent the viewpoint of the individual who lives with or without a voice problem; it does not include any clinical evaluation data or psychological/speech assessment. Nevertheless, they do represent a reliable measure to identify participants who present higher risk for vocal damage or impairment, even though neither the VHI nor the SRQ have diagnostic value. Individuals identified with voice or mental symptoms in such questionnaires should be better evaluated with more accurate assessments tools. Finally, we did not follow these
teachers during the 3-year period. Thus, they may have resolved their initial voice disorder at some point and developed a voice disorder prior to the second assessment period 3 years later. Based on the results of this study, further research should seek to understand the specific behaviors that increase the occurrence of mental and vocal disorders in this population, as well as evaluate preventative measures for teachers. CONCLUSION Teachers who suffer from a voice disorder and acute common mental disorder symptoms tend to have persisting voice disorders. These may be referred to as recurring or chronic voice disorders. REFERENCES 1. Smith E, Lemke J, Taylor M, et al. Frequency of voice problems among teachers and other occupations. J Voice. 1998;12:480–488. 2. Gassull C, Casanova C, Botey Q, et al. The impact of the reactivity to stress in teachers with voice problems. J Folia Phoniatrica et Logopaedica. 2010;62:35–39. 3. De Medeiros AM, Assun¸c ~ao AA, Barreto SM. Absenteeism due to voice disorders in female teachers: a public health problem. Int Arch Occup Environ Health. 2012;85:853–864. 4. Houtte EV, Claeys S, Wuyls F, et al. Voice disorders in teachers: occupational risk factors and psycho-emotional factors. Logoped Phoniatr Vocol. 2012;37:107–116. 5. Gianinni SPP, Latorre MRDO, Ferreira LP. Dist urbio de voz e estresse no trabalho docente: um estudo caso-controle. Cad de Saude Publica. 2012;28:2115–2124. 6. Behlau M, Zambon F, Guerrieri AC, et al. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26. 665.e9-18. 7. Amorim SNMC. Dist urbio vocal e estresse: os efeitos do trabalho na sa ude de professores/as do ensino fundamental de Goi^ania [disserta¸c ~ao-mestrado]. Universidade Catolica de Goias. 2006;1:1–121. 8. Guimar~aes I. Os problemas de voz nos professores: preval^encia, causas, efeitos e formas de preven¸c ~ao. Revista Portuguesa de Saude Publica. 2004;22:33–41. 9. Behlau M. Organizadora. Voz: o livro do Especialista. 2. Rio de Janeiro: Revinter; 2005. 10. Centro de Refer^encia em Sa ude do Trabalhador, Coordenadoria de controle de doen¸c as, Secretaria de Estado da sa ude de S~ao Paulo (CEREST, CCD, SES-SP). Boletim epidemiol ogico paulista - informe mensal sobre agravo a sa ude p ublica2006; (26). 11. Martins MGT. Sintomas de estress em professores brasileiros. Revista Lusofona de Educa¸c ~ao. 2007;10:109–128. 12. Emsley R, Emsley L, Seedat S. Occupational disability on psychiatric grounds in South African school-teachers. Afr J Psychiatry. 2009;12:223–226. 13. Behlau M, Pontes P. Avalia¸c ~ao e tratamento das disfonias. S~ao Paulo: Lovil; 1995. 14. Nerriere E, Vercambre MN, Gilbert F, et al. Voice disorders and mental health in teachers: a cross-sectional nationwide study. J BMC Public Health. 2009;9:1–8. 15. Simberg S, Sala E, Vehmas K, et al. Changes in the prevalence of vocal symptoms among teachers during twelve-year period. J Voice. 2005;19:95–102. 16. Behlau M, Park K. Perda da voz em professores e n~ao professores. Revista Sociedade Brasileira de Fonoaudiologia. 2009;14:463–469. 17. Alvear RMB, Martinez-Arquero G, Bar on FJ, et al. An interdisciplinary approach to teachers’ voice disorders and psychosocial working conditions. J Folia Phoniatrica et Logopaedica. 2010;64:24–34.
ARTICLE IN PRESS Luise Marques da Rocha, et al
Voice Disorders in Elementary School Teachers
18. Roy N, Merrill RM, Thibeault S, et al. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47:542–552. 19. Giannini SP, Latorre Mdo R, Fischer FM, et al. Teacher’s voice disorders and loss of work ability: a case-control study. J Voice. 2015;29:209–217. https://doi.org/10.1016/j.jvoice.2014.06.004. Epub 2014 Dec 9. 20. Rocha LM, Souza LDM. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. 21. De Ceballos AGC. Apoio social e fatores associados com a disfonia em professores. Salvador: Tese [Doutorado em Sa ude Coletiva] - Instituto Sa ude Coletiva da UFBA; 2009. 22. Giannini SPP. Dist urbio de voz relacionado ao trabalho docente: um estudo caso-controle. S~ao Paulo: Tese [Doutorado em Sa ude P ublica]. Faculdade de Sa ude P ublica da USP; 2010. 23. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med. 2008;58:74–76. 24. Da Costa V, Prada E, Roberts A, et al. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 25. e Seligmann-Silva E. Uma hist oria de “crise de nervos”: sa ude mental e trabalho. (org.). In: Rocha, Rigotto, Buschinelli, eds. Isto e trabalho de gente? Vida, doen¸c a e trabalho no Brasil. S~ao Paulo: Vozes; 1993:609–635. 26. Rossi-Barbosa LA, Barbosa MR, Morais RM, et al. Self-reported acute and chronic voice disorders in teachers. J Voice. 2015. Available from: http://dx.doi.org/10.1016/j.jvoice.2015.08.003. 27. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3S2): S1–S31. 28. Rocha LM, Souza LDM. Voice handicap index associated with common mental disorders in elementary school teachers. J Voice. 2013;27:595–602. 29. Barros AJD, Victora CG. Indicador econ^ omico para o Brasil baseado no censo demogr afico de 2000. Revista de Saude Publica. 2005;39:523– 529. 30. 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.
5
31. Behlau M, Oliveira G, Santos LMA, et al. Valida¸c ~ao no Brasil de protocolos de auto-avalia¸c ~ao do impacto de uma disfonia.Barueri-SP. Revista Pro-fono de Atualiza¸c ~ao Científica. 2009;21:326–332. 32. Behlau M, Madazio G, Moreti F, et al. Efficiency and cutoff values of self-assessment instruments on the impact of voice problem. J Voice. 2015. Published Online: July 11. 33. Mari JJ, Williams P. A validity study of a psychiatric screening questionnaire (SRQ-20) in primary care in the city of S~ao Paulo. Br J Psychiatry. 1986;148:23–26. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/3955316. 34. Gon¸c alves DM, Stein AT, Kapczinski F. Avalia¸c ~ao de desempenho do self-reporting questionnaire como instrumento de rastreamentopsiquiatrico: um estudo comparativo com o structured clinical interview for DSM-IV-TR. Cad Saude Publica Rio de Janeiro. 2008;24:380–390. 35. Barros AJ, Hirakata VN. Alternatives for regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. 36. Moy FM, Hoe VC, Hairi NN, et al. Cohort study on clustering of lifestyle risk factors and understanding its association with stress on health and wellbeing among school teachers in Malaysia (CLUSTer)—a study protocol. BMC Public Health. 2014;14:611. 37. Meulenbroek LFP, de Jong FICRS. Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study. Folia phoniatr Logop. 2010;62:47–54. 38. Epstein R, Hirani SP, Stygall J, et al. How do individuals cope with voice disorders? Introducing the Voice Disability Coping Questionnaire. J Voice. 2008;23:209–217. 39. McHugh-Munier C, Scherer KR, Lehmann W, et al. Coping strategies, personality, and voice quality in patients with vocal fold nodules and polyps. J Voice. 1997;11:452–461. 40. Van Opstal MJMC. A systematic, holistic and integrative process of self-control for voicing with optimal coping effects in teachers. 1. A process of awareness an expert’s opinion. Folia Phoniatr Logop. 2010;62:61–70. 41. Meulenbroek LF, Thomas G, Kooijman PG, et al. Biopsychosocial impact of the voice in relation to the psychological features in female student teachers. J Psychosom Res. 2010;68:379–384.