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Teachers Voice Disorders and Loss of Work Ability:

A Case-Control Study
rio Dias de Oliveira Latorre, kFrida Marina Fischer,
*,,Susana Pimentel Pinto Giannini, Maria do Rosa

{Ana Carolina de Assis Moura Ghirardi, and #Leslie Piccolotto Ferreira, *yzxk{# S~ao Paulo, Brazil
Summary: Background. Teachers constitute a profession with a high occurrence of voice disorders due to the occupations intense vocal demands and unfavorable work environment.
Purpose. To identify the association between voice disorders and work ability among teachers from public schools in
S~ao Paulo, Brazil.
Methods. This is a case-control study. The case group comprised teachers with voice disorder complaints, vocal
quality deviations in speech pathology evaluations, and vocal fold lesions according to an evaluation by an otorhinolaryngologist. The control group was randomly selected from the same schools as those in the case group. Both groups
answered the following questionnaires: sociodemographic, lifestyles, working conditions, work organization,
conditions of vocal productionteacher (CVP-T), and Work Ability Index (WAI). The analysis used the chi-square association test and univariate and multivariate regression models.
Results. The analyses of both groups showed comparable populations with no significant differences in the demographic and control variables. The groups differed, as expected, in vocal symptoms. Analyzing associations with the
WAI, there was an association between decreased work ability and voice disorder (P < 0.001). This association remained
in multivariate analyses where decreased (OR 9.5, P 0.001) and moderate (OR 6.7, P < 0.001) work ability were
also associated with voice disorders. Analyzing the ability to work, age, and acoustics; decreased (OR 12.2,
P < 0.001) and moderate (OR 7.7, P < 0.001) work ability, age 5065 years (OR 3.7, P 0.006) and poor acoustics
(OR 2.7, P 0.007) were factors associated with voice disorders.
Conclusions. The occurrence of voice disorders is significantly associated with work ability, which may eventually
compromise teachers ability to continue working.
Key Words: Occupational healthVoice disordersWork ability index evaluationTeachers.
INTRODUCTION
Teachers occupy a privileged position in society, playing an
important role in human development and the educational process. However, this occupation has been undergoing a loss of
prestige over the past years and as a result there is a growing
association between teaching and various illnesses. Mental
and vocal disorders are the main causes of temporary absences
or permanently leaving work.13 Teachers report multiple
symptoms that negatively affect their performance during
teaching activities and voice disorders are a source of stress
and frustration.4 The social importance of withdrawal from
work is not restricted to the economic aspects, which are not
to be ignored, but being removed from teaching activities leads
to faculty members feeling insecure and isolated.5 When the
teacher loses his or her voice, he or she is unable to perform

Accepted for publication June 5, 2014.


This study was presented at the 18th Brazilian Speech-Language Pathology and Audiology Congress (September 2225, 2010, in Curitiba, Parana, Brazil) (http://www.sbfa.
org.br/fono2010/pdf/trabahospremiadoscongresso2010.pdf).
From the *Public HealthEpidemiology at the School of Public Health, University of
S~ao Paulo (FSP-USP), S~ao Paulo, Brazil; yCity Public Health Care System, Brazil;
zEducation and Rehabilitation Division of Communication Disorders (DERDIC-PUCSP), S~ao Paulo, Brazil; xDepartment of Environmental Health, School of Public Health,
University of S~ao Paulo (FSP-USP), S~ao Paulo, Brazil; kSchool of Public Health, Department of Epidemiology, University of S~ao Paulo (FSP-USP), S~ao Paulo, Brazil; {Program
in Speech-Language Pathology, Pontifical Catholic University of S~ao Paulo, S~ao Paulo,
Brazil; and the #Program in Speech-Language Pathology and Audiology, Pontifical Catholic University of Sao Paulo (PUC-SP), S~ao Paulo, Brazil.
Address correspondence and reprint requests to Susana Pimentel Pinto Giannini,
Avenida Nhandu, 334Planalto Paulista, CEP 04059-000, S~ao Paulo, Brazil. E-mail:
ppgiannini@uol.com.br
Journal of Voice, Vol. 29, No. 2, pp. 209-217
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.06.004

routine classroom functions, and loses his or her professional


identity.
Personal characteristics like excessive speaking or yelling and
biological aspects like allergies or pharyngeal/laryngeal reflux, in
addition to the inappropriate environmental characteristics of
schools, are factors associated with voice disorders. On the other
hand, aspects that originate in various patterns of work organization also play a preponderant role in determining teachers vocal
illnesses.6,7 The decrease in work ability is the result of a process
that involves multiple variables including sociodemographic
aspects, lifestyles, mental resources, chronological age,
work requirements, and health status, which are the main
determinants.8,9 Voice disorders make teaching difficult or
impossible, and characterize an inability to work as a teacher.
This case-control study aims to advance the identification of
factors related to teachers working conditions and work organizational aspects associated with work ability. The purpose of
this study is to determine the association between voice disorders and loss of work ability among female teachers at public
schools in S~ao Paulo.
METHODS
Study design
This was a case-control study with cases and controls paired by
school to control for exposure to physical, chemical, and biological environmental aspects.
Sampling
The study was conducted with female preschool, elementary,
middle, and high school teachers working in the public school

210
system of S~ao Paulo (Brazil). Teachers with organic vocal fold
disorders and those who were not actively performing classroom
functions for medical reasons or who were performing administrative work at the time of data collection were excluded from the
sample. Teachers who might have previously received guidance
or treatment were not excluded because there is a current Vocal
Health Program run by the citys medical administration office.
To determine the sample size, a type I error of 5% was
assumed, and test power of 80%, maximum exposure frequency
among the controls of 40%, and minimum odds ratio (OR)
value of 2.5. Based on these assumptions, we estimated that
85 cases and 85 control subjects would be needed for the study.
Definition of cases and controls
The main methodological difficulty in this study was the definition of cases, because the dependent variable voice disorder is
a dynamic and functional manifestation. Thus, it is quite difficult
to create dichotomist definitions of illness and absence of illness.
The definition of cases is crucial in case-control studies and,
where voice disorders are concerned, it is difficult to define the
illness (case) in opposition to the absence of any sign or symptom. This definition is found in different forms and classifications
in the literature. Most studies rely solely on the presence of voice
symptoms when considering the presence or absence of the disorder.10 However, such manifestations are not specific enough to
distinguish healthy and unhealthy individuals. A number of authors1113 have stated that the presence of symptoms and a
professional evaluation, especially a laryngeal evaluation,5
should be included. However, there is presently no consensus
on which evaluation procedure should be the gold standard to
clearly define a case of voice disorder.
In the present study, the case definition was based on the results of both vocal and laryngoscopic assessments. Considering
the aspects regarding these evaluations, the case definition could
have been done in three different ways: (1) teachers with disorders in the perceptive-auditory voice evaluation and without
the disorder in the perceptive visual otolaryngology evaluation.
In this situation, two possibilities may be considered: the existence of minimal structural disorders in the vocal folds that could
not be seen during laryngoscopy, or an initial vocal manifestation
without a corresponding organic sign; (2) subjects without a disorder in the perceptive-auditory vocal evaluation and a disorder
in the perceptive visual evaluation. Even teachers who have a
slight or moderate disorder on the medical examination who
have a well-adapted voice could fit this category; (3) subjects
with disorders in both perceptive-auditory and perceptive visual
assessments. Although situations (1) and (2) could be considered
cases of voice disorders from a clinical standpoint, the option in
this study was to consider as cases only those teachers classified
as (3); that is, those with a consensus between the voice and
laryngeal evaluations, whereas those classified in the other categories were excluded from the analysis.
The teachers considered cases were those with alteration in
their vocal evaluations (GRBASI scale 2 or 3) and the presence
of a lesion or irritative and/or structural disorder or chinks in the
vocal folds during an ear, nose, and throat (ENT) perceptive and
visual assessment. The control group comprised subjects with

Journal of Voice, Vol. 29, No. 2, 2015

an absence of or mild vocal quality alterations in the


perceptive-auditory assessment (GRBASI scale 0 or 1) and
those with no observed alterations in the ENT assessment.
Teachers who had disorders in only one of the two different assessments were removed from the study to obtain groups that
were clearly distinct categorized by the illness focused on in
this study.
Instruments
Two questionnaires were used: (1) the conditions of vocal production of teachers (CPV-P) instrument, which has been used in
different studies in Brazil, can adequately characterize the conditions of school environments and the vocal profile of teachers.
In this study, the answers provided sociodemographic, lifestyle,
occupational, environmental, and school-work organization
data.14,15 In the present study, the answers were given on a
Likert scale (never, seldom, sometimes, always, and I dont
know) and provided data regarding the variables of
sociodemographics, lifestyles, and occupational and work
environment and organization. These variables were analyzed
in two categories: no (never, seldom, I dont know) and yes
(sometimes, always). The answers to the question what
symptoms do you currently experience? were the basis for
determining the number and frequency of vocal symptoms.
Likewise, subjects were deemed to be without symptoms
(never, seldom, I dont know) or with symptoms (sometimes,
always). (2) The Work Ability Index (WAI) assesses a
persons work ability to suggest intervention measures and
health promotions to prevent further losses and to maintain
the persons current work ability.16 The WAI originated from
occupational health studies in Finland.17 The questionnaire
may be completed from the time the subject enters the workforce to determine a reliable prognosis of changes in work ability of different professional groups. The WAIs contribution in
the study of work ability is owed to its predictive value for
disability, health/illness, and death rate.18
The assessment considers the physical and mental requirements of the work, the workers health conditions, and his/her
mental and physical resources.8 It has been translated and validated by researchers from the Public Health School of the University of S~ao Paulo and other Brazilian institutions.19 The WAI
may detect early disorders associated with work ability and may
be used to predict the risk of disability in the near future independently of age.
It is composed of seven dimensions: current work ability
compared with the best in life, work ability in relation to
work demands, current number of illnesses diagnosed by a doctor from a list of 51 illnesses, estimated loss of work because of
illnesses, and work absences because of illnesses. The score is
calculated as the sum of points scored for each of the seven dimensions, and varies between 7 and 49, where 727 corresponds to low ability, 2836 to moderate ability, 3743 to
good ability, and 4449 to excellent work ability.17
Data collection
The selection of participants took place in two phases. The
participants in the first phase were all teachers attending the

Susana Pimentel Pinto Giannini, et al

Voice Disorders and Work Ability Among Teachers

Speech-Language Pathology service of the Public City Workers


Hospital with vocal complaints between July 2007 and May
2009, and who underwent vocal and laryngoscopic assessments.
In the second phase, researchers went to the schools where the
case teachers worked and randomly selected teachers from the
same schools for the control group. All selected teachers were
subjected to the same procedures previously mentioned. Teachers who had a voice disorder were placed in the case group,
and those classified as without a voice disorder were assigned
to the control group.
Speech examinations were performed by speech-language
pathologists on the same day of the week (Friday mornings)
so that a minimum of 12 hours of vocal rest was assured.
Data were registered directly in a portable computer using a
headset microphone. The option of conducting a perceptiveauditory analysis was given because this is the standard procedure in vocal assessments, and for using the GRBASI scale,20,21
an instrument that is widely used internationally and that has
high agreement rates. Vocal evaluation was performed
simultaneously using three speech-language pathologists experienced in the field. The pathologists had no knowledge of the
subjects identities. Each voice was classified as altered (moderate or intense alteration, grades 2 or 3) or not altered (normal
or mild, grades 0 or 1).
All otorhinolaryngologic evaluations were performed by the
same ENT doctor, experienced in laryngology on Fridays after
voice sample collections. A video laryngoscopy was performed
with both rigid and flexible laryngoscopes under local anesthesia (lidocaine spray) when needed. The assessment protocol
included general ENT and specific laryngeal aspects. Subjects
were classified as altered when lesions, irritative structural disorders, or chinks in the vocal folds were detected, or not altered
in the absence of any lesions or disorders.
The perceptual auditory voice assessment, which was performed by a speech-language pathologist, and the perceptive visual evaluation, which was performed by the ENT doctor, had a
good agreement level (76.9%, P 0.525).
Variables
The dependent variable was the presence of voice disorder
(yes case; no control), and the independent variable of interest was work ability (low, moderate, good, and excellent).
Independent control variables included characteristics
regarding sociodemographics (age, marital status, and education level); lifestyle (alcohol consumption and smoking), teaching (time in profession, type of work contract, number of
teaching hours per week), environment (noise, echo, dust, humidity, classroom temperature, acoustics; classroom size and
lighting, school cleanliness, use of harmful cleaning chemical
products), and work organizational factors (quietness, presence
of constant supervision, stressful work pace, time to accomplish
all tasks at school, rest area, job satisfaction, school maintenance, monotonous work, repetitive work, stress and violence
at work and how often, abuse of school property, theft of personal items, threats toward teachers, need for police intervention, racism, lack of discipline, fights, aggressions, insults,
violence, drug issues, and graffiti).

211

Statistical analyses
The WAIs internal consistency was assessed by calculating
Cronbach alpha coefficient. A descriptive analysis and a study
of the association with the variable of interest to compare the
case and control groups were conducted (chi-square association
test with Yates correction coefficient). Logistic regression
models were estimated to calculate the crude and adjusted
OR to assess the risks in relation to the independent variable
of interest. For multivariate analysis, independent control variables were selected with significance levels less than 0.10
(P < 0.10) in univariate analyses. The variables that remained
significant after adjustment for the other variables were kept
in the model. Evaluation of the adjustment of the final multiple
models was done using the Hosmer-Lemeshow test.
Ethical guidelines
The study was approved by the Research Ethics Committees
of the School of Public Health of the University of S~ao Paulo
(protocol n 173/07) and the Public Servant Municipal Hospital
(protocol n 101/07). All subjects were informed and voluntarily agreed to participate in the study by signing a free consent
form. This study was funded by the Research Support Foundation of the State of S~ao Paulo (Fundac~ao de Amparo a Pesquisa
do Estado de S~ao PauloFAPESP).
RESULTS
In total, 354 assessments were conducted. At the end of this process, the case group comprised 167 teachers, and the control
group comprised 105 teachers. The group analysis showed
that the samples were comparable because there was no difference between groups with regards to sociodemographic, lifestyle, and occupational characteristics as shown in Table 1.
Age was identified as an independent control variable
(P < 0.10) in the logistic regression analysis.
There was also no difference between the case and control
groups in the characterization of perceived work environment
conditions (Table 2) and work organization (Table 3), which
was expected because participants in both groups were paired
by their work places. The only variable that showed a difference
was acoustics, which was also added to the logistic regression
analysis for adjustment.
Regarding vocal and nonvocal symptoms, the groups were
differentiated because all of the evaluated symptoms were associated as shown in Table 4.
It should be noted that although symptoms such as hoarseness, tiredness while speaking, or strained speech may be
associated with the case group, these manifestations were
not proven to be specific enough to distinguish, in isolation,
individuals who do and do not have a voice disorder. This
was confirmed by observing that 51% (n 52) of the subjects in the control group reported hoarseness, 50%
(n 51) tiredness when speaking, and 52.4% (n 54)
strained speech.
The WAI general score had a Cronbach alpha coefficient of
0.75 showing good reliability for the instrument in this study.
An association was observed between work ability reduction

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Journal of Voice, Vol. 29, No. 2, 2015

TABLE 1.
Distribution of Cases and Controls, According to Sociodemographic and Lifestyle Characteristics
Controls (n 105)
Sociodemographic Characteristics
Age
2029 years
3039 years
4049 years
5065 years
Married status
Single
Married
Separated/widow
Education
Up to incomplete college degree
College degree and over
Working time as a teacher
 10 y
1115 y
1620 y
 21 y
Contract
Main teacher
Substitute teacher
Weekly working hours
 10
1120
2130
3140
 41
Smoking habits
Non-smoker
Ex-smoker
Smoker
Alcohol consumption
Never
Seldom
Sometimes

15
38
33
19

Cases (n 167)


P Value (c2)

14.3
36.2
31.4
18.1

21
50
77
19

12.6
29.9
46.1
11.4

0.092

27
62
16

25.7
59.0
15.2

49
100
18

29.3
59.9
10.8

0.513

4
101

3.8
96.2

13
154

7.8
92.2

0.187

33
23
29
19

31.7
22.1
27.9
18.3

40
29
62
36

24
17.4
37.1
21.5

0.244

101
4

96.2
3.8

158
9

94.6
5.4

0.552

14
16
32
24
19

13.3
15.2
30.5
22.9
18.1

29
22
31
48
37

17.4
13.2
18.6
28.7
22.2

0.187

84
11
10

74.1
10.5
9.5

132
16
19

79.0
9.6
11.4

0.238

45
43
16

43.3
41.3
15.4

78
60
29

46.7
35.9
17.4

0.666

and voice disorder (P < 0.001). In the control group, 66.6%


(n 58) of subjects considered their work ability good or excellent, whereas 67.4% (n 99) of subjects in the case group
considered their work ability either poor or moderate.
Two multivariate analysis models of the variable of interest
and the presence of a voice disorder were studied, with the results shown in Table 5.
Model 1 shows the univariate analysis of voice disorder and
the WAI categories. Low and moderate work ability was associated with having a voice disorder.
Model 2 looked at the association between voice disorder
and the WAI after adjusting for the control variables that met
the P < 0.10 requirement in the chi-square association test
(age and acoustics). The categories of poor and moderate
work abilities remain significant independently of the age
group and the presence of unfavorable acoustics in the school.
These were also independent factors associated with voice
disorders.

DISCUSSION
This paired case-control study assessed the association between
having a voice disorder and loss of work ability among female
teachers working at public schools in S~ao Paulo.
The case and control groups were similar with regard to practically all sociodemographic, lifestyle, occupation, work environment, and organization factors. Regarding vocal aspects,
all vocal symptoms evaluated were associated with the presence
of a voice disorder, which confirms that the groups were differentiated specifically by the presence of a voice disorder. It
should be noted that although symptoms such as hoarseness,
tiredness when speaking, and strained speech were associated
with the case group, these manifestations were not specific
enough to distinguish between those with or without a voice
disorder.
The only environmental exposure variable associated with
voice disorder was acoustics (P 0.010). When selected in
multivariate analyses, acoustics remained significant in the

Susana Pimentel Pinto Giannini, et al

Voice Disorders and Work Ability Among Teachers

213

TABLE 2.
Distribution of Cases and Controls, According to Physical Work Environment Characteristics
Controls (n 105)
Physical Work Environment Aspects
Presence of disturbing noise
No
Yes
Unfavorable acoustics
No
Yes
Presence of echos
No
Yes
Dusty environment
No
Yes
Humidity
No
Yes
Pleasant classroom temperature
No
Yes
Adequate classroom size
No
Yes
Adequate lighting
No
Yes
Satisfactory cleanliness
No
Yes
Satisfactory cleanliness in restrooms
No
Yes
Irritative cleaning products
No
Yes

Cases (n 167)


P Value (c2)

3
99

2.9
97.1

4
162

2.4
97.6

0.791

20
85

19.0
81.0

55
109

33.5
66.5

0.010

19
85

18.3
81.7

35
129

21.3
78.7

0.541

10
94

9.6
90.4

1
155

7.2
92.8

0.476

24
78

23.5
76.5

39
123

24.1
75.9

0.919

22
80

21.6
78.4

41
125

24.7
75.3

0.557

53
51

51.0
49.0

91
76

54.5
45.5

0.571

7
98

6.7
93.3

9
94.6

16
89

15.2
84.8

21
146

12.6
87.4

0.533

6
99

5.7
94.3

20
147

12.0
88.0

0.087

24
81

22.9
77.1

31
135

18.7
81.3

0.404

multiple regression model and was independent of age and


work ability. Unfavorable acoustics at school is one of the
main environmental factors associated with teachers voice disorders.10,22,23 Background noise during teaching activities was
reported by 75% of teachers, and elevated and unbearable noise
perception in the classroom and school is strongly associated
with and has a positive intensity gradient with the presence of
mental disorders.7
Regarding sociodemographic aspects, the variable age
met the P < 0.010 requirement and was further tested in multiple regression models as an adjustment variable. The
5065 year age bracket was associated with having a voice disorder independent of work ability.
There is no consensus regarding when the process of vocal
aging begins, but the voice undergoes changes with age,24
with a greater chance of having a vocal disorder increasing
with the teachers age.1
Likewise, duration of exposure time to teaching functions
is associated with a greater frequency of negative, acute, or

9
158

0.663

chronic effects on the voice.25 Teachers with five or more years


of work experience have a 35% greater chance of having
dysphonia than those with less years of experience in the occupation.26 Previous studies also showed that the voice disorder
favors a change in occupation or untimely removal from classroom functions.27
The present study verified an association between reduced
work ability and having a voice disorder. In the association
analysis conducted with all the independent variables of interest, poor and moderate work ability were statistically associated
with having a voice disorder, regardless of age and acoustics
(Table 5, Model two). In all WAI analyses, the presence of a
dose-response is observed; that is, the longer the exposure,
the greater the chance of having the outcome and the greater
the observed outcome (Table 5). This is one of the strongest indicators of a causal relationship.
The concept of work ability is anchored in the interaction between work demands and the workers physical and mental resources, representing a measurement of functional aging.8 In

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Journal of Voice, Vol. 29, No. 2, 2015

TABLE 3.
Distribution of Cases and Controls, According to Work Organization Characteristics
Controls (n 105)
Aspects of Work Organization

Calm environment
No
37
Yes
67
Constant supervision
No
11
Yes
90
Stressful work pace
No
1
Yes
104
Enough time to accomplish work activities
No
19
Yes
86
Able to leave the classroom
No
32
Yes
73
Satisfaction with position
No
4
Yes
101
Monotonous work
No
26
Yes
69
Repetitive work
No
19
Yes
84
Violence at work
School property abuse
No
23
Yes
81
Theft of personal belongings
No
36
Yes
68
Threats to the teacher
No
28
Yes
76
Racist manifestations
No
31
Yes
72
Lack of discipline
No
7
Yes
98
Fights
No
18
Yes
87
Violence against employees
No
34
Yes
71
Drug abuse issues
No
29
Yes
76

this study, the WAI proved to be a marker strongly associated


with having a voice disorder. It also illustrates the
repercussions of vocal illnesses on teachers lives and careers.
The results point toward early functional aging in teachers
with voice disorders, regardless of the decline associated with

Cases (n 167)


P Value (c2)

35.6
64.4

60
100

37.5
62.5

0.751

13.2
89.1

22
145

13.2
86.8

0.582

1.0
99.0

2
163

1.2
98.8

0.843

18.1
81.9

37
127

22.6
77.4

0.379

30.5
69.5

68
41

41.0
59.0

0.081

3.8
96.2

6
160

3.6
96.4

0.934

27.4
72.6

41
117

25.9
74.1

0.804

18.4
81.6

32
132

19.5
80.5

0.829

22.1
77.9

42
124

25.3
74.7

0.551

34.6
65.4

60
107

35.9
64.1

0.826

26.9
73.1

51
116

30.5
69.5

0.524

30.1
69.9

56
111

33.5
66.5

0.557

6.7
93.3

10
156

6.0
94.0

0.832

17.1
82.9

28
137

17.0
83.0

0.971

32.4
67.6

52
114

31.3
68.7

0.856

27.6
72.4

38
129

22.8
77.2

0.365

age. Aspects referring to health are determinants of work ability


and, in this case, the vocal symptoms play a pivotal role.
Educators essentially depend on their voices for their ability
to work, and the development of a voice disorder leads to
self-distancing from the active work of teaching.

Susana Pimentel Pinto Giannini, et al

Voice Disorders and Work Ability Among Teachers

215

TABLE 4.
Distribution of Cases and Controls, According to Vocal Symptoms
Controls (n 105)
Vocal and Nonvocal Symptoms
Hoarseness
No
Yes
Voice loss
No
Yes
Shortage of breath when speaking
No
Yes
Pain when speaking
No
Yes
Tiredness when speaking
No
Yes
Strained speech
No
Yes
Dry throat
No
Yes
Stingy throat
No
Yes
Phlegm
No
Yes

Cases (n 167)

n

n

P Value (c2)

50
52

49.0
51.0

11
156

6.6
93.4

<0.001

82
21

79.6
20.4

70
95

42.4
57.6

<0.001

75
29

72.1
27.9

72
93

43.6
56.4

<0.001

68
34

66.7
33.3

63
102

38.2
61.8

<0.001

51
51

50.0
50.0

22
144

13.3
86.7

<0.001

49
54

47.6
52.4

23
143

13.9
86.1

<0.001

36
67

35.0
65.0

23
143

13.9
86.1

0.001

56
47

54.4
45.6

43
123

25.9
74.1

<0.001

37
68

35.2
64.8

29
136

17.6
82.4

0.011

The severity of the voice disorder can be indirectly estimated


by the loss of work ability.27 Teachers have more limitations in
professional performance and in social interactions than nonteachers, and one in every three teachers has to reduce teaching
activities because of voice disorders, which interferes with the
satisfaction, performance, and effectiveness of teaching.1,28
Teachers also find it more difficult to accomplish daily
communication tasks25 and miss more work days because of
vocal issues1,3,29 than workers in other professional
categories. A voice disorder causes physical discomfort, with
some level of pain, and causes the teacher dissatisfaction and
limits his/her professional activities.30 Teachers are among
the category representing the highest rates of medical leaves
from their tasks due to communication problems.31
If the work cannot be accomplished, removal from the function is suggested. Data on teacher removals do not allow for a
direct association between these issues and work; however, a
strong relationship with work conditions is indicated. One study
showed that teachers health conditions are affected by the intensifying process of the teaching workload, and are more prone to
illnesses, especially when overworked under difficult conditions,
which leads them to surpass their own personal limitations.7
When a teacher is unable to work, removal from the classroom is characterized by absences, medical leaves, or functional reassignment, a resource used in the public education

system when a teacher is physically or mentally unable to


remain in his or her usual activity. When being reassigned,
the teacher is removed from classroom activities and assumes
a function where there is no need for intensive use of their
voice. However, while not using his/her voice, the teacher
ceases to be in the position of one who sustains a position of
knowledge. On the other hand, while relocated he/she is also
kept away from classroom stress. When resuming his/her position, vocal use for an extended period of time is required and the
teacher is returned to the same stressful situation.32
When not removed from the classroom, teachers many times
opt to resign. Data from the Department of Education of the
state of S~ao Paulo between 1990 and 1995 showed that there
was a 300% increase in resignations in the public school system. Low salaries, poor work conditions, work dissatisfaction,
and lack of professional recognition are among the factors accounting for why teachers leave the occupation.
Workers in occupations that predominantly require mental
demands such as educators tend to have more preserved work
ability than those whose occupations require mainly physical
demands.18 However, occupations with such characteristics in
general involve recognition and professional prestige,
autonomy, participation in decision-making and higher salaries,8 characteristics that, currently, are not associated with a
teaching job.

216

Journal of Voice, Vol. 29, No. 2, 2015

TABLE 5.
Multivariate Analysis of Factors Associated to Voice
Disorders

Variable

Model 1

Model 2

OR* (P)

ORy adj (P)

WAI
Poor
8.0 (0.001)
Moderate
5.9 (0.001)
Good
1.7 (0.308)
Excellent
1.0
Age
2029
1.0 (0.092)
3039
0.93
4049
1.7
5065
0.7
Unfavorable acoustics
No
2.1 (0.010)
Yes
1.0

12.2 (<0.001)
7.7 (<0.001)
1.9 (0.262)
1.0
1.0
2.4 (0.228)
1.8 (0.006)
3.7
2.7 (0.007)
1.0

* OR: Crude Odds ratio.


y
OR: Adjusted Odds Ratio.

Studies of voice disorders resulting from professional voice


usage have intensified in Brazil over the past several years.3
This ailment has led an increasing number of teachers into situations of leave and an incapacity to perform their functions,
resulting in both financial and social costs.
Promoting work ability actions as a way of preventing illnesses and accidents is more efficient and less expensive than
the cost of treatment.8 The issues involving the health-illness
process regarding the voices of teachers should be understood
not only in terms of individual choices, lifestyle options, and
voice-related behaviors, but also in terms of the discussions
of work and daily life involving the entire community.33
CONCLUSION
Although the case-control study design does not enable the
establishment of a relationship between exposure and the effects on health, this study confirms an association between
loss of work ability and teachers voice disorders. There was association between having a vocal disorder and poor and moderate work ability regardless of age and unfavorable acoustics.
Because of its predictive value, the WAI instrument is an
important tool for the early detection of health ailments in
teachers and for early prediction of leave from professional activities. The results of this study may contribute to ways of
devising of strategies for health promotion and specific public
policies that will favor the maintenance of teachers health.
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