Teachers' voice: analyses of brazilian laws in the perspective of health promotion

Abstracts

PURPOSE:

to analyze the Brazilian policies about teacher's vocal health, from the perspective of health promotion.

METHODS:

61 documents published between 1998 and 2010 were collected and organized according to the categories: terminology, aim, predicted strategies and support to the teacher. The data received a qualitative and quantitative treatment.

RESULTS

: the terminology used in the documents was program (88.52%), campaign (6.55%) and vocal health policies (4.91%); as for the aims, the most mentioned was prevention of dysphonia in teachers (83.60%); the privileged strategy to approach the teacher's voice consisted of an annual theoretical-practical course (80.32%) and the teacher's predicted support was the access to speech-pathology therapy and to a physician in case of dysphonia (65.57%). The majority of the documents did not indicate any support available to the teachers' vocal health and were limited to the treatment of dysphonia, revealing that the teachers' vocal health is not taken as an object of concern by the State.

CONCLUSION

: despite their relevance, the analyzed documents present a very incipient and superficial content, especially in terms of promoting teachers' vocal care and health. Mostly, except for the occasional vocal health recommendation concerning the rehabilitation of voice disorders, there is no foundation on a comprehensive teachers' vocal health policy. Speech therapists

and related professional entities should play an effective role in the elaboration of documents to assist policy makers in the promotion of teachers' health in an objective and extensive way.

Voice; Faculty; Laws; Health Promotion; Teaching

OBJETIVO:

analisar as leis brasileiras sobre saúde vocal do professor, na perspectiva da promoção da saúde.

MÉTODOS:

foram captados, no período de 1998 a 2010, 61 documentos publicados, sendo organizados nas categorias: terminologia, objetivo, estratégias previstas e garantias ao professor. Os dados receberam tratamento quali-quantitativo.

RESULTADOS:

as terminologias utilizadas nos documentos foram: programa (88,52%), campanha (6,55%) e política de saúde vocal (4,91%); quanto aos objetivos, a prevenção de disfonias em professores (83,60%) foi o mais citado; a estratégia privilegiada para abordar a voz do professor se resumiu a curso teórico-prático anual (80,32%) e a garantia prevista ao professor foi o acesso ao tratamento fonoaudiológico e médico em caso de disfonia (65,57%). A maioria dos documentos não indicou qualquer garantia de direitos aos professores, limitando-se ao tratamento da disfonia, demonstrando que a voz do professor e seu cuidado, ainda não constituem objeto de preocupação do Estado.

CONCLUSÃO:

os documentos analisados, apesar de sua importância, apresentam conteúdo muito incipiente e superficial, especialmente quanto à linha de cuidado e à promoção da saúde vocal dos professores. Salvo raras exceções, restringem-se à indicação de ações pontuais voltadas à reabilitação de seus distúrbios da voz, desvinculadas de uma política de saúde vocal de base consistente. Há necessidade do fonoaudiólogo e seus órgãos de classe participar efetivamente na assessoria às figuras públicas visando à elaboração de documentos para que, de forma objetiva e abrangente, promovam a saúde do professor.

Voz; Docentes; Leis; Promoção da Saúde; Ensino

Introduction

The occupational hazards present in schools relating to work environment and organization are evident and are harmful to the health and voice of teachers^{1 - 5}. The Speech-Language Pathologist has been the professional of choice to revert this health hazardous situation with constant participation in devising documents that aim towards a broader understanding of the relationship between the work, health and voice of teachers¹.

There are recognized social, economic, technological and organizational determinants of workers' health that are responsible for the life conditions and aspects related to the environment and organization, present in work processes⁶. The consideration of occupationally derived voice disorders is undergoing an analysis process⁷ aiming to include them on the list of ailments that should be notified to the Ailment Notification Information System (SINAN).

Health is linked to the concepts of Health Promotion that date back to the first International Conference on Health Promotion, held in Ottawa, in 1986. The Charter defined Health Promotion as the "process of enabling the community to improve their quality of life and health, including a greater participation in the control of this process" ⁸. In Brazil, the Sanitary Reformation, made possible by the Federal Constitution of 1988, established a policy where health is understood as a universal right and a duty of the State⁹ .

In this context, health is conceived as a dynamics social process, derived from the experiences and manifestations of life. Furthermore, it is considered an important indicator of quality of life¹⁰, defined as the way through which each subject perceives his position in life, in the context of culture and the values in which he is immerse and implies two aspects: subjectivity and multidimensionality. The first regards how each one is self-assessed; and the second, to the fact that the construct involves different dimensions, such as physical aspects, psychological aspects, social relationships and environment¹¹.

The guidelines of Health Promotion should include the process of construction, (re)qualification and (re)construction of healthier urban spaces, potentially health cities and Health-Promoting Schools (HPS) that aim towards social transformation in order to ensure better quality of life to citizens and reclaiming of citizenship¹².

From this perspective, education and health have an indissoluble relationship, as health is a requirement for learning, and education as a strategy that will lever health.

School may engage in the health promotion of its community, having faculty members as the essential element for this job, since teachers, when interacting with the students will multiply information and may generate curiosity and desire for knowledge in students. In this quest for promoting health, the teacher's attitudes, beliefs and ideas will be exteriorized through the modulations of his voice that will convey energy, call for attention, compromise and establish priorities¹³.

The use of dialogue and the voice in it is related to what is called soft technology¹⁴. This term is discussed by one author who, when approaching health care, establishes three types of resources: hard technology, soft-hard and soft. Hard technology involves the instruments or equipment used in treatments, the exams and organization of information; the soft-hard type regards the knowledge of the different well-known fields of health, such as clinical health, epidemiology, as well as the professionals involved in the team who develop the work process. Soft technology happens in the inter-subjective relationship, in the encounter between the health professional and the user, and this is why the author calls it a live work, in action. This kind of resource involves dialogue, listening, bonding and taking responsibility for others and the problems that afflict them.

Not only schools but all segments of society should be involved in the movement of Health Promotion, as devising laws that ensure the use of strategies aiming towards the well-being of the population is an important resource in this direction, since public policies are valid throughout the entire country and are an advance in the acquisition of social rights.

The high occurrence of voice disorders among teachers, associated to the discussions on Health Promotion has led politicians to devise Bills with the purpose of ensuring actions so as to, at least, decrease voice disorders, especially of teachers. Limited disclosure of this kind of Brazilian legislation has motivated the researchers to characterize the laws about vocal health¹⁵.

At this moment, the purpose of this study is to analyze Brazilian laws about the vocal health of teachers, in the perspective of health promotion.

Methods

The material for the present study was composed by the survey of laws that concerned vocal health in the period from 1998 to 2010. Since this is a documental study, there was no need for submission to an Ethics Committee or for an informed free consent term.

The identification of this material began with searches through the websites of Legislative Assemblies, Houses of City Representatives, state governments and city halls, performed by one of the authors, who works in government. A questionnaire devised by the authors was sent to a discussion panel on voice, of which participated several Speech-Language Pathologists who were interested in this field. These professionals sent information about laws or documents on vocal health of teachers of which they knew, or sent the laws to the authors.

The inclusion criteria was being Laws and Bills approaching issues about the voice of teachers, and those directed to parents or students, focusing on other issues of the Speech-Language Pathology field were excluded.

After reading and analyzing all the obtained documents and excluding those that did not meet the purpose of the study, there was a total of 61 documents from all of Brazil that were organized chronologically (Figure 1) and had content specifically directed towards the vocal health of education professional.

Afterwards, the following analysis categories were created based on detailed reading of the material and analysis of its content: terminology, purpose, strategies and guarantees offered.

In addition to this global analysis, five documents received special attention, for they had more complex proposals and detailed actions to be developed, and thus were different from the others.

It should be noted that the expression vocal health was used throughout the entire paper because it is recurrent in the title or the content of all the analyzed laws, in spite of the criticism to the use of this expression, especially in the field of Collective Health, as they consider that health should be understood as an indissoluble whole, and not segmented.

Results

Figure 1 shows Brazilian laws about vocal health in the period from 1998-2010 that were the material for analysis in the present study.

Figure 1:
Presentation of the laws about vocal health in the period between 1998-2010

Table 1 shows the analysis data of the documents using the categories: terminology, purposes, strategies and guarantees for the teacher, present in Brazilian laws about vocal health in the period between 1998 and 2010.

Table 1:
Distribution of vocal health laws existing in Brazil in the period between 1998 and 2010, according to the categories terminology, purpose, strategies and guarantees (n=61)

Figure 2 shows the five laws which texts represent advances in the rights and guarantees for teachers and have broader action proposals when compared to the group of analyzed documents. It was found that the documents are mostly from State governments, including a federal bill, PL 1128/2003, for its broad spectrum and approval by congress and that is under process in the House of Representatives.

Figure 2:
Summary of the advances found in the documents regarding the organization and structure of the proposals of teachers' vocal health programs

Discussion

On the 61 analyzed documents, there is a proposal for the creation of a resource or some kind of action that are named either as Campaign, Programo r Policy.

Campaigns refer to punctual actions and need to be held constantly in order to achieve lasting results (Table 1). Voice disorders in teachers are different from other health conditions, especially infectious and contagious diseases that are treated with vaccines or other medicines. Although it has a powerful value of health education, this strategy, when used in isolation, is not comprehensive enough to eliminate voice disorders usually caused by issues related to work activities, since merely improving hydration or not smoking, among other clarifying and important information disclosed in voice campaigns, alone, are not actions with potential for eliminating voice disorders or protecting teachers' voices from dysphonia, faced with so many problems encountered in the daily work life of these individuals that affect their health and their voices. Therefore, campaigns are a resource that may be used alongside other health actions¹⁶, as a component of a policy or program.

On the other hand, a Program or a Policy imply articulated and synergic actions that include all issues involving care, and thus is more complete and resolute, with proposals of actions in the different levels of attention and complexity. Given the factors that intervene on teachers' voice disorders, this would be the best option to protect their health and their voices.

The initiatives shown reflect the adopted conception regarding teachers' health care. The traditional curative practice prevails, one that is established through medical and Speech-Language Pathology consultation and treatment when the voice disorder is already occurring and, therefore, focuses on rehabilitation. In 83.6% of the vocal health programs analyzed in this study there is an advance towards a broader perspective, aiming at the prevention of teachers' voice disorder, but however the perspective is not to promote health but to avoid the worsening of the disease that continues to be the focus of action.

It should be noted that, in the analysis of the documents shown in Figure 1, it was clear that the law's use of the expression "program" did not imply that its content included the requirements and broadness required by this concept, and the text was limited to mention care actions for the teacher diagnosed with a voice disorder. Thus, there was not always consonance between use of terminology and the content of the documents.

This preventive way of acting upon the health-illness-voice care process comes from the model of Preventive Medicine¹⁷, where prevention measures are established in a progressive order, in a normative and prescriptive model, focused on the individual or in specific groups at risk aiming to intercept the disease. This model was transposed to the field of Speech-Language Pathology during the end of the 1990's¹⁸, advancing beyond a purely rehabilitative practice, albeit still restrained to the prevention of diseases, immediate treatment and interruption of consequences of the disorder. Health promotion considers broader aspects that are: sanitary education, food safety, dignified housing and work, leisure, all responsibility of public powers, and not related to the competence of health professionals, particularly the Speech-Language Pathologist.

Three documents did not have a stated purpose, which seems to indicate that texts that will become laws are not always devised in a structured and objective way so as to clarify its purpose and thus making its execution more difficult.

The majority of the analyzed laws propose, among other strategies, an annual theoretic and practical course. It is important to mention that this strategy is being discussed as one of low impact when changes of attitudes of the subjects are proposed, since this strategy agrees with a conception of illness that is solved with medication and population control (which justifies the expression "vocal health"), in detriment of their empowerment aiming at quality of life and improvement of their health conditions. In a study¹⁹, in which the authors used concepts by Antonio Zabala, it was stressed that when the aim is to ensure the occurrence of the teaching-learning process, the education professional should keep in mind the need to work with concepts alongside procedures in order to later seek a change in attitude of those involved. Thus, the proposal of theoretic and practical courses may solely enable the presentation of concepts and possible procedures, however will hardly account for the changes in attitude or behavior. In order for this to happen, the work must be continuous, with a commitment for active participation of the subjects and with the purpose of constantly raising awareness and questioning the information brought by the participants. Some of the broader laws, that will be discussed further ahead, seek to promote the health of teachers by proposing actions that are linked and systemic.

In fact, the idea of constancy or continuity is, once again, discarded when it is made clear in more than half of the documents that the periodicity should be annual. This sole contact of the Speech-Language Pathologists with the teachers enables punctual actions and the development of behaviors and attitudes that will very likely be forgotten or negligence as soon as the difficulties in a healthy voice use in school arise, due to the lack of maintenance of professional support. A very small number of propositions (Figure 2) suggest permanent actions that proved the opportunity for the use of more active methodologies by the involved parties and would favor changes in attitudes regarding health. On the other hand, part of the documents bring no information regarding the strategies that should be used in vocal health programs, showing a lack of knowledge or also postponing ways of reaching the purpose, and thus their conduction may become even more difficult.

When approaching the process of work in the field of health, several kinds of resources should be used¹⁴, and the importance of soft technology is pivotal, since the dialogic involvement of the Speech-Language Pathologist with the teacher enables the approximation and understanding of the first professional about the life, work and health conditions of teachers and generates more consistent subsidies for the conduction of actions that are in agreement with the demands that come from them.

Although the initiatives aim towards preventive actions, a preoccupation with the assistance to teachers with voice disorder may be identified, when part of the Programs announce that, in the presence of the disorder, the participants will have access to Speech-Language Pathology, medical or even psychological treatment.

The need for advancing in the perspective of Health Vigilance should be stressed. In this perspective, special attention must be paid to the document being devised in the National Health Department that highlights the structural and essential role played by Vigilance in Workers' Health, associated to the model of Integral Attention in Workers' Health⁷. It should also be stressed that sanitary knowledge and practices should have intra and inter-sectorial links, in addition to focusing on the work environment and processes, with the participation and, especially, with the knowledge of the workers.

Thus, the actions that approach the vocal health of teachers, as pointed out in the programs shown in Figure 2, should be always associated to others of inter-sectorial nature, aiming to minimize the risks found in the work environment (noise, dust, lighting, for example) and organization (among which are: goals to be met, excess work and occurrence of violence).

When discussing group management by the Speech-Language Pathologist, one study²⁰ presents the experience of the City of São Paulo in the development of workshops for vocal well-being, encouraging the participants to create or take part in the Internal Committee for Accident Prevention (CIPA) in schools, as a way of continuing the discussions regarding work environment and organization.

In regard to teacher guarantees, the fact that almost one third of the documents not mentioning this issue stands out, as they seem to not consider the teacher as a worker, with rights and duties. This is possibly due to the fact that teaching has been considered, for a long time as a mission, denying it a professional role²¹, or even the assumption that a voice disorder is not as incapacitating as other conditions that may ail the teacher. This may also account for the fact that almost one third of the documents did not so much as mention these rights.

The analysis of the documents showed that a small part of the initiatives, devised throughout time, differed from the rest in regard to the detail of its texts and for bringing advances concerning the voice of teachers, as they approach it in different levels of attention in an integrated and global way (Figure 2).

These documents that are valid state-wide (Pernambuco/2001, Paraná/2005 and Minas Gerais/2006), city-wide (São Paulo/2005) and nation-wide (Brasília/2003) date from the beginning of this century, from the same time as the publication of official documents that outline the line of care and relevance of integral health attention, as set by the National Health System (SUS) ⁹.

These documents detail the actions of health promotion, education, protection and recovery, from the admission medical exam that receives the teacher with voice disorder, hiring him under special conditions, that is, offering adequate treatment and/or workload decrease until fit for completely performing his job. They offer courses on teacher vocal qualification, aiming at their empowerment so that they may become promoting agents of their own health and of those with whom they live and work. In addition to personal care, they focus on teaching-learning technology and improvement of the physical space such as acoustics, noise, heat/cold, humidity, ventilation, dust, as well as white-boards, availability of drinking fountains and sound equipment in order to reduce risks and cooperate for teacher health promotion.

Finally, in addition to the vocal rehabilitation of dysphonic teachers, they leave room for the analysis of their working situation, proposing temporary or definitive re-adaptation in order to assure their rights as workers.

These documents, as opposed to the rest, express a consideration for teachers, their value as education professional and establish actions along the entire line of health care, in agreement to the principles of health promotion, in a detailed and objective manner¹⁵.

It should be noted that in these documents the Speech-Language Pathologist is repeatedly mentioned as the professional who is responsible for the vocal care of teachers and the coordinator of the work teams. This professional's inter-relationship with other professionals, especially the otolaryngologist doctor with whom he establishes a partnership regarding the pertinent care measures to the field of professional voice use is also made clear.

Conclusion

In spite of their importance, the analyzed documents have very incipient and superficial texts regarding the line of care, especially promotion of teachers' health, remaining restricted to the indication of punctual actions aiming towards rehabilitation of their voice disorders, with few exceptions.

It was hoped that the laws would contemplate a broader concept of health with a consequent determination of broader and more articulated procedures, as well as the maintenance of guarantees for the teacher as a worker, in both health and illness situations.

Speech-Language Pathologists and their professional representation organs have an important role in aiding public figures in devising documents so that, in a broad and objective manner, they may be directed to integral health attention, focusing on its promotion.

• ¹
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Publication Dates

• Publication in this collection
  Nov-Dec 2014

History

• Received
  24 June 2013
• Accepted
  25 Nov 2013