ARTICLE IN PRESS

Effectiveness of the Teacher’s Vocal Health Program

(TVHP) in the Municipal Education Network of Campo
Grande, MS
Paulo Roberto Haidamuss de Oliveira Bastos and Elisangela Carelli Hermes, Campo Grande, MS, Brazil

Summary: Objective. This study aimed to implement and evaluate the effectiveness of the Teacher’s Vocal Health
Program in the Municipal Education Network in Campo Grande, MS, in the 2016 school year so as to reduce or ex-
tinguish the high prevalence of vocal symptoms among teachers.
Methods. This is an experimental research with convenience sampling of 48 teachers presenting with vocal symp-
toms. The Vocal Symptoms Scale was used to collect data, which according to the criteria of the Scientific Advisory
Committee of the Medical Outcomes Trust, present proved psychometric properties and is specific to evaluate indi-
viduals with vocal alterations. The proposed Vocal Program is considered as a brief intervention one (3 months) and
consists of qualification or instruction, as well as application of 5 daily vocal techniques and is controlled through in-
dividual monitoring spreadsheets.
Results. The total score average had statistically significant reduction in the experimental group when compared with
the control group, which represents a positive effect concerning the program adhesion. The fact that there was no nullity
in the subscales (limitations, physical, emotional) means that even submitted to the intervention, the teachers still present
with vocal symptoms.
Conclusion. Teacher’s Vocal Health Program represents an effective Vocal Health Program model for the teachers.
Key Words: Collective health–Voice–Voice training–Teacher–Speech therapy.

INTRODUCTION reliance on the treatment, adhesion, need to miss work to attend

Work-related dysphonia may be etiologically related to vocal
misuse or vocal abuse, worsened by the fear of unemploy-
ment, lack of information about vocal techniques for professional
use, and other contingencies of the modern working world, which
force workers to endure these symptoms for long periods of time
and to keep working until there is an escalation in their clini-
cal condition, demanding more complex therapeutic interventions.
Vocal health programs are considered the best form of inter-
vention to control labor dysphonia. They focus on improving voice
production and reducing the negative impact on teachers’ life
quality. Despite scientific efforts, literature presents small quan-
tity of evidence, which prove the effectiveness of programs with
speech therapeutic techniques to treat the behavioral vocal
conditions.1,2 One of the restrictions in obtaining evidence of
quality is not the absence of positive intervention effect, but the
methodological inaccuracy of the experiments, especially con-
cerning a detailed description of the program used.2,3
It is necessary to reflect on the aspects that may compro-
mise the treatment to understand the philosophy underlying the
programs: chronicity of the disorder, nature of voice alteration,
medical history, presence or absence of secondary gains with
dysphonia, variability of vocal techniques, length of treatment,
clinician’s skill and knowledge and clinician’s personality. In
addition to that, we can also consider the patient’s motivation,
Accepted for publication August 28, 2017.
Support Source: CAPES.
From the Federal University of Mato Grosso do Sul, Avenida Senador Filinto Muller,
Campo Grande, MS, Brazil.
Address correspondence and reprint requests to Elisangela Carelli Hermes, Avenida
Senador Filinto Muller, Federal University of Mato Grosso do Sul, Campo Grande, MS
79.070-900, Brazil. E-mail: elisangelacarellihermes@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2017.08.029
treatment sessions and difficulty in changing vocal behavior. A
defined program increases the chances of bonding and volun-
tary adhesion because of the possibility of previously knowing
the stages of the work and its aims.2–4
To deepen the studies on the effectiveness of the vocal health
Programs, the Department of Communication Disorders of the
University of Utah (USA) developed a vocal education program
whose main component is a 20-minute videotape called Teacher
Vocal Abuse Prevention Program. The videotape could be used
before work or during working hours, in groups or individual-
ly, leading to further discussion on voice related subjects (vocal
anatomy and physiology; hyper functional dysphonia; case study
about two teachers with dysphonia; vocal hygiene notions and
strategies to improve vocal potential in the classroom). Re-
searchers claim that after extensive field research with teachers,
response to the project was extremely positive5–8 Validating the
research on effectiveness, the Department of Speech and Hearing
Sciences of the Hong Kong University investigated 25 teach-
ers, twelve of which belonging to the experimental group (EG),
who received training and practiced vocal hygiene daily during
2 months. Vocal records of all the participants of both groups
were carried out through acoustic and electroglottographic evalu-
ations. These records data were collected at the beginning and
at the end of the Program, in the morning (8:30–10:00 am) and
in the afternoon (5:30–7:00 pm) to detect possible vocal alter-
ation. The results showed that the vocal quality of the EG
improved significantly after the vocal hygiene Program and the
Control Group (CG) did not present change in the vocal quality
from the beginning to the end of the Program.9–12
Another important reference is The Voice Care Network UK,
which originated in the late 80’s, with speech and language thera-
pists who realized that there was a large number of teachers with
vocal disorders: over 30% of the patients with vocal problems
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2017
were teachers and according to the estimates, one out of ten teach-
ers would have some kind of vocal problem throughout their
careers. Voice Care Network was created to prevent vocal prob-
lems and help teachers to have vocal control in the classroom.
As a result, training workshops were developed in local centers.
This program issues a newsletter (Voice Matters) three times a
year to keep its members in touch and informed about all the
topics dealt with at the workshops. Voice Care Network was later
on introduced at universities through Education Post Gradua-
tion courses. A total of 630 students from three universities
participating the workshops were registered through question-
naires; 311 showed present vocal symptoms; 447 considered
having received positive feedback and 440 considered it impor-
tant to develop future vocal work.13–15
Brazil is also currently developing extensive research in the
teacher’s voice field. The Programa Integral de Reabilitação Vocal
(Vocal Rehabilitation Full Program), for instance, is an assis-
tance model proposed by the Instituto da Laringe (Larynx
Institute) in 1970s and expanded to the Larynx and Voice Am-
bulatories of the Federal University of São Paulo. It was expanded
and reorganized in 2000 and is based on three founding pillars:
orientation, psychodynamics and vocal training. The vocal ori-
entation pillar concerns hygiene or vocal wellness through the
identification of harmful vocal behaviors and habits, offering sub-
stitutes validated by the participant. For the psychodynamics work,
audio and video files are used to identify vocal deviations and
to analyze the impact of altered voices from the professional,
social and emotional perspectives. The dysphonic participants’
vocal image is dealt with, where the aspects they would like to
change are defined. The third vocal training pillar (body-voice,
glottic source, resonance, pneumophonoarticulatory coordination
and communicative attitude) is crucial in the direct interven-
tions and consists of exercises for the speech subsystems, three
to five times a day, registered on media to help their develop-
ment. Daily practice provides an increase of resistance and larynx
muscle mass besides learning at the cortical level, acquisition
retention and learning memorization.3
It is also relevant to mention an important 2013 study with
394 teachers by the Federal University of Mato Grosso do Sul
(Brazil), to outline the epidemiologic scenario on dysphonia in
the Public Education Network. The prevalence of the self-referred
vocal symptoms represented 21.5% from the studied popula-
tion out of 4,957 active teachers (CEMED CENSUS/ 2013).4
It means 1,066 teachers are vocally asymptomatic classified as
belonging to a risk group to vocal cords disorders and daily
exposed to the worsening of this established condition. Bearing
that in mind, the present study proposes the development of a
Program model with consistent methodology to promote teach-
ers’ vocal health to be implemented in the Education Network
and evaluated as to its effectiveness, contributing to an advance
in teachers’ labor health to control, reduce and/or extinguish be-
havioral dysphonia because of vocal misuse or vocal abuse.4
METHODS
This study was forwarded to the Human Subjects Research Ethics
Committee of the Federal University of Mato Grosso do
Sul—CEP/UFMS for analysis and approved by Opinion n.
1.045.295/2015. All the participants signed the Free and Clari-
fied Consent Form, in accordance with Resolution MS/CNP/
CONEP n. 466/14.
This is an experimental study using convenience sampling,
whose factor in study was the presence of self-referred vocal
symptoms, pre and post adhesion to the Teacher’s Vocal Health
Program (TVHP).
As inclusion criteria two groups were separated: EG—34
vocally symptomatic teachers, teaching for at least 6 months,
with employment contract. Participation in all the activities of
the TVHP consisted of two instruction lectures, two training work-
shops, at least 80% of the three-month vocal exercise spreadsheet
routine, reading of the complementary material on vocal hygiene
(printed booklet); CG—14 teachers following the EG require-
ments, except for joining the TVHP.
A written authorization was requested from the Municipal Ed-
ucation Secretary for the research to be developed in three urban
schools. This document made it possible for the researcher to
contact each school and check their availability of dates to take
part in the study. For the schools to authorize the development
of the study it was necessary to adapt data collection so as not
to affect the participants’ work routine. Therefore the factor in
study was measured through the application of a self-evaluation
questionnaire among the subjects.
The selected instrument was the Vocal Symptom Scale (VoiSS).
The translation and validation of this collection instrument un-
derwent the criteria of the Scientific Advisory Committee of the
Medical Outcomes Trust.16 This validation process followed a
strict four-stage scientific analysis. The first stage was the trans-
lation into cultural and linguistic adaptation; the second stage
was the validity of content and construct; the third stage was
the evaluation of reliability (internal consistency and test-
retest reproducibility) question; and finally the fourth stage
measures the individual sensitivity of the protocol questions and
change with the treatment. According to the Committee, the VoiSS
presents proved psychometric properties for self-evaluation of
vocal symptoms and of the impact of voice problems; it is a
perfect classifying instrument, with cutoff value of 16 points.
This value was used as pass or fail criteria at the selection screen-
ing of the vocally symptomatic teachers.
The 48 participants answered the VoiSS at the first and final
stage of the research. The scale is made up of 30 questions, 15
of which belonging to the limitation area (functional symp-
toms), 8 questions from the emotional area (psychological
symptoms), and 7 from the physical area (organic symptoms).
Each question was scored according to the occurrence frequen-
cy of the symptoms at “never” (zero); “rarely” (one point);
“sometimes” (two points); “quite often” (three points); and
“always” (four points). The total VoiSS, calculated through the
simple addition of each question value, shows the general level
of vocal alteration. The maximum score is 120 points, 60 of which
are related to the limitation area, 32 points to the emotional area,
and 28 points to the physical area. The individuals were told to
mark the answer corresponding to the occurrence frequency of
each one of the symptoms.
About the studied variables: (1) group identification: EG—
vocally symptomatic teacher submitted to intervention;
 ARTICLE IN PRESS
Paulo Roberto Haidamuss de Oliveira Bastos and Elisangela Carelli Hermes Effectiveness of the Vocal Health Program 3

CG—vocally symptomatic teacher without intervention; (2) in- homepage, e-book, cell phone application, WhatsApp groups,
tragroup relationship: vocal symptoms in EG and CG at the initial and squeeze bottles showing the five exercises in the program
and final stages of the research. (3) gain stage: intergroup score (Figures 1, 2, 3).
differences at the final-initial stage. The following board specifies strategies and techniques applied
After group selection, EG participants underwent the inter- at the six meetings during the 2016 school year.
vention. The TVHP developed and implemented at MEN consists
of a brief (4-month) intervention program, whose focus is to
provide the teachers with basic means in their careers so that
they can develop their own mechanisms and potentially improve
their vocal resources at the work environment. The strategies
applied at the schools were two lectures (notions on voice, dys-
phonia, vocal hygiene, and voice imposition), two 8-hour training
workshops about the five techniques applied to the program (vocal
warm-up and cool-down, hydration, resonantal balance, full
breathing), as well as monitoring of the vocal exercises through
daily individual spreadsheets. To stimulate adhesion to the FIGURE 2. E-book available at <papyuseditor.com/web/34976/livro>.
program, digital tools and support material were developed:

FIGURE 1. Homepage available at <http://elisangelahermes.wix FIGURE 3. Cell phone application available at

.com/fonoaudiologia>. <galeriafabricadeaplicativos.com.br/programa_saude_vocal_docente>.

Teacher’s Vocal Health Program (BASTOS; HERMES, 2016)

BOARD 1.
Description of the Six Meetings in the Teacher’s Vocal Health Program (TVHP)
Intervention I—Visit to the school for project presentation.
Scheduling of activities to program meetings during PTA meetings, monthly, for four months.
Intervention II—First school month
Self-evaluation of the initial level of vocal alteration (control and experimental)
Experimental group training
Estimated time—4 h
Guidance:
1. Research presentation in multimedia material (PowerPoint) and TFCC signature (30 min).
2. Application of the Vocal Symptom Scale (VoiSS) as selection criteria for the control and experimental groups,
intergroup voluntary adhesion (30 min).
3. Beginning of intervention with the experimental group (120 min): lecture with multimedia resources (PowerPoint)
about basic notions on the phonological apparatus, larynx lesions because of inadequate voice use, good and bad
phonation-related habits, and vocal exercises training.
4. Distribution of printed material—edited booklet, printed by UFMS publishing house (10 min).
5. Information about the use of technology for interpersonal communication (e-book, cell phone application, homepage,
WhatsApp group formation for briefing) (50 min).
6. Distribution of daily monitoring spreadsheets about the vocal exercises procedure (hydration, warm-up and cool-
down, resonantal balance, full breathing).
7. Distribution of individual and personalized squeeze bottles to stimulate daily hydration.
(continued on next page)
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2017

BOARD 1.
(Continued )
Specificity:
About daily vocal training
Accompanied through daily monitoring spreadsheets.
Minimum of 15 min of vocal care procedures a day considering the following aspects:
HYDRATION/VOCAL WARM-UP BEFORE CLASSES/RESONANTAL BALANCE/FULL BREATHING/VOCAL COOL-DOWN
AFTER CLASSES.
HYDRATION TECHNIQUE
Objective—vocal fluidity
Specificity:
Minimum amount of liquid to be ingested—2 L a day. Fractioned ingestion. Teachers should take a bottle of water to the
classroom to stimulate this practice.
VOCAL WARM-UP TECHNIQUE
Objective—balance of aerodynamic and myoelastic forces of the vocal tract.
Specificity:
Do the exercises before classes. Inhale deeply, always through the nose and vibrate lips or tongue, letting the air out
through the mouth, without effort (1 min or 10 times). Slow, sounding, non-nutritional chewing—Humming (1 min).
Stretching of the neck muscles with nodding, shaking, and side movements (1 min or 10 times). Facial mimicry
activation with pouting and smiling movements plus tongue snapping (1 min or 25 times).
VOCAL COOL-DOWN TECHNIQUE
Objective—balance of aerodynamic and myoelastic forces of the vocal tract.
Specificity:
Do the exercises after classes. Through active rest, inhale deeply through the nose and slowly vibrate lips or tongue
letting the air out through the mouth, in a smooth or descendent scale (1 min or 10 times); For the neck muscles to
perform semi-circular movements, with the head slowly moving back and forth (three times each side). Warm water
gargling (1 min).
RESONANTAL BALANCE TECHNIQUE
Objective—activation of the resonantal balance between nose and mouth.
Specificity:
Blow the nose and moisturize each nostril (at least three times a day). The nostrils should always be moisturized (with
only water or solution) before blowing the nose.
FULL BREATHING TECHNIQUE (BACK-DIAPHRAGMATIC-ABDOMINAL):
Objective—increase of the respiratory support for phonation and pneumophonic coordination.
Specificity:
Inhale deeply through the nose, moving the abdomen “outward” and exhale, letting the air out through the mouth and
moving the abdomen “inward” (2 min or 25 times).
Reading a page (free topic) a day, coordinating speech and full breathing. (pneumonic coordination)
After finishing the technique, apply full breathing during the whole speech.
Intervention III—Second school month
Reinforcement of the daily spreadsheets exercises.
Workshop on full breathing
Collection of the first monitoring spreadsheet
Distribution of the second monitoring spreadsheet
Estimated time—2 h
Intervention IV—Third school month—first fortnight
Reinforcement of the daily spreadsheets exercises
Workshop on vocal warm-up and cool-down
Collection of the second monitoring spreadsheet
Distribution of the third monitoring spreadsheet
Estimated time—2 h
Intervention V—Third school month—second fortnight
Reinforcement of the daily spreadsheets exercises
Workshop on life and voice quality
Estimated time—2 h
Intervention VI—Fourth school month
Application of the Vocal Symptom Scale (VoiSS) in the final phase.
Collection of the second, third, and last monitoring spreadsheet
Briefing on TVHP and reinforcement for maintenance of vocal health actions.
Estimated time—2 h
 ARTICLE IN PRESS
Paulo Roberto Haidamuss de Oliveira Bastos and Elisangela Carelli Hermes
Next, material resources and information and communication
technology were applied to the research to stimulate adhesion
to the program.
The sampling features were described in tables and graphs.
For continuous variables and variables with normal distribu-
tion, Student paired t test was used. P values < 0.05 were
considered significant. To compare the CG and the EG, both at
the initial stage (pre intervention) and at the final stage (post in-
tervention), test analysis of variance was used. All the confidence
intervals built along the work represent 95% statistical confi-
dence, with significance level 0.05 (5%).
RESULTS
The results will be initially presented comparing the VoiSS scores
I (subscales: limitation, emotional, physical, total) at the initial
stages (pre intervention) and final ones (post intervention) for
each one of the groups.
Sampling characterization
The sociodemographic characteristics of the teachers in the study
were as follows: predominance of the female gender, teaching
as exclusive activity, university level schooling and teaching career
time between 2 and 20 years. It is interesting to note that the
teachers having classroom activity for more than 2 years means
they are susceptible to daily, intense exposition to risk factors
to vocal health such as the ones cited in the literature: environ-
mental noise, stress, abuse or vocal misuse, etc, which are proven
triggers or aggravators of dysphonia (Table 1).
Changes in the Vocal Symptom Scale scores for the
experimental group and thw control group
respectively
From the 48 sampled vocal symptomatic teachers, 34 joined the
TVHP representing the EG and 14 teachers did not join the TVHP,
representing the CG. Table 2 and Figure 4 show the score evo-
lution for EG in the period before and after the intervention.
Table 3 and Figure 5 show the score evolution for the CG at
the beginning and at the end of the research.
The data found in the CG show that there is a statistically sig-
nificant difference between the initial and final moments for most
subscales, except the physical subscale. The data point out the
increase of vocal symptoms, with rising curve for all areas. It
was noticed that the non-intervention or non-adhesion to the
program worsened the functional or psychological symptoms.
Table 4 and Figure 6 show the moment gain, that is, the
difference of scores of the VoiSS (final-initial phase), compar-
ing EG and CG.
In the moments gain there was significant intergroup differ-
ence for all of the areas (limitation, emotion, physical, and total).
DISCUSSION
Changes in the Vocal Symptom Scale scores for the
experimental groups
It is possible to note that at the initial stage, the limitation subscale
represents the most affected area concerning vocal health, fol-
lowed by the physical subscale. The emotion subscale was the
least expressive area. It means that the phonatory dysfunction
Effectiveness of the Vocal Health Program 5
TABLE 1.
Demography of Teachers Participating in the Study, in the
City of Campo Grande, Brazil
Variable %
Gender
Female 85.0
Male 15.0
Schooling
University 90.0
University Inc. 3.0
Specialist 7.0
Career time
6 mo–2 y 7.0
2 y 1 d–20 y 60.0
+20 y 33.0
is the most referred to or perceived vocal symptom by EG teach-
ers, followed by the organic and less expressive symptoms—the
psychological effects. After the intervention, the EG kept the order
for the compromised subscales. It is important to note a marked
falling curve for all the vocal symptoms, that is, the total EG
score average was significantly reduced, which represents a pos-
itive effect concerning adhesion to the TVHP. The fact that there
was no nullity at the subscales expresses the idea that even sub-
mitted to the intervention, the teachers keep presenting with
vocal symptoms. There is literary consensus about this aspect
as cited that when persistent, the vocal symptoms reveal that the
vocal folds may have suffered alterations at the structural level,
being subject to lesions, edemas, fissures, among other
alterations.4,5,17
It is understood that the school environment represents a con-
flict zone that encompasses family, economic, and sociocultural
issues involving the students, as well as administrative and political
disagreements about the teaching career.18,19 According to some
authors,3,18 to understand the philosophy underlying the Vocal
Health Programs, it is necessary to reflect on the aspects that
may influence their results: disorder chronicity, nature of voice
alteration, medical history, presence or absence of secondary gains
with dysphonia, variability in vocal techniques, intervention du-
ration, skills and knowledge of the ones involved, and teachers’
and instructors’ personality. In addition to these, one can also
point out the group’s motivation in the school environment and
reliance on the vocal training, adhesion, need to attend the train-
ing, and difficulty in changing behavior.
During the application of the TVHP, adhesion and interest from
the EG were observed. Some fragility traits were also noticed
such as difficulty in schedule compatibility and available time
for training without interfering in the school calendar; atten-
dance to the lectures because of work issues; changes in school
management; and great turnover of teachers with temporary con-
tracts. In spite of that, the EG followed the proposed schedule.
Applied techniques in the Teacher’s Vocal Health
Program
During the in loco training with teachers, the proposed exer-
cises revealed that the hydration, resonantal balance, and vocal
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2017

TABLE 2.
Changes in the Vocal Symptom Scale Scores for the Experimental Group, Campo Grande, Brazil, 2016
Experimental (EG) Average Median Pattern Deviation VC* % Min Max N* CI* P Value
Limitation Initial 17.6 15.0 11.4 65 7 46 34 3.8 <0.001
Final 6.0 4.5 4.7 78 0 22 34 1.6
Emotion Initial 4.4 2.5 6.9 156 5 29 34 2.3 0.001
Final 1.4 0.0 2.6 190 0 12 34 0.9
Physical Initial 8.9 10.0 4.5 50 5 18 34 1.5 <0.001
Final 3.1 3.0 2.7 88 0 10 34 0.9
Total Initial 31.0 28.0 20.0 64 17 93 34 6.7 <0.001
Final 10.5 7.5 7.9 75 0 27 34 2.7
ANOVA test.
* Subtitles.
Abbreviations: CI, confidence interval; N, total population number; VC, variation coefficient.

40
35
30 31
25
20
17.6
15
10 10.5
8.9
5 6
4.4 3.1
0 1.4
Inicial Final

Limitação Emoção Físico Total

FIGURE 4. Changes in the Vocal Symptom Scale scores for the experimental group, Campo Grande, Brazil, 2016.

TABLE 3.
Changes in the Vocal Symptom Scale Scores for the Control Group, Campo Grande, Brazil, 2016
Control (CG) Average Median Pattern deviation VC* % Min Max N* CI* P Value
Limitation Initial 12.9 11.5 8.7 67 4 30 14 4.6 0.010
Final 20.1 19.0 11.3 57 7 50 14 5.9
Emotion Initial 2.5 1.0 3.1 123 6 9 14 1.6 0.044
Final 5.0 4.5 5.1 101 0 19 14 2.6
Physical Initial 8.6 9.5 4.2 49 7 15 14 2.2 0.169
Final 10.7 10.5 5.4 51 2 22 14 2.9
Total Initial 24.1 20.0 14.5 60 17 51 14 7.6 0.004
Final 35.8 31.0 18.1 51 18 88 14 9.5
ANOVA test.
* Subtitles.
Abbreviations: CI, confidence interval; N, total population number; VC, variation coefficient.

40
35 35.8
30
25 24.1
20 20.1
15
12.9
10 10.7
8.6
5 5
2.5
0
Inicial Final
Limitação Emoção Físico Total
FIGURE 5. Changes in the Vocal Symptom Scale scores for the control group, Campo Grande, Brazil, 2016.
 ARTICLE IN PRESS
Paulo Roberto Haidamuss de Oliveira Bastos and Elisangela Carelli Hermes Effectiveness of the Vocal Health Program 7

15 11.7
10 7.1
5 2.5 2.1
0
-5 -3.1
-10 -5.8

-15 -11.6
-20
-20.5
-25
Limitação Emoção Físico Total
Experimental Controle
FIGURE 6. Change in Vocal Symptom Scale scores comparing the experimental group and the control group (final phase-initial phase) in the
city of Campo Grande, in 2016.

TABLE 4.
Changes in the Vocal Symptom Scale Scores Comparing Groups: Experimental and Control (Final Phase-Initial Phase),
in the City of Campo Grande, Brazil in 2016
Gain Average Median PD VC* % Min Max N* CI* P Value
Limitation EG −11.6 −9.0 8.0 69 −34 −2 34 2.7 <0.001
CG 7.1 4.0 8.8 124 −1 30 14 4.6
Emotion EG −3.1 −1.0 4.9 158 −24 0 34 1.6 <0.001
CG 2.5 1.5 4.2 167 −3 13 14 2.2
Physical EG −5.8 −6.0 2.7 47 −11 −1 34 0.9 <0.001
CG 2.1 1.0 5.3 257 −5 18 14 2.8
Total EG −20.5 −17.5 13.5 66 −66 −4 34 4.5 <0.001
CG 11.7 8.0 12.7 109 −2 37 14 6.7
Paired Student t test.
* Subtitles.
Abbreviations: CI, confidence interval; N, total population number; VC, variation coefficient.

warm-up techniques were the health-promoting measures with
the best response among EG teachers. The cool-down and full
breathing techniques showed higher difficulty level to be carried
out daily. Studies with voice professionals, who do those exer-
cises routinely, show an increase of sound potential, better clarity
in sound emission, softer vocal attack, and firmness at sound emis-
sion continuity, which favors the propagation of the sound wave
in a continuous and homogeneous way.5,8,19
Concerning vocal cool-down, it was possible to observe the
predominance of active vocal rest followed by gargling. Liter-
ature diverges about the practice of the absolute or passive
phonatory rest after long voice use. Some authors advise not to
interrupt muscle activity totally, but keep reduced level of those
activities (active rest) for faster and easier recovery. Absolute
vocal rest may cause loss of muscle conditioning, transform-
ing a transitory problem into a long-term dysfunction.13 During
physical activity, metabolism produces lactic acid—a sub-
stance that leads to muscle fatigue—which is more quickly
reduced during active rest, as in vocal cool-down.14 Its use is
recommended after the end of public presentations, especially
when there is no use of microphones, through exercises to return
to speaking voice, using yawning and graver and weaker speech.3
The exercises may be associated with body movements.
Reflecting on gargling, research reveals that this technique mo-
bilizes the vocal fold mucosa, promotes mechanical cleaning in
the larynx, being a resource to relieve dysphonia-related pain
and hoarseness.20 Warm water, in its turn, gets in contact with
the wounded mucosa and its warmth causes dilation of pharyn-
geal blood vessels. This increase in circulation helps a larger
number of white blood cells to move to the affected tissue, re-
ducing inflammation.
Changes in the Vocal Symptom Scale scores for the
control group
When not treated by a specialist, chronic vocal problems tend
to remain or worsen. Literature claims that even when joining
Vocal Health Programs, teachers with organic dysphonia are un-
likely to succeed because they need to undergo medical or speech
therapeutic treatment according to their condition.12,21 The pho-
natory disorders caused by organic dysphonia happen regardless
of the person’s vocal habits and behaviors, and this is why the
emotional consequences may be more relevant.22
On the other hand, the organofunctional or functional dys-
phonia, with higher or lower influence of vocal behavior, generally
represent previous vocal alteration, and although the symp-
toms are frequent, they may be less referred by an adaptation
and habituation process. Dysphonia from different etiology is
a challenge for the speech therapeutic intervention. It is essen-
tial to understand the differences between the etiologic categories
to ensure a good clinical practice.16
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2017
The voice symptoms such as throat pain or discomfort, themes
that are common at the questions of the physical area of the VoiSS
(eg, “Do you feel anything stuck in your throat?” or “Do you
have any secretion or hem in your throat?”), normally referred
by individuals with vocal alterations of any nature. There is pos-
itive correlation between the VoiSS scores and the vocal self-
evaluation: the worse the self-evaluation, the higher the VoiSS
score, which highlights a greater perception of vocal symp-
toms. The correlation values are regular, close to the good
correlation bands.16,22 This statement verifies the relevance of
VoiSS to detect vocal alterations (dysphonia) from either func-
tional, organofunctional, or organic origins.
Intergroup stage gains (difference between final and
initial scores)
The EG obtained negative scores because of the decrease of vocal
symptoms, that is, in the period before the intervention, teachers
presented higher vocal symptom score when compared with the
period after the adhesion to the TVHP, and the opposite was ob-
served for the CG. This statistical difference is highly significant
(P value <0.001) because it represents the TVHP effectiveness.
CONCLUSION
The TVHP developed at the Municipal Education Network in
Campo Grande/MS/Brazil, is a brief and innovative interven-
tion program concerning the use of communication and
information technology tools, such as homepage, cell phone ap-
plications, and e-books to reach its goals. It aims to provide
teachers with basilar vocal training in their work environment,
optimizing human communicative potential.
Joining the TVHP did not result in nullity of vocal symp-
toms. The distinction of dysphonia is suggested so that teachers
can undergo medical or speech therapeutic treatment accord-
ing to their condition. For other etiologies, namely functional
or organofunctional dysphonia, better results are expected after
adhesion to the program.
Considering the proposed exercises, the hydration, resonantal
balance, and warm-up techniques had fast adhesion among teach-
ers. The self-referred techniques with higher resistance were vocal
cool-down and full breathing. It is necessary to continue the train-
ing on these aspects.
After becoming aware of solutions to vocal suffering and
through training on anatomophysiology of the phonatory appa-
ratus, dysphonia etiology, vocal hygiene, and vocal techniques,
teachers could improve their phonatory practices in the classroom.
There was improvement in vocal performance after adhe-
sion to TVHP as the vocal symptoms were reduced for the EG
and were stable or increased for the CG. TVHP represents an
authentic and reliable Vocal Health Program model for teach-
ers, capable of being reproduced in the work environment, which
provides the Municipal Health and Education Department with
an innovative work tool to promote collective health. It is up to
public administrators to decide on its continuity, ensuring that
teachers have vocal longevity and life quality measures, which
are the values fostered in this work.
The use of science and technology in favor of collective health
enables both the Education Network and the Health Network
to improve results concerning the services demand, besides
reducing public expenses. This is because attention given to
primary and secondary health issues reduces the risk of dis-
eases onset or aggravation, disability retirement, work
absenteeism, as well as the need for job substitutions or rear-
rangements. Above all, it guarantees that teaching professionals
can work with dignity and satisfaction, observing the funda-
mental principles inherent in every occupation.
REFERENCES
1. Koufman JA, Isacson G. Voice Disorders. Philadelphia: Saunders; 1991.
2. Bos-Clark M, Carding P. Effectiveness of voice therapy in functional
dysphonia: where are we now? Curr Opin Otolaryngol Head Neck Surg.
2011;19:160–164.
3. Behlau M, Pontes P, Vieira VP, et al. Apresentação do Programa Integral
de Reabilitação Vocal para o tratamento das disfonias comportamentais.
Codas. 2013;25:492–496.
4. Hermes EGC, Bastos PHO. The Prevalence of Teachers’ Vocal Symptoms
in Municipal Network of Education in Campo Grande, Mato Grosso do Sul,
Brazil. J Voice. 2015;1997:205–212.
5. Ferreira LP, Giannini SPP, Alves NLL, et al. Voice disorder and teaching
work ability. CEFAC. 2016;18:932–940.
6. Simões-Zenari M, Latorre MDRDD. Changes in behavior associated to the
use of voice after a speech therapy intervention with professionals of child
day care centers. Pró-Fono. 2008;20:61–66.
7. Luchesi KF, Mourão LF, Kitamura S, et al. Problemas vocais no trabalho:
prevenção na prática docente sob a óptica do professor. Saúde e Sociedade.
2010;18:673–681.
8. Cancian P, Passos GC, Martins EC, et al. Projeto Saúde Vocal do Professor:
estratégias de intervenção em grupo-relato de experiência. Ferreira, LP, Silva
MAA, Orgs. Saúde Vocal: práticas fonoaudiológicas. São Paulo: Rocca;
2002:191–197.
9. Dragone MLS, Giannini SPP, Ditscheiner ES, et al. Voz do professor.
2013;20:12.
10. Verdolini-Marston K, Titze IR, Druker DG. Changes in phonation threshold
pressure with induced conditions of hydration. J Voice. 1990;4:142–
151.
11. Verdolini-Marston K, Sandage M, Titze IR. Effect of hydration treatments
on laryngeal nodules and polyps and related voice measures. J Voice.
1994;8:30–47.
12. Sataloff RT. Vocal Health and Pedagogy, Vol. II: Advanced Assessment
and Practice. Plural Publishing; 2006.
13. Mendonça RAD, Sampaio TMM, Oliveira DD. Avaliação do programa de
exercícios funcionais vocais de Stemple e Gerdeman em professores. CEFAC.
2010;12:471–482.
14. Scarpel RD, Pinho SMR. Aquecimento e desaquecimento vocal. Tópicos
em voz. Rio de Janeiro: Guanabara; 2001.
15. Rehder MIBC, Behlau M. Perceptual, auditory and acoustic vocal analysis
of speech and singing in choir conductors. Pró-Fono. 2008;20:195–
200.
16. Moreti F, Zambon F, Oliveira G, et al. Cross-cultural adaptation, validation,
and cutoff values of the Brazilian version of the Voice Symptom
Scale—VoiSS. J Voice. 2014;28:458–468.
17. Santos MND, Marques AC. Condições de saúde, estilo de vida e
características de trabalho de professores de uma cidade do sul do Brasil.
Ciência & Saúde Coletiva. 2013;18:837–846.
18. Hermes EGC, Nakao M. Educação vocal na formação do docente.
Fonoaudiol Bras. 2003;2:48–59.
19. Ijuim JMO, Lacerda CBF. A presença de ruído ambiental e a qualidade da
voz do professor em uma escola cenecista. São Paulo: UNIMEP; 2006.
20. Costa ACD, Jacarandá MB, Coentro V. Programa de saúde vocal em
educadores dos programas educativos da UNICAMP. Sínteses: Revista
Eletrônica do SIMTEC. 2016;307.
21. Thompson AR. Pharmacological agents with effects on voice. Am J
Otolaryngol. 1995;16:12–18.
22. Behlau M, Moreti F, Zambon F, et al. 2016;18:323–325.