Quality of Life, Self-Perceived Dysphonia,
and Diagnosed Dysphonia Through Clinical
Tests in Teachers
*Iara Barreto Bassi, *Ada Ávila Assunção, †Adriane Mesquita de Medeiros, Letı́cia Neiva de Menezes,
‡Letı́cia Caldas Teixeira, and ‡Ana Cristina Côrtes Gama, *yzMinas Gerais, Brazil
Summary: Objectives. To examine the impact of voice on the quality of life of teachers and to assess whether the
degree of dysphonia and otorhinolaryngologists’ (ORL) diagnostics are correlated with the quality of life.
Methods. Eighty-eight female teachers from the municipal schools of Belo Horizonte who were in speech therapy at
the Speech Therapy Clinic of the Hospital das Clı́nicas of Minas Gerais participated in the study. The variables studied
were age, ORL diagnosis, perceptual-hearing assessment of voice through GRBAS scale, and vocal activities and participation profile (VAPP) protocol. Statistical analysis was performed through the descriptive analysis of the data and the
Spearman coefficient of correlation.
Results. The average age of the participants was 38 years. Vocal deviation: degree 1—56 teachers (63.6%); degree
2—27 teachers (30.6%); and without vocal deviation—five teachers (5.6%). It was found that 57.9% of the teachers
presented combined ORL diagnosis. No statistically significant relationship was observed among the ORL diagnosis,
the degree of dysphonia, and the parameter values of quality of life assessed by VAPP.
Conclusions. The examined participants of this study presented light degree of vocal deviation and ORL combined
diagnosis. According to the figures obtained by VAPP, there was negative impact of voice on the quality of life of female
teachers, but these impacts were not correlated with ORL diagnosis and grade of dysphonia.
Key Words: Quality of voice–Quality of life–Teachers.
INTRODUCTION
The health concept of the World Health Organization (WHO)1
was extended to include aspects of quality of life in the definition of physical, mental, and social wellness. For WHO, quality
of life concerns the individual’s perception of his or her position
in life according to the cultural context and value systems in relation to his or her goals, expectations, and interest standards.
The quality of life can be affected by physical and psychological health, level of dependency, social relationships, and
personal beliefs besides the environment.
This study aims to analyze the quality of life related to vocal
health of female teachers. The dysphonia is manifested in different ways, such as hoarseness, voice loss, pain and fatigue
when speaking, voice failures, lack of voice projection, and difficulty in speaking with high intensity. Such complaints cause
sick leave, removal, and functional readaptations, with clear
damage for the teacher, the school community, and the society
as a whole.2
Considering the multidimensional nature of dysphonia, the
Phoniatry Committee of the European Society of Laryngology
suggests the use of a broad protocol for vocal quality, including
the perceptual hearing, videostroboscopic, acoustic, aerody-
Accepted for publication October 26, 2009.
From the *Department of Health Science, Universidade Federal de Minas Gerais, Belo
Horizonte, Minas Gerais, Brazil; yDepartment of Biological Sciences, Centro Universitário de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil; and the zDepartment of
Speech Therapy, Universidade Federal deMinas Gerais, Belo Horizonte, Minas Gerais,
Brazil.
Address correspondence and reprint requests to Iara Barreto Bassi, Av. Bernardo de
Vasconcelos, 2600/306 Ipiranga, CEP 31160-440, Belo Horizonte, Minas Gerais, Brazil.
E-mail: [email protected]
Journal of Voice, Vol. 25, No. 2, pp. 192-201
0892-1997/$36.00
Ó 2011 The Voice Foundation
doi:10.1016/j.jvoice.2009.10.013
namic, and self-perception of vocal-alteration assessment
through quality-of-life protocols.3
The self-perceived quality of life is a key point in the therapeutic approaches. This is because the self-assessment in front
of a voice alteration and its impact on everyday life may influence the motivation and adherence to the treatment.
From this perspective, the protocols of self-assessment are
developed aiming to measure results based on the perception
of the patient. The strategy is to collate subjective measures
(self-perception) and objective measures (in this case, the
professional speech assessment) to have a more appropriate
clinical perspective. In this direction, multiple-choice selfassessment alternatives and visual analog scale are used.4
It is important to highlight that validated instruments—whose
goals are vocal self-assessment—exist and that some are translated to Portuguese. Four of these instruments are widely cited
and used in specific studies, namely, (1) Voice Handicap Index
(VHI),5 (2) Voice-Related Quality of Life (V-RQOL),6 (3) Voice
Outcome Survey (VOS),7 and (4) Voice Activity and Participation Profile (VAPP)8 (Appendix 1).
The VAPP was used in the present study, because it presents
the attempt to capture the effects of voice alterations on occupational activities. The VAPP (Appendix 2), translated and
validated to Brazilian Portuguese,9 allows the identification—
through responses to a self-applied questionnaire—of relationships between the presence of a vocal alteration and the willingness to participate in daily activities. It is a protocol of easy
application and provides valuable information about the impact
of voice on the life of the individual.
The profile of the teachers referred to speech therapy was
studied to identify elements for the elaboration of measures to
promote vocal health, with the aim of assessing the vocal quality of life. The study was carried out with approximately 150
Iara Barreto Bassi, et al
Impact of Voice on Quality of Life of Teachers
teachers from the municipal schools of the city of Belo Horizonte (BH). Participants were patients of the Speech Therapy
Clinic of the Hospital das Clı́nicas of the Universidade Federal
de Minas Gerais (AF-HC-UFMG).
The article analyzes the impact of voice on the quality of life
in the dysphonic teachers referred to speech therapy. The following variables were considered for analysis: results of the
VAPP of teachers with dysphonia and parameters, such as
age, grade of dysphonia, and otorhinolaryngologist’s (ORL)
diagnosis. The purpose was also to identify associations among
ORL diagnosis, degree of dysphonia, and the VAPP results of
teachers referred for speech therapy.
METHODS
A cross-sectional study was conducted based on the vocal evaluation of municipal teachers in BH with dysphonia referred for
speech therapy in AF-HC-UFMG. Confirmation of dysphonia
by the speech assessment and the teacher occupation were
the criteria for inclusion in the sample. Male teachers were
excluded.
Eighty-eight teachers participated in the study. The participants were evaluated from August 2007 to May 2008 through
the following protocols: (1) the protocol specifically developed
for this study and (2) the VAPP. The protocol developed for this
study specifically addressed the following parameters: age,
vocal auditory-perceptual assessment (degree of dysphonia),
and ORL diagnosis.
The perceptual-hearing vocal assessment was performed
using the GRBAS scale.10 This scale examines the following
characteristics: voice roughness (R), breathiness (B), asthenia
(A), and strain (S) that together determine the grade of dysphonia (G). Each of these aspects can be classified on a scale from
0 to 3, where 0: ‘‘no alteration,’’ 1: ‘‘mild alteration,’’ 2: ‘‘moderate alteration,’’ and 3: ‘‘severe alteration.’’ The parameter G,
which determines the grade of dysphonia, was the only one
considered in the data analysis.
Regarding the ORL diagnosis, responses were grouped into
categories of laryngeal normality, glottic gap, benign mass
lesion (nodule, polyp, edema, thickening, leukoplakia), and
combined diagnosis (identification of two investigated alterations on the same subject).
The VAPP is composed of 28 questions, divided into five
parameters: self-perception of the vocal problem severity and
the effects of this alteration at work, daily communication, social communication, and expression of emotions. Besides the
five mentioned parameters, it is still possible to measure activity
limitation and participation restriction—the first is calculated
by the sum of the first questions of each parameter, and the second is calculated by the sum of the second questions of each
parameter. For each question, the participants’ answer according to their perception is represented on an analog scale of
10 cm: not affected (left) and affected (right). The scores
were tallied in the following manner:
A. Each section of the questionnaire constitutes a section
score. Therefore, there were five section scores:
B.
C.
D.
E.
193
1. Self-perceived voice problem score (one question,
maximum score ¼ 10)
2. Job section score (four questions, maximum score ¼ 40)
3. Daily communication section score (12 questions,
maximum score ¼ 120)
4. Social communication section score (four questions,
maximum score ¼ 40)
5. Emotion section score (seven questions, maximum
score ¼ 70)
The sum of the five section scores gave rise to the total
score (maximum score ¼ 280).
Items in each of sections 2 (job), 3 (daily communication), or 4 (social communication) were further computed
to give rise to two additional scores for each section:
1. Activity limitation score (ALS): computed from the
first question of each situation, which ascertained
the extent of activity limitation
2. Participation restriction score (PRS): computed from
the second question of each situation, which ascertained the extent of participation restriction
The ALS from sections 2, 3, and 4 were summed to give
the total ALS.
The PRS from sections 2, 3, and 4 were summed to give
the total PRS.
Age, grade of dysphonia, ORL assessment, and VAPP
parameter data were analyzed to characterize the participants
of the study. Additionally, a few variables were correlated to
identify the factors related to the quality of life of the sample.
Statistical analyses were performed through measures of
central tendency and dispersion and Spearman correlation
coefficient. The statistical software Statistical Package for the
Social Sciences (SPSS) version 15.0 (IBM Company, Chicago,
IL) was used. The coefficient values ranged from 1 to 1.
The value 0 corresponds to the existence of no linear relationship. The value 1 indicates perfect linear relationship, and the
value 1 also indicates perfect linear relationship, however
reversed, that is, when one variable increases, the other one decreases. The closer a correlation is to 1 or 1, the stronger is the
linear association between the two variables. The significance
level adopted in this study was P < 0.05. This study was approved by the Research Ethics Committee of the Federal University of Minas Gerais under number 482/08.
RESULTS
The age of the 88 teachers who participated in the study ranged
from 25 to 68 years, and the average age was 38 years. On the
hearing perceptual assessment, only five teachers (5.6%)
showed no degree of vocal alteration, 56 (63.6%) presented degree 1 (mild) vocal alteration, and 27 (30.6%) presented degree
2 (moderate) vocal alteration.
The following distribution of participants was obtained
according to ORL diagnosis: seven (7.9%) presented laryngeal
normality, 17 (19.3%) presented glottic gap, 13 (14.7%)
presented a benign mass lesion, and 51 (57.9%) presented
a combined diagnosis (Table 1).
194
Journal of Voice, Vol. 25, No. 2, 2011
TABLE 1.
Frequency (%) of Degree and Otorhinolaryngological
Diagnosis
TABLE 2.
Average Values of the Parameters of the VAPP
Variable
Variable
n
%
G (degree of dysphonia)
0 ¼ no alteration
1 ¼ mild alteration
2 ¼ moderate alteration
5
56
27
5.6
63.6
30.6
Otorhinolaryngological diagnosis
Laryngeal normality
Glottic cleft
Benign mass lesion
Combined diagnosis
7
17
13
51
7.9
19.3
14.7
57.9
Median
Mean
SD
62.3
4.1
9.25
12.7
43.3
4.1
12
22.2
54.4
2.6
11.1
26.5
5.5
7.3
13.4
31.1
27
14.2
27.3
26
VAPP
Total
Autoperception
Effect at work
Effect in daily
communication
Effect in social
communication
Effect in the emotions
Activity limitation
Participation restriction
3
11.85
22.95
18.85
Abbreviation: SD, standard deviation.
The following values were obtained for the five parameters
related to quality of life measured through VAPP: total, 62.3;
self-perception, 4.1; effects at work, 12; effects on daily communication, 22.2; effects on social communication, 5.5; and effects
on emotion, 13.4. The measure concerning the limitation of
activity was 31.1, and the one concerning the restriction of participation was 27 (Table 2). The first VAPP parameter—vocal
self-assessment—was positively correlated to other qualityof-life parameters. It was obtained as a positive mean association
(Table 3). There was no statistically positive association among
the five parameters and the total VAPP score with other variables
(grade of dysphonia ‘‘G’’ and ORL diagnosis) (Table 4).
DISCUSSION
The results described show that the impact on quality of life
resulting from dysphonia is not correlated to the speech therapist’s and ORL diagnoses. One the other hand, it was observed
that the negative impact on quality of life is correlated to the
perception of the individual about his or her voice. To be
precise, the more dysphonic the individual consider himself
or herself, higher the VAPP results are, reflecting limitations
in daily activities related to voice use.
The mean age of the sample—38 years—is similar to the findings of other studies on the teacher population.11–14 The degree
of dysphonia exhibited—obtained through the perceptive hearing assessment—were as follows: 63.6% of teachers presented
mild degree and 30.6% presented moderate degree (Table 1).
Similar results were found on a study that assessed 40 teachers
with voice alterations who were distributed as follows: 9%
presented no degree of vocal deviation, 50% presented mild
alteration degree, 20% presented moderate alteration degree,
and 7.5% presented severe alteration degree.15
About 57.9% of the sample presented combined ORL diagnosis, that is, the existence of more than one laryngeal alteration
(Table 1). It is plausible to assume that this result is related to
the occupation of the participants, once it is expected that the
intense and excessive voice demand—sometimes associated
with adverse ergonomic conditions—explains the vocal abusive
behaviors and risks of developing dysphonia.16,17
The obtained result is in disagreement with another study18
that identified the combined diagnosis in only 17.1% of
teachers in a sample of 164 teachers of the municipal schools
of the city of BH, who were kept away because of vocal
problems. Discrepancies among studies may be attributed to
the lack of standardized classification of the laryngeal disorder
grouping or to the differences in the parameters used by ORLs.
The values found for the VAPP parameters (Table 2) may be
considered low if taking into account the maximum score
allowed by the test. However, the scores are above the average
values measured for quality of life in cases of normal vocal situations according to the creators of the protocol.8 This is in line
with the translation and validation for Brazilian Portuguese9
(Table 5).
There was a study in which 40 participants with dysphonia
and 40 participants with no vocal alterations were assessed using the vocal assessment and VAPP. The group with dysphonia
showed superior results in all parameters when compared with
that without dysphonia.8
Regarding the translated and validated VAPP,9 authors
analyzed the responses of 25 dysphonic subjects and 25 individuals without complaints of dysphonia through a questionnaire.
Higher values were observed in the group of participants with
TABLE 3.
Spearman’s Correlation Between Autoperception and
Other VAPP Scores
Pair of Variables
Autoperception/work
Autoperception/daily
communication
Autoperception/social
communication
Autoperception/emotions
Autoperception/total
Autoperception/activity
limitation
Autoperception/
participation restriction
Significant correlation, P < 0.01.
Spearman R
P Value
0.61
0.57
0.000
0.000
0.37
0.000
0.59
0.69
0.68
0.000
0.000
0.000
0.60
0.000
30.8
34.1
43.3
13.4
5.5
22.2
12
4.1
Data of the research
Teacher
Abbreviation: NI, not informed.
NI
NI
NI
12.5
4.2
13.4
2.3
Dragone, 200820
Teacher
5.8
NI
NI
NI
NI
1.8
98.8
0.4
24.2
0.2
12.7
0.9
43.1
0.1
5.5
Ricarte and Behlau, 20069
Normal
With dysphonia
0.2
13.3
4.7
48.1
4.2
39.3
23.8
7.7
41.3
26.8
16.8
114.5
69.77
3.3
27.8
15.5
1.5
12.3
6.1
8.1
50.4
33.8
2.2
18
10.6
dysphonia when compared with the results obtained from the
group of participants without dysphonia.
In summary, the results of the present study converge to those
of other studies regarding the self-perception of quality of life in
participants with dysphonia. It is possible that, despite the low
values obtained for the VAPP parameters, there is a high negative impact of dysphonic processes on the quality of life of the
group of teachers.
The values obtained by the dysphonic group regarding the
validation of the VAPP translation9 were higher than those obtained in the present study for the parameters of daily, social,
and emotional communication. However, there are similarities
among the findings regarding the parameter ‘‘work effects.’’
This convergence suggests that there is no doubt regarding
the effects of dysphonia on the scope of work when studying
the quality of life in dysphonic teachers.
When analyzing studies involving teachers,19 the authors
evaluated three different groups, categorized as follows: the
first group composed of 30 individuals without voice alteration,
the second one composed of 30 dysphonic individuals, and the
third one composed of 30 teachers who participated in a workshop for vocal enhancement. The findings indicated that the
group with lower values—and, therefore less impact on quality
of life—was the group of teachers with no vocal alteration,
followed by the group of teachers with no complaint, and
then by the dysphonic teachers. Such results suggest that the
presence of dysphonia itself generates an impact on quality of
life followed by the exposure of the professional use of voice.
TABLE 5.
VAPP Values in Centimeters of the Various Studies8,9,19,20
Significant correlation, P < 0.01.
1.1
6.2
3.7
0.53
Ma and Yiu, 200219
Normal
With dysphonia
Teacher
0.06
7.5
56.8
0.06
0.31
0.40
13.2
111.1
0.20
0.10
0.09
0.4
3.5
0.92
0.3
3.1
0.01
0.58
4.2
0.54
0.75
0.4
4.3
0.06
0.03
1
6.2
0.11
Ma and Yiu, 20018
Normal
With dysphonia
0.17
Activity
Limitation
Diagnosis ORL/
autoperception
Diagnosis ORL/work
Diagnosis ORL/daily
communication
Diagnosis ORL/social
communication
Diagnosis ORL/emotions
Diagnosis ORL/total
Diagnosis ORL/activity
limitation
Diagnosis ORL/participation
restriction
Total
0.07
0.49
0.52
0.97
0.33
0.45
0.42
0.65
Effect in
the Emotions
0.19
0.07
0.07
0.00
0.10
0.08
0.08
0.04
Effect in Social
Communication
G/autoperception
G/work
G/daily communication
G/social communication
G/emotions
G/total
G/activity limitation
G/participation restriction
Effect in Daily
Communication
P Value
Effect at
Work
Spearman R
Participation
Restriction
TABLE 4.
Spearman’s Correlation Between VAPP Scores and
Degree of Dysphonia and Otorhinolaryngological
Diagnosis
Pair of Variables
195
Impact of Voice on Quality of Life of Teachers
Autoperception
Iara Barreto Bassi, et al
196
There is convergence with the results of another study20 that
assessed 502 teachers who did not present dysphonia diagnosis
and participated in a workshop of vocal improvement.
The author found VAPP parameter values superior to those
found by other researchers19 in groups of patients with no vocal
alteration (control group). However, the parameter values obtained for the control group were lower than those of the group
of dysphonic participants.
According to these results, when comparing dysphonic with
nondysphonic teachers, one can affirm that the negative impact
on quality of life is more intense in the first group.
High standard deviation values were observed for the VAPP
parameters. However, it is important to consider the power of
the sample, homogeneous regarding the origin and the occupational position and also regarding the vocal characteristics. This
may explain the origin of VAPP parameter results’ dispersion,
which occurs probably because of the peculiarity of vocal manifestation over the quality of life, showing that teachers experience dysphonia in a very particular manner.
In the present study, there was a positive average correlation
between the self-vocal perception and the other VAPP parameters (Table 3). This positive correlation, which indicates the
impact of vocal alteration on the quality of life, was also studied
in a sample of 93 teachers from eight kindergartens of the city
of São Paulo. The authors found a prevalence of 79% of selfreported vocal alteration, which was statistically associated
with the presence of dysphonia diagnosed by vocal assessment
(79%).21 In another study,4 similar results were obtained in
a group of 31 dysphonic individuals. The authors observed a statistically significant correlation between the results of V-RQOL
and vocal self-perception, in social/emotional and physical
domains.
There was no positive strong correlation among VAPP
parameters, the degree of dysphonia, and the ORL assessment
(Table 4). This indicates that the manifestation of dysphonia
and the fact of living with the speech therapy and ORL diagnosis may not influence life and work quality.
In the literature, studies that used different protocols to assess
quality of life and that investigated possible relationships
among the impacts on quality of life, such as degree of dysphonia, speech pathology, and ORL diagnostic, were found. In a set
of studies, parameters that correlate with the mentioned categories22–24 and studies that do not confirm the relationship
among these categories4,25–27 are presented.
Discrepancies in the results of the quality-of-life assessment
are observed. These discrepancies are dependent on the type of
diagnostic procedure for dysphonia: speech pathology or ORL
assessment.26 For the authors, in the first case, when aiming the
perception of the patient, the results approximate to social and
emotional vocal effects. This occurs, because it is considered
from the point of view of the patient as to his or her dimensions.
In the second case, the clinical evaluation aims to identify the
perception of dysphonia in a relatively sterile context. In summary, patient and clinical experiences do not assess dysphonia
and its implications under the same aspects.
A study28 evaluated the factors associated with the poorer
quality of life related to voice in 2133 teachers of BH. The inter-
Journal of Voice, Vol. 25, No. 2, 2011
nationally standardized questionnaire—the V-RQOL—was used
to measure the life quality. The V-RQOL presents two domains:
socio-emotional and physical. Despite the high prevalence of
vocal fatigue and worsening of vocal quality observed, the
V-RQOL scores did not reflect the expected influence of these
symptoms on quality of life of the surveyed teachers. Less creativity at work and bad relationships with students were related to
the poorer quality of life related to voice in both domains. Mental
disorder was associated only with the socio-emotional domain.
Classroom noise was associated only with the physical component. Therefore, such findings reflect that the aspects that may
negatively influence the quality of life related to voice are not
purely restricted to vocal factors, but they interact with social,
emotional, and environmental factors.
It is plausible to assume that the perception of patients on
what is ‘‘acceptable’’ or ‘‘normal’’ widely varies according to
their expectations. Altered voices according to the diagnosis
of the specialist may continue to allow the development of
the patient responses to social and professional demands of
the patient. In this case, there will be no perceived limitation.
Such questions may ask wider approaches regarding the set
of dimensions involved in the health-disease process and the
connections between work and health.
Regarding the instruments used, it is important to note that
the Scientific Advisory Committee, created by Medical Outcomes Trust, set a series of attributes and criteria to evaluate
the reliability of instruments for measuring quality of life.
Five years later, such criteria were updated and reviewed. These
new criteria are the following: sensitivity, interpretability, management and response demand, alternative forms of implementation, cultural and linguistic adaptation, conceptual and
measurement model, reliability, and validity.29
A study30 was carried out with the aim to evaluate four quality-of-life protocols related to voice. The study compared the
aforementioned eight criteria. None of the four tested protocols
satisfactorily responded to the eight criteria. VHI and V-RQOL
responded well to seven criteria, VOS to five, and VAPP to four.
The protocols present peculiarities that make them complementary and not entirely interchangeable.
The VAPP was used in the present research, because at its
core is the attempt to capture the effects of voice disorders on
occupational activities. Among all the existing instruments
that evaluate quality of life related to the voice, VAPP more
contemplates in its questions situations related to the occupational context seeking the relationship between quality of life
and voice in the dimension of work. Thus, if dealing with a study
with professional citizens of the voice, the choice of the VAPP
is made relevant.
Voice use is an integral part of the teaching profession; hence,
one may expect that it would be difficult for teachers to avoid
voice activities related to their jobs, despite the limitation imposed by their voice problems.
This report has shown how some members of the teaching
profession perceived the impact of voice problems on their
lives. It should be noted that voice problems affect not only their
jobs as teachers but also have an impact on their daily communication, social communication, and emotions. These
Iara Barreto Bassi, et al
Impact of Voice on Quality of Life of Teachers
consequences are not merely determined by the severity of the
voice problem; they are related to how an individual perceives,
reacts, and adjusts to the voice problem.
Such information is useful because health care workers can
plan their services appropriately for this professional group in
response to what and how different communicative activities
are being affected by voice disorders. Health care workers
may want to consider how they could modify the working
environment of the teaching profession to reduce the limitation
imposed on teaching activities and restore their quality of life.
The results suggest the introduction of the functional impact
of dysphonia on traditional evaluations strongly focused on
perceptual hearing and acoustic data. Thus, it may be useful
to address the aspects surrounding the life of the individual
and the self-perception of the problem, which affect the alteration itself, and to provide a comprehensive approach of the
dysphonia.
FINAL CONSIDERATIONS
The teachers referred to speech therapy present functional and
organic-functional dysphonia with mild degree of vocal deviation and combined ORL diagnosis. There was no statistically
significant relationship between the studied categories (degree
of dysphonia and ORL diagnostic) and the VAPP parameters.
However, the VAPP values demonstrated negative impacts of
the voice on the quality of life of the investigated individuals.
There is a positive average correlation between vocal selfperception of dysphonic teachers and the analyzed dimensions
of quality of life.
The results of the present study allowed us to know the profile
of the teachers with dysphonia and the development of
measures for promoting the vocal health. The patient’s perception about his or her own voice helps in therapeutic direction
and approach, which may contribute to treatment adherence
and success. Furthermore, such knowledge can contribute to
a therapeutic action in accordance with the present demands.
Acknowledgment
This research would not have been possible without the assistance of Research Support Foundation of the Minas Gerais FAPEMIG (4281-5.06/2007).
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APPENDIX 1. VOICE ACTIVITY AND PARTICIPATION PROFILE
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APPENDIX 2. PERFIL DA PARTICIPAÇÃO E ATIVIDADES VOCAIS
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