Vocal Health Practices Among School Teachers: A Study From Chennai, India

Special Education Teachers' Self-Assessed Voice Health Regarding Voice Use Habits

OBJECTIVES

Special education teachers (SETs) work with students with disabilities. To get and keep these students' attention during the lesson, they may use their voices with high loudness and frequent pitch changes. These situations can be tiring for their voices and affect their vocal health. This study aimed to compare SETs' voice fatigue, reflux symptoms, and self-assessments according to their voice use habits in their work and social lives.

METHODS

A total of 208 SETs were included. A Teacher Voice Use Habits Questionnaire was developed by considering the literature, taking expert opinion, and conducting a pilot study. In addition, the Vocal Fatigue Index (VFI), Voice Handicap Index-30 (VHI-30), and Reflux Symptom Index (RSI) were used. One-way ANOVA, Mann-Whitney U, Kruskal Wallis-H, and Pearson correlation analyses were performed.

RESULTS

Of SETs, 37.5% reported frequent hoarseness, and 65.4% reported voice fatigue during/at the end of the day. Those who answered "yes" to the questions about talking loudly at home, having the television on at home, feeling stressed in the work environment, eating and drinking before going to bed at night, smoking, having frequent colds, talking loudly during the day, and voice fatigue during/at the end of the day had significantly higher scores in all scales. Those who used their voice for more than 6hours were found to have significantly higher scores on the VFI and RSI. In all scales, the scores of those who made very frequent long phone calls were significantly higher.

CONCLUSION

According to the SETs' reports, it was concluded that they did not comply with the rules of vocal hygiene, although they used their voices for a long time. This situation should be considered an occupational health problem in schools, and it may be helpful to screen this group's voice disorders and design preventive programs.

An eclectic Voice Therapy Program for the Treatment of Hyperfunctional Voice Disorders (HFVD)

PURPOSE

An eclectic voice therapy program includes sequenced and structured set of exercises combining direct and indirect intervention methods. Tailor-made exercise prescription with specific cultural adaptations are needed to provide a holistic change to voice quality.1 This study detailed the construction of an exercise prescription for participants with hyperfunctional voice disorder [HFVD] in the Indian context.

METHOD

The exercise program was developed based on literature related to vocal therapy approaches and delivery methods. Adaptations were introduced to a selected set of exercises. Five voice experts verified the exercises and their prescription for content and feasibility of use in the Indian context. Modification suggested by the experts were included for framing the final version of the exercise program. This structured therapy program was planned for 6 weeks (30 minutes duration/session offered individually twice per week, with a gap of two days between sessions in a week) with the goals to improve voice quality, flexibility, and endurance while speaking. Five participants with HFVD partook in the study for pilot testing. Stroboscopy, perceptual voice analysis, Dysphonia Severity Index (DSI) and Vocal Fatigue Index in Tamil (VFI-T) were used to report the therapy outcomes. Participants' report on the learning process and generalization of the program were documented. Wilcoxon-signed rank test was used to test the pre-post outcome measures.

RESULTS

An eclectic voice therapy program, i.e., Comprehensive Voice Habilitation Program [CVHP] was constructed and it included vocal hygiene instructions, warm-up & cool-down, easy onset, resonant voice, and carry over exercises. Participants completed the program in 14-18 sessions (over 7 to 9 weeks of therapy). All participants showed significant changes in vocal fold movement patterns, reduction in ventricular hyperadduction, overall grade of voice quality, DSI and VFI-T. Participants reported that pictorial illustrations, feedback, and monitoring sheets were useful in learning the exercises.

CONCLUSION

CVHP showed significant change in the voice-related outcome measures and was a viable program for treating HFVD.

Voice-Related Problems, Vocal and Non-Vocal Habits in Naradiya Kirtankars: A Preliminary Study

OBJECTIVE

Naradiya kirtan is a part of India's rich folk heritage. Voice demands of the kirtankar (kirtan performer) include a combination of recitation, narration, and singing. Slight to moderate deviations in their voice could hamper their public image as well as endanger their career. A preliminary study was undertaken to explore the voice problems, vocal and non-vocal habits of Naradiya kirtankars.

STUDY DESIGN

Cross-sectional study design.

METHOD

A 22-item questionnaire was developed in English language and translated to Marathi language. This questionnaire was administered on 40 Naradiya kirtankars through purposive sampling. Participants included Naradiya kirtankars located in Mumbai and Pune cities with minimum of one-year training in the field and proficiency in Marathi language.

RESULTS

Statistical analysis revealed that kirtankars might be at a risk of developing voice problems. Among the kirtankars with voice problems, frequently pursued primary occupations involving extensive voice use, performed in a noisy environment, indulged in excessive talking, strained the neck muscles while voicing, impersonated voice, had reduced duration of sleep, and hearing difficulty as compared to kirtankars without voice problems.

CONCLUSION

Study findings highlight the need for dedicated efforts towards increasing the awareness among the kirtankars' about the vocal, non-vocal factors associated with voice problems and the role of voice health-care professionals in voice care.

Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female School Teachers With Voice Problems

BACKGROUND

Teachers suffer greater impacts of voice problems due inappropriate voice use and other contributing factors such as physiological, environmental, and individual & work related issues. Structured vocal hygiene programs (VHP) prevent/reduce the risk of vocal trauma and promote vocal health in teachers. This study aimed to estimate the outcome of instituting a sociocultural relevant vocal hygiene program in facilitating vocal health among female school teachers using a comprehensive voice assessment protocol.

METHOD

VHP was developed emphasizing adequate hydration, healthy vocal diet, posture and alignment, vocal practices while teaching, and ideal speaking environment. This was administered via a face to face session to seventeen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objective, and self-perceptual vocal measures) before and four weeks after the VHP. Inter-rater reliability for perceptual and visual examination was estimated using Intra-Class Coefficient. Wilcoxon signed ranks test was used to compare the pre- and post-treatment measures of continuous variables (acoustic, Maximum phonation time, s/z ratio, Vocal Fatigue Index [VFI] & Voice Disorder Outcome Profile [V-DOP]), and McNemar test was used for categorical variables (vocal health questionnaire, visual examination of larynx and perceptual evaluation of voice).

RESULTS

Teachers reported reduction of unhealthy vocal & nonvocal practices after VHP. Improvements in vocal and related symptoms such as sensation of heart burn (P = 0.031), discomfort around the throat (P = 0.008), inadequate breath control while speaking (P = 0.016) were noticed. Perceptually, minimal improvement was seen in voice quality (overall grade). However, MPT & s/z ratio showed no significant difference. Improvement was observed in frequency range (P = 0.004), low I₀ (P = 0.044), shimmer (P = 0.017), and DSI (P = 0.013). Changes were evident in all parameters of stroboscopic evaluation (except nonvibratory portion & ventricular fold hyper-adduction). V-DOP scores indicated positive change in the overall severity (P = 0.002), physical (P = 0.003) and functional domain (P = 0.034). VFI indicated improvement in teachers voice after a period of voice rest (P = 0.048).

CONCLUSION

Though VHP facilitated in improving the teachers' awareness of at risk phono-traumatic behaviors and vocal health, its efficiency was limited in producing physiological improvement in teachers' voice. The comparison of vocal metrics before & after the treatment provides information on changes that can be expected in teachers after guiding them through a systematic VHP.

Vocal Fatigue in Beat Boxers

PURPOSE

Beatboxers are elite professional voice users with increased vocal loading and therefore are at high risk for developing vocal fatigue. Scientific literature has a wealth of information on self-perceived ratings of vocal fatigue in teachers and singers but not in beat boxers.

AIM OF THE STUDY

The present study measured vocal fatigue in beat boxers and compared their rating of vocal tiredness with two control groups.

METHOD

One hundred seventeen participants enrolled in an online survey. 40 nonsingers, 37 beat boxers, and 40 untrained singers filled the 19 questions of the standardized Vocal Fatigue Inventory in the English language on the Google Form platform.

RESULTS

Mean scores suggest nonsingers rating lowest scores of vocal tiredness followed by beat boxers, and ratings of untrained singers were highest. Statistical significance was observed between and within-group analysis at P < 0.05. Self-awareness of experiencing vocal fatigue was 72.5% and 48.6% in untrained singers and beat boxers, respectively.

CONCLUSION

In sum, the state of evidence suggests that beat boxers have lower scores of vocal fatigue than untrained singers.

The Effectiveness of Vocal Health Programs in the Prevention of Voice Disorders in Teachers: A Systematic Review and Meta-Analysis

PURPOSE

To assess the effectiveness of voice disorder prevention programs and to verify the effectiveness of direct and indirect voice training on the Voice Handicap Index (VHI), Voice-Related Quality of Life (V-RQOL), maximum phonation time (MPT), fundamental frequency and shimmer, for the prevention of voice disorders in regular-school teachers.

METHODS

This is a literature review with meta-analysis, carried out through an electronic search in PubMed, Cochrane Central, Embase, Web of Science, Scopus and BVS, and Google Scholar, as well as ClinicalTrials.gov databases for gray literature.

SELECTION CRITERIA

Randomized clinical trials and quasi-experimental studies were selected. The population consisted of regular schoolteachers, adults, with no vocal complaints submitted to a vocal health education and prevention program of voice disorders classified as direct (direct vocal tract training) and indirect (vocal hygiene guidelines that influence voice production). The outcomes vocal self-assessment: fundamental frequency, aerodynamic measurements (maximum phonation time), acoustic measures (shimmer) was analyzed in comparison with other vocal interventions or no vocal intervention.

DATA ANALYSIS

Studies were independently assessed using the Cochrane Risk of bias and ROBINS-I tools. Effect sizes were calculated only at post-treatment. GRADE criteria were used to assess the quality of evidence.

RESULTS

Twenty-six studies were included but, only 12 studies were included in the meta-analysis and investigated for direct and/or indirect intervention compared to no intervention. No studies were judged to be at low risk of bias, and the quality of evidence was considered high only for the Voice Handicap Index. No evidence was found that suggested effectiveness of direct and indirect voice training for any of the outcomes: VHI -1.87 (95% CI -7.03, 3.30), maximum phonation time -1.11 (95% CI -3.40, 1.17), fundamental frequency 0.87 (-1.06, 2.79) and shimmer 0, 28 (-1.50, 2.05).

CONCLUSION

Results of this study were not considered significant to conclude on the effectiveness of voice training for preventing dysphonia in teachers.

Prevalence of Work-Related Voice Disorders in Voice Professionals: Systematic Review and Meta-Analysis

OBJECTIVE

To analyze the prevalence of work-related voice disorders (WRVD) among the voice professionals.

METHODS

The study protocol was registered in PROSPERO (CRD42021250121). The search was performed in the Embase, Lilacs, Medline, SCOPUS, and Web of Sciences databases. There were no limitations to the year of publication and the search included observational studies which reported data on the prevalence of dysphonia in voice professionals measured through vocal complaints, vocal self-assessment, the auditory-perceptual judgment of the voice, and laryngoscopy examinations. The critical appraisal instrument for studies reporting prevalence data was used to analyze the risk of bias of the studies. Data analysis was performed using Jamovi and R software with a significance level of 5%.

RESULTS

The initial search identified 561 articles, 73 of which were finally included and analyzed. The total number of participants was 63,126. Dysphonia was diagnosed in 45,996 participants based on a vocal complaint, 12,843 using vocal self-assessment, 1,254 using the auditory-perceptual judgment, and 1,683 using laryngoscopies. The prevalence of total dysphonia was 44.0 (95% CI 38.47; 49.69). The prevalence of vocal complaints was 43.9% (95% CI 37.37; 50.52), 42.5% (95% CI 28.57; 57.08) for self-assessment, 53.0% (95% CI 29.87; 77.19) for auditory-perceptual judgment, and 36.9% (95% CI 18.62; 57.08) for laryngoscopic examination. In the auditory-perceptual judgment, voice professionals in class 3 (moderate quality, high demand) had a higher prevalence of dysphonia than those in class 4 (moderate quality, moderate demand) (P = 0.04). In the auditory-perceptual judgment (P = 0.04), there was a higher prevalence of dysphonia in teachers than among other voice professionals non-teachers, and in the laryngeal evaluation, no differences were found between professionals (P = 0.8).

CONCLUSION

There was a high prevalence of dysphonia in voice professionals, especially in the detection by auditory-perceptual judgment. High vocal demand and being a teacher influenced the increase in the prevalence of WRVD.

Comparison of Client-Led Asynchronous and Clinician-Led Synchronous Online Methods for Evaluation of Subjective Vocal Measures in Teachers: A Feasibility Study

BACKGROUND

COVID-19 has transformed face to face teaching in classrooms to online and hybrid modes. Increased vocal intensity/ pitch to call attention of students and transact in the online class, inappropriate posture (head, neck & upper trunk) while using the laptop and other online tools cause vocal loading leading to voice related concerns in teachers. Tele voice assessment is a feasible alternative means to seek professional help in the current situation and possibly in the future too. Client-led asynchronous and clinician-led synchronous voice recordings for clinical vocal measures among school teachers were compared in this study.

METHOD

Twenty-five school teachers (21 females & four males) from Chennai consented to the study. Information of voice use, its impact on the day-to-day situations, self-perception of vocal fatigue, and their recorded voice sample (phonation & speaking) were obtained online (asynchronous mode). Within a period of ten days, the clinician-led synchronous session was planned on a mutually convenient time for obtaining voice samples through zoom call. The voice samples obtained were compared for clinical measures and perceptual voice evaluation.

RESULTS

Participants reported of vocal symptoms and increased vocal fatigue scores. The maximum phonation time values obtained through synchronous mode were lesser when compared to asynchronous mode. Also, variability was noted in the perceptual vocal measures of voice samples obtained through synchronous mode. During synchronous voice recording & evaluation, the background noise, internet stability, audio enhancement feature, and microphone placement & quality could be monitored, and immediate feedback was provided. Additionally, the asynchronous recording can be supplemented for synchronous recording, with clear instructions & demonstration.

CONCLUSION

This study explored the feasibility of using synchronous and asynchronous voice recording for voice analysis in school teachers. The findings could serve as a base to understand the advantages and challenges of using client-led asynchronous and clinician-led synchronous methods for estimating vocal measures.

Perception of Primary School Teachers Towards Voice Problems and Vocal Health-Seeking Behaviors: A qualitative study

OBJECTIVE

Teachers are the most common occupational group reporting to the voice clinics with dysphonia across the globe. However, less is known about teachers' perceptions about their voice and voice problems. Hence the present study aimed to explore teachers' perception about their teaching voice, voice problems and vocal health-seeking behaviors.

METHOD

A qualitative phenomenological research design using semi-structured interviews were conducted with fifteen female primary school teachers. Participants were asked to express their perception of teaching voice, vocal health care knowledge, and vocal hygiene practices. Using inductive analysis, the researchers converted the raw data into concepts or themes and discussed.

RESULT

The present study results showed that teachers perceive voice as the primary tool for their profession. However, teachers consider voice problems as part of their professional commitments. Despite knowing the harmful effects of voice problems, teachers' pay less attention to their voice problems and perceive them as usual, unavoidable and part of their profession. Due to their demanding work schedule and not getting enough support from the management, they hesitate to consult medical professionals unless it severely affects them.

CONCLUSIONS

The data obtained from this study can be used to improve the teachers' knowledge regarding vocal health and convince the school management to extend their support for the successful implementation of the vocal health training programs for teachers.

Risk factors for voice disorders in public school teachers in Cyprus

AIMS

The purpose of this study was to investigate risk factors for self-perceived voice disorders in teachers in Cyprus in order to determine the necessity for a preventative vocal hygiene education program which could improve their work performance.

METHODS

An online questionnaire was completed by 449 teachers. The questionnaire extracted data regarding risk factors that may contribute to the development of voice disorders, occupational consequences of voice disorders and vocal hygiene education, as well as, a self-perceived severity of a participant's voice problem. Subjects were split into two groups, teachers with Voice Disorder Index (VDI) ≤ 7 and teachers with VDI > 7. The chi-squared test was used to explore the differences in responses for each voice risk factor, occupational consequence and vocal hygiene education between the two groups.

RESULTS

Teachers in the VDI > 7 group were more likely to frequently experience nasal allergies and respiratory infections, coughing, throat clearing, stress and yelling, have shorter breaks between classes, use loud voice, use their voice to discipline students, teach above students talking, etc. than teachers in the VDI ≤ 7 group. Moreover, teachers in the VDI > 7 group were more likely to limit their ability to perform certain tasks at work and reduce their activities or interactions "3-5 or more days" annually due to voice problems.

CONCLUSIONS

Health, voice use, lifestyle, and environmental factors may play a part in the development of voice disorders in teachers and have an impact on their job. Therefore, a preventative vocal hygiene education program is suggested.

Occupational voice is a work in progress: active risk management, habilitation and rehabilitation

The current article reviews recent literature examining occupational voice use and occupational voice disorders (January 2018–July 2019).

Cultural and Linguistic Adaptation of Vocal Fatigue Index for Tamil-Speaking Population (VFI-T)

OBJECTIVE

To adapt the vocal fatigue index (VFI) for the Tamil-speaking population.

STUDY DESIGN

Cross-sectional research design METHOD: VFI developed originally in English was translated in the Tamil language, a South Indian Dravidian language. Content validity and reverse translation of VFI in Tamil [VFI-T] was done. The final of VFI-T was administered on 251 subjects with voice concerns/ problems and on 100 individuals with perceptually normal voice for validity and reliability measures.

RESULTS

Factor analysis of VFI-T yielded four factors as opposed to three factors in the English version of VFI. The four factors were extracted based on Eigenvalue and variance contributed by each factor namely, I-physical discomfort; II-tiredness of voice and avoidance of voice use; III-increased effort and its effect on voice quality, and IV-Improvement of symptoms with rest. Varimax rotation and factor loading values for individual items identified five items under factor I; seven items under factor II; four items under factor III, and three items were preserved under factor IV. Overall Cronbach's alpha coefficient was 0.91 and alpha values for four factors ranged from 0.75 to 0.85. Item-to-total correlation revealed good internal consistency between the items. The median and interquartile range of VFI-T for cases and controls were viz., I-6.00 (10.00); 0.00 (1.00), factor II-12.00 (11.00); 1.00 (3.00), factor III-7.00 (8.00); 1.00 (2.00), and factor IV-6.00 (6.00); 1.00 (3.00), respectively. Mann-Whitney U test revealed a significant difference between the scores of cases and controls (P < 0.00). Logistic regression suggested sensitivity of 96% and a specificity of 79% for the inventory in the Tamil language.

CONCLUSION

VFI-T identified and documented vocal fatigue under four factors in subjects with voice disorders.