ARTICLE IN PRESS

Risk Factors of Voice Disorders and Impact of Vocal

Hygiene Awareness Program Among Teachers in Public
Schools in Egypt
*Sarah A. Bolbol, *Marwa M. Zalat, *Rehab A.M. Hammam, and †Nasser L. Elnakeb, *†Egypt

Summary: Objectives. Even though many studies have explored the problem of voice disorders among teachers
worldwide, this problem is still not adequately studied in Egypt. The following study was conducted to investigate the
risk factors of voice disorders among an Egyptian sample of school teachers, to measure the effect of a vocal hygiene
awareness program on them, and to investigate their vocal cord lesions.
Methods. One hundred fifty-six teachers working in public schools and 180 administrative workers in the Faculty
of Medicine in the same city participated in this study. They completed a self-administered questionnaire investigating
voice disorders, and were subjected to a voice awareness program and a clinical examination.
Results. Voice-related symptoms and Voice Handicap Index were statistically significantly higher among teachers
compared with the control subjects. Work duration and high frequency of classes per week of ≥15 were the most sta-
tistically significant indicators influencing a teacher’s voice. Three months after application of vocal hygiene awareness
program, the teachers who were studied showed a statistically significant increase in their awareness about vocal hygiene
tips.
Conclusions. Egyptian teachers working in public schools are dealing with classes that include a great number of
students per class. They also have to deal with unprofessional facilities and limited assisting resources. Therefore, they
are highly exposed to the risk of voice-related disorders. Increasing awareness about healthy behavior with the voice
in their occupations will help in improving their quality of work and in minimizing any permanent impairments and/
or disability.
Key Words: Risk factors–Teachers–Vocal hygiene–Voice disorders–Voice Handicap Index.

INTRODUCTION Moreover, voice abuse or misuse, laryngeal irritation, and voice

Voice-related disorders represent a high risk of a disorder that
has been found among professional voice users like teachers.1
Voice problems can be seen as a combination of self-reported
symptoms and clinically observed signs.2 This has been pro-
posed by the World Health Organization in the new version of
the International Classification of Impairments, Disabilities and
Handicaps.3 Therefore, if individuals during their career report
sufficient apprehensions and continuous disruption in their voice,
their observations to their own voice health should not be
overlooked.
The prevalence of vocal dysfunction among teachers com-
pared with other occupations in one of the largest epidemiologic
studies to date (Roy et al1) was significantly high, P < 0.001
(11.0% vs 6.2%). Teachers’ job requirements of being able to
speak loudly for long periods in loud classrooms enhance the
occurrence of occupational voice-related disorders.4 Also, the un-
suitable work environment like a hot, poorly ventilated loud
environment, overcrowded classrooms, chalk dust, work orga-
nization problems, violence, lack of discipline, and disrespect
can predispose individuals to adverse general and vocal health.
Accepted for publication July 18, 2016.
Competing interests: The authors declare that there are no competing interests. This
research paper was financed totally by the authors of the study.
From the *Department of Community, Environmental and Occupational Medicine, Faculty
of Medicine, Zagazig University, Egypt; and the †Department of Phoniatrics, Faculty of
Medicine, Zagazig University, Egypt.
Address correspondence and reprint requests to Sarah A. Bolbol, Department of
Community, Environmental and Occupational Medicine, Faculty of Medicine, Zagazig
University, Egypt. E-mail: sar_bo@yahoo.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.07.010
competition all can lead to voice disorders.5
In like manner, high rates of population growth in Egypt lead
to rapid increase in the number of students’ enrollment rates,
which leads to high class density in Egyptian public schools,
with the average amount of students in class for elementary,
middle, and high schools being 44, 42, and 39, respectively, as
reported by the Ministry of Education.6
Voice problems have disadvantageous effects on teaching per-
formance and communicative capacity, and can also impair daily
activities and social functioning.7 These effects lead to work per-
formance that is below the standard, increase absenteeism, and
can even force teachers to end their career because of vocal
difficulties.7,8 The economic load of voice dysfunction in teach-
ers is enormous in the form of lost wages, decreased productivity,
cost of substitute teachers, and impact on non-work activities.
The estimated societal cost of voice problems among U.S. teach-
ers, as an example, is $2.5 billion annually, considering lost work
days and treatment expenses.9
In Egypt, the teaching profession tends to be associated with
a low social and economic status, as teachers’ salaries rarely
amount to more than 1600 LE ($281) a month, which leads teach-
ers to double their work hours and pay as private tutors in order
to supplement their salaries.10 They do this because they need
to be able to live off of their occupation. As they studied earlier
in life for this occupation, they are not able to change their career
paths into a more successful one now.
The problems of overcrowding within classes in Egyptian
public schools in addition to faulty facilities do not create an
environment conducive to learning. However, to reduce the pres-
sures caused by overcrowding, many schools operate in shifts,
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016
especially with limited resources as the government budget is
already under strain. All these combined factors lead to increas-
ing the risk of having occupational voice disorders among working
teachers in Egyptian public schools and persistent need of ap-
plying solutions and awareness programs to reduce these
occupational problems.11,12
Voice educational programs directed toward the prevention
of dysphonia and control of vocal alterations should be recom-
mended in work settings to improve the quality of life of
professionals who frequently use their voice.13
Overall, this study was conducted to investigate the under-
lying risk factors of voice problems among teachers, and equally
important to measure teachers’ knowledge about vocal care and
treatment, to assess the effect of a short voice educational program
on raising awareness toward vocal hygiene habits, and to dem-
onstrate vocal cord lesions that originated from the constant use
of their voices.
METHODS
Study design and settings
A comparative cross-sectional study was conducted from January
1, 2015 to April 30, 2015 on a sample of public schools in the
western district, Sharkia governorate. Then, an interventional study
was conducted from May 1, 2015 to October 30, 2015.
Study sample and procedures
The total number of teachers working in the public schools of
the western district at the time of the study was 5362, and the
number of schools was 270. A multistage stratified random
sampling technique was done to obtain a representative sample,
suitable for the purpose of the study. A sample size of 248
teachers was calculated through Epi Info program version 6.1
(CDC, Atlanta, Ga, USA). A sample frame of all schools was
obtained from the Western Educational Administration. In the
first stage, the schools were divided into elementary, middle,
and high schools. In the second stage, the schools within each
section were classified into urban and rural. One school was
selected randomly from each of the previously mentioned sec-
tions. After the six schools were selected, a sample frame of
teachers working in each of those six schools was obtained
from the school records. The estimated ratio of elementa-
ry : middle : high schools in the western district at the time of
the study was 2:1:2, and the ratio of urban to rural schools was
1:3. The third stage was done by choosing teachers from each
one of the six schools randomly from the obtained frames in
accordance to the previously mentioned ratios. Then the exclu-
sion criteria were applied on the selected sample (teaching
experience of less than 1 year, history of throat and chest
surgeries, endotracheal intubation, recurrent upper respiratory
tract infection, nasal allergy, nasal septum deviation, hormonal
problems, and gastrointestinal reflux). Two hundred three teach-
ers were eligible to participate in this study.
After excluding teachers who had only participated in the pilot
study, 156 of them accepted to participate in the next study. A
matched control group of 180 administrative workers were ran-
domly selected from the Faculty of Medicine in Zagazig
University. The pilot study was conducted in January 2015. The
validity of the questionnaire was tested through the opinions
of three experts on language clarity, content, relevancy, ability
to understand questions, and the time needed to answer. A re-
liability test using reliability coefficients was conducted to
determine the internal consistency of the items, and this re-
sulted in a Cronbach’s alpha of .8, which was suitable for the
questionnaire. The pilot sample was 25 teachers, and they were
not included in the study because the questionnaire was then
modified due to the removal of a part related to absenteeism as-
sociated with voice disorders. It was removed after receiving
complaints from the participants of it being so long.
Procedures of the study
The study was separated into two phases:
Phase 1
This phase included offering a self-administered structured ques-
tionnaire to participants through a 15-minute standardized face-
to-face interview. The researchers first explained the purpose of
the study and how to fill the questionnaire, and assured the privacy
of personal information being obtained from all teachers ac-
cepted to participate. The interviews were conducted in the
teacher’s lounge during recess. The questionnaire consists of four
parts: Part I: demographic characteristics: gender, age, marital
status, level of education, living habits, and medical and occu-
pational history. Part II: voice-related symptoms14. Part III: Voice
Handicap Index (VHI), which was developed by Jacobson et al15
and used for assessment of voice and its effects on the teach-
er’s life. It included three domains: functional, physical, and
emotional. The initial reference values that were used for the
VHI were ≤30 for minimal effects and >30 for serious effects.16
Part IV: Teachers’ knowledge about vocal care and treatment-
seeking behavior.17
Phase 2
This phase was conducted after scheduling appointments with
the participants during their recess. It included an application
of a vocal hygiene health education program after the research-
ers stated the objective.
Objectives
The study aimed to increase teachers’ awareness and improve
their attitude toward vocal hygiene.
Message
The introduction contains knowledge about the anatomy of the
vocal cords and physiology of phonation, causes and risk factors
harming the voice, and warning signs of vocal fatigue. These
messages were delivered by the researchers and the phoniatric
specialist, and encouraged to answer any questions and respond
to teachers’ concerns. The teachers were then presented with a
slide presentation designed by the researchers containing ex-
planatory pictures and video clips. These messages focused
on healthy vocal habits tips, eg, importance of drinking water,
eating healthy food, and vocal rest after work. They were also
given advice on how to protect their vocal cords by avoiding
 ARTICLE IN PRESS
Sarah A. Bolbol et al Impact of Vocal Hygiene Awareness Program Among Teachers 3

shouting, speaking with background noise, frequent throat clear- RESULTS

ing, regular consumption of too hot or too cold drinks, regular One hundred fifty-six teachers who work in public schools in
consumption of caffeine, and smoking. Flyers containing this the western district, Sharkia governorate, participated in the current
information were also distributed among teachers as a form of study, and a group of 180 administrative employees from Zagazig
continuous education so as to recall each point that was talked University were included as the control group of this study. The
about. majorities of both groups were married non-smoking women aged
≥40 years old and have been in the current job for ≥15 years,
Methods with no significant statistical difference between them. More than
First, a pretest was given to the participants, which included ques- 80.0% of the participants in both groups drink caffeinated drinks
tions about vocal hygiene tips and unhealthy habits harming their regularly. Twenty-eight percent of the teachers teach Science/
voice, followed by the message. Math courses, whereas 71.8% teach Languages/Arts courses.
More than half of the teachers (58.3%) speak in a high loud voice
Setting when they teach. Among the studied teachers, 73.1% reported
The educational sessions were given to teachers during recess that they give classes for 45 minutes, and 52.6% have more than
in the teachers’ lounge at six randomly selected schools. The 15 classes per week.
total numbers of sessions were 12 (two sessions at each school Voice-related symptoms reported by the studied teachers
in two different days). The number of teachers in each session and their control group from the administrative workers re-
ranged from 10 to 13. Each session lasted for about 20 minutes; vealed that there was a statistically significant difference between
it included the message and filling in of the vocal hygiene both groups regarding all symptoms. The significance level was
questionnaire. very high (P < 0.001) in hoarseness of voice, sore throats, vocal
tiredness, and frequent throat clearing among teachers (79.5%,
Evaluation of the effectiveness of the program 73.7%, 68.6%, and 66.0%) compared with the control subjects
A posttest, which included the same questions in the pretest, was (29.3%, 45.3%, 33.3%, and 46.7%), respectively. Also, the total
conducted after delivering the message within the same set- score of VHI was statistically significantly higher among teach-
tings with the participants to make sure that the message has been ers compared with the control subjects (P < 0.05) (Table 1).
delivered in a correct, clear, and complete manner. However, Comparing voice-related symptoms reported by the studied
the results of this posttest cannot measure the effectiveness of teachers in different educational levels, results showed that
the intervention due to the very short time after delivering the there was no significant difference between them regarding all
message. So 3 months after the application of the vocal hygiene symptoms (P > 0.05). The total score of VHI also showed no
program evaluation was conducted, teachers were also offered statistically significant difference among teachers in different edu-
a free clinical examination of their vocal cords, which was done cational levels (P > 0.05) (Table 2).
in the Phoniatrics Unit, Zagazig University. One hundred three
teachers agreed to visit the clinic and were subjected to
laryngo-video-stroboscopy,18 which was used to demonstrate
lesions in their vocal cords. TABLE 1.
Voice Related Symptoms and Score of Voice Handicap
Ethical issues Index Among Both Studied Groups
A written consent was obtained from all the participants after Teachers (%) Control (%)
clarification of the aim of the study and the privacy of personal Variables N = 156 N = 180
data. The necessary official permissions were obtained before Voice-related symptoms
data collection. Approval to conduct the research was obtained Vocal tiredness 107 (68.6)† 25 (33.3)
from an institutional review board (IRB #2617). Collected data Dry throat 115 (73.7)† 34 (45.3)
were kept strictly confidential and were used only for research Sore throat 75 (48.1)* 24 (32.0)
purposes. Shortness of breath 90 (57.7)† 18 (24.0)
Hoarseness of voice 124 (79.5)† 22 (29.3)
Statistical analysis Frequent throat clearing 103 (66.0)† 35 (46.7)
The collected data were computerized and statistically ana- Low voice 46 (29.5)* 11 (14.7)
Difficulty in continuing 88 (56.4)† 17 (22.7)
lyzed using the SPSS program version 19.0 (SPSS, Chicago, IL).
speech
Statistical calculations, data coding, and comparison between cat-
Losing voice 81 (51.9)† 13 (17.3)
egorical variables were done by a chi-squared test. The test results Throat pain 75 (48.1)† 21 (28.0)
were considered significant when P value ≤0.05. Bivariate anal- VHI
ysis was done initially using the chi-squared test to identify the VHI ≤ 30 125 (80.1)* 162 (90.0)
risk factors in terms of unadjusted odds ratio (OR); then, step- VHI > 30 31 (19.9)* 18 (10.0)
wise logistic regression was done to identify independent Chi-squared test.
determinants after adjusting results by potential confounders. * Significant at P ≤ 0.05.
McNemar’s test was conducted to compare between pre- and
†
Highly significant at P < 0.001.
Abbreviation: VHI, Voice Handicap Index.
posttest results.
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4 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 2.
Voice Related Symptoms and Score of Voice Handicap Index Among Teachers in Different Educational Levels
Elementary (%) Middle (%) High (%)
Variables N = 62 N = 31 N = 63
Voice-related symptoms
Vocal tiredness (n = 107) 46 (43.0) 17 (15.9) 44 (41.1)
Dry throat (n = 115) 50 (43.5) 20 (17.4) 45 (39.1)
Sore throat (n = 75) 36 (48.0) 11 (14.7) 28 (37.3)
Shortness of breath (n = 90) 40 (44.5) 13 (14.4) 37 (41.1)
Hoarseness of voice (n = 124) 54 (43.6) 21 (16.9) 49 (39.5)
Frequent throat clearing (n = 103) 47 (45.6) 16 (15.5) 40 (38.8)
Low voice (n = 46) 18 (39.1) 8 (17.4) 20 (43.5)
Difficulty in continuing speech (n = 88) 36 (40.9) 13 (14.8) 39 (44.3)
Losing voice (n = 81) 31 (38.3) 13 (16.0) 37 (45.7)
Throat pain (n = 75) 32 (42.7) 14 (18.7) 29 (38.7)
VHI
VHI ≤ 30 (n = 125) 52 (41.6) 24 (19.2) 49 (39.2)
VHI > 30 (n = 31) 10 (32.3) 7 (22.6) 14 (45.2)
Chi-squared test. All variables are not statistically significant.
Abbreviation: VHI, Voice Handicap Index.

A bivariate analysis was conducted to identify risk factors in
terms of unadjusted OR. Work duration (years) followed by the
increased number of classes per week and voice loudness were
the significant variables that affect teachers’ voice. A logistic re-
gression analysis was done to study the significant independent
determinants influencing teachers’ voices, and revealed that in-
creased work duration followed by the increased number of classes
per week are the most important indicators influencing voices
among teachers (Table 3).
Teachers in the current study reported that they did not take
any courses or training about vocal care during their prepara-
tion for their current job, and the 30.8% who reported that they
have some knowledge gained it through their own initiatives. Also,
73.1% of the studied teachers did not seek any medical advice
and 87.2% of them did not receive any treatment (Table 4).
To test the knowledge acquired by teachers regarding vocal
hygiene tips immediately after intervention, pre- and posttests
were compared and the results showed highly statistically
significant difference between all items of the pre- and posttests,
except for avoiding smoking which was non-significant (P > 0.05)
(Table 5).
Comparing the results of pre- and posttests regarding vocal
hygiene tips acquired by teachers 3 months after the applica-
tion of the health education program about awareness of vocal
hygiene tips also revealed that there was a highly statistically
significant difference between all items of the tests, except

TABLE 3.
Risk Factors Influencing Teachers’ Voice and Results of Logistic Regression Analysis
Unadjusted OR Adjusted OR
Risk Factors for High Score of Voice Handicap Index (95% CI) (95% CI)
Work duration (≥15 y) 2.46 (1.14–5.29)* 1.08 (1.01–1.14)*
Number of classes/week (≥15) 3.96 (1.59–9.86)* 1.10 (1.01–1.21)*
Voice loudness (high) 2.55 (1.06–6.12)* 1.98 (0.78–5.02)
Age (≥40) 1.05 (0.48–2.32) 0.28 (0.07–1.14)
Gender (female) 1.56 (0.62–3.91) 1.27 (0.36–4.53)
Marital status (married†) 3.63 (0.42–27.67) 1.74 (0.18–16.78)
Smoking (nonsmokers) 0.49 (0.06–4.05) 0.36 (0.03–4.15)
Caffeinated drink (yes) 3.19 (0.39–25.48) 2.75 (0.19–38.90)
School courses (Language/Arts) 1.82 (0.69–4.79) 1.86 (0.56–6.14)
Class duration (≥45 min) 1.69 (0.64–4.45) 1.47 (0.43–5.08)
Grades assigned to teach in elementary and middle school‡ 2.26 (0.86–5.93) 0.03 (0.35–1.17)
Chi-squared test and stepwise logistic regression.
* Significant at P ≤ 0.05.
†
Unmarried = single/widowed/divorced.
‡
Elementary and middle school versus high schools.
Abbreviations: CI, confidence interval; OR, odds ratio.
 ARTICLE IN PRESS
Sarah A. Bolbol et al Impact of Vocal Hygiene Awareness Program Among Teachers 5

DISCUSSION
TABLE 4.
Teachers’ Knowledge About Vocal Care and Treatment-
In Egypt, voice disorders among school teachers are currently poorly
Seeking Behavior documented. There are no national surveys or large-scale studies
that have addressed the issue of occupational dysphonia despite
Teachers (%) being the most frequently encountered occupational complaint.19
Variables (no. 156)
The present study aims to highlight this problem among Egyp-
Information received by the teacher tian teachers working in public schools, which represent a very
During education to be a teacher 0 (0.0) important occupational sector that affects the outcome of future
During training after employment 0 (0.0) generations.
By your own initiative 48 (30.8) In the current study, 70.5% of the participants were female
Treatment-seeking behavior
teachers, and the previous studies on Egyptian teachers19 dem-
No seeking for medical advice 114 (73.1)
The school physician 0 (0.0)
onstrated that being a female teacher increased the risk for
The general practitioner 0 (0.0) developing dysphonia compared with male teachers (OR = 1.53).
ENT specialist 42 (26.9) Evidence has accumulated that women are more liable to vocal
Receiving treatment health issues than men. This finding has been traditionally
Yes 20 (12.8) reported in previous studies and has certainly to be ascribed
No 136 (87.2) to anatomic and physiological reasons and/or behavioral
Type of treatment* characteristics.20,21 Additionally, students usually fear the anger
Medicines 11 (55.0) of a male teacher than a female one. Therefore, controlling the
Soothing agents 20 (100.0) noise and disordered classes is a difficult task for a female teacher
Voice therapy 4 (20.0) who uses her voice at a maximum volume to control the stu-
Surgery 1 (5.0)
dents and to overcome a loud and misbehaved class environment.
* Some of the teacher received a combination of treatment. Also, our results affirmed that 58.3% of the school teachers use
loud voices during their teaching, which could be attributed to
the large number of students per class, as the average esti-
for avoiding smoking which was non-significant (P > 0.05) mated number of students in a class is 43, and up to a maximum
(Figure 1). of 50 as documented by the Egyptian Ministry of Education.22
One hundred three teachers showed compliance and were sub- These figures may be higher today with the growing number of
jected to free clinical examination after the use of the health population.
education program through the laryngo-video-stroboscopy ex- Hamdan et al23 stated that smoking has a significant associ-
amination. The results of examination showed that among the ation with vocal attrition. Also, it was reported by Al-Saleem
103 examined teachers, 61 teachers (59.2%) had normal laryn- and Al-Saleem16 that the most common unhealthy vocal habit
geal imaging, 23 teachers (22.3%) had chronic nonspecific among teachers was smoking. In the current study, smoking was
laryngitis, and 19 teachers (18.4%) had minimal associated patho- not a prevalent symptom among the studied teachers as most of
logic lesions of the vocal folds: 15 teachers (14.6%) had vocal them were female, and as a consequence the frequency of cig-
fold nodules, 3 teachers (3.0%) had vocal fold polyp, and only arette smoking among them was low (5.8%) as by culture and
1 teacher (0.97%) had vocal fold cyst. traditions cigarette smoking is not prevalent among women in

TABLE 5.
Pre and Posttest Results of Teachers’ Knowledge About Aspects of Vocal Hygiene Immediately After Intervention
Teachers (no. 156)
No. (%)
Aspects of Vocal Hygiene Pretest Posttest (immediately)
Frequent voice rest 98 (62.8) 156 (100.0)*
Consuming healthy food/avoiding spicy food 22 (14.1) 142 (91.0)*
Increasing fluid intake 103 (66.0) 156 (100.0)*
Avoiding throat cleaning 54 (34.6) 125 (80.1)*
Avoiding shouting/speaking loud 62 (39.7) 133 (85.3)*
Avoiding speaking in a noisy environment 34 (21.8) 128 (82.1)*
Avoiding too hot or too cold drinks 66 (42.3) 136 (87.2)*
Avoiding excessive tea and coffee 26 (16.7) 149 (95.5)*
Avoiding smoking 151 (96.8) 156 (100.0)
McNemar’s test.
* Highly significant at P < 0.001.
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6 Journal of Voice, Vol. ■■, No. ■■, 2016
FIGURE 1. Pre- and posttest results of teachers’ knowledge about aspects of vocal hygiene 3 months after intervention. McNemar’s test. **Highly
significant, P < 0.001.
Egypt.24 This explains why smoking was not a predictor or risk
factor of voice-related disorders in the present study.
The results of the present study affirmed that the most fre-
quent voice-related symptoms were hoarseness of voice (79.5%),
followed by dry throat (73.7%), vocal tiredness (68.6%), and fre-
quent throat clearing (66.0%). These results are higher than the
results of the previous studies that have been conducted in dif-
ferent communities worldwide, eg, Kamel et al25 in Kuwait, Al-
Saleem and Al-Saleem16 in Saudi Arabia, Hamdan et al23 in
Lebanon, and Araujo et al26 in Brazil. Differences in the pro-
portions of reported voice-related symptoms are due to variation
in using assisting technology in teaching, like smart boards, in
addition to different methodologies, definition criteria, charac-
teristics, and the size of the study sample.
The comparison between participants working in elementa-
ry : middle : high school regarding voice-related symptoms and
the score of VHI did not reveal any statistically significant dif-
ference. This could be attributed to the high similarity among
Egyptian public schools in all educational stages in terms of class-
room density and lack of facilities and assisting technologies to
help education process.
Voice production and vocal health are a complex issue with
a range of physiological and no physiological risk factors. Lack
of awareness of these risks may ultimately increase an occupa-
tional voice users’ vulnerability to voice disorders.27 In the present
study, the total VHI score was higher among the teachers than
the non-teachers. The current study showed that a high score in
voice handicap was significantly affected by the level of voice
loudness in the classroom, as well as the number of classes given
weekly and the number of working years. However, the logis-
tic regression revealed that the significant predictors for high VHI
were high numbers of classes (≥15) per week and working in
the current job for more than 15 years. This could be attributed
to the fact that such predictors are not under teachers’ control
as the school management normally decides the frequency of
classes per week.
The results of the present study revealed that none of the teach-
ers who participated in this study reported that they received
knowledge or information regarding voice care during their ed-
ucation nor during their training after employment; they also
reported that they acquired their knowledge only by their own
initiative. This may be due to the lack of an informative aware-
ness program concerning professional voice disorders, which may
be attributed to poor consideration of the problem by employ-
ers and authorities.
Many teachers regard their vocal symptoms as something that
is inherited and they do not necessarily take appropriate counter
measures.28 The present study revealed that only 26.9% of the
teachers sought for medical treatment because of their voice health
problems, and 12.8% received medical treatment, mainly in the
form of throat soothing agents, and some of the teachers re-
ceived a combination of treatments and only one case underwent
surgical therapy for cause of voice disorders. Similarly, evi-
dence has been provided in previous studies that only a small
percentage of teachers (14% and 17.5%) who reported voice
problem sought for professional help.1,24 Having the inconve-
nience of taking time off from work and fear of negative
perception may justify these small percentages seeking for pro-
fessional help.29
There is evidence that a vocal hygiene awareness program with
information on strategies aims to promote optimal voice pro-
duction, and that to eliminate abusive vocal behaviors is effective
in treating voice problems.30 In the current study, it was very im-
portant to emphasize on clarifying teachers’ knowledge toward
vocal hygiene tips after application of the health education
program, as it is known that vocal hygiene habits, such as taking
care of hydration, not shouting in the classroom, and not speak-
ing with strong intensity in a noisy environment, and other
educational programs have been proven to improve teachers’ vocal
quality.31,32
As a consequence to the application of vocal hygiene edu-
cational program immediately and after 3 months, the results of
this study showed statistically significant improvement (P < 0.05)
in teachers’ knowledge in all aspects of vocal hygiene tips, except
for avoiding smoking which showed high percentage in both the
pre- and posttests as most of the studied subjects were actually
 ARTICLE IN PRESS
Sarah A. Bolbol et al Impact of Vocal Hygiene Awareness Program Among Teachers
non-smokers. This significant improvement and high positive
changes may probably be due to the fact that the participating
teachers were highly motivated to resolve their voice problems
and improve their voice quality.
Comparing the results reported immediately and after 3 months,
there was overall a significant drop in the knowledge percent
especially in consuming healthy food and avoiding spicy food
(91% vs 55.8%) and avoiding excessive caffeine (95.5% vs
33.3%), which could be attributed to their personal preference.
The results also reflected that only tips that were consistently
practiced were recalled.
One hundred three teachers agreed to be subjected to free video-
laryngo-stroboscopy examination after use of the intervention
health education program as a first step in seeking for proper
management. The results revealed that 59.2% had normal la-
ryngeal imaging; on the other hand, we found chronic nonspecific
laryngitis in 22.3% and minimal associated pathologic lesions
of the vocal folds as vocal fold nodules, polyp, or cyst in 18.4%
of teachers. Preciado-Lopez et al33 reported the prevalence of
pathologic subjects being 51.6% versus 16% of the control sub-
jects, and attributed these anomalies to weakened vocal muscle
from persistent vocal adaptation to increased vocal loading.
LIMITATIONS
There are very few national publications concerning voice dis-
orders in the field of occupational health. Some points remain
problematic, notably the definition of voice disorders, the iden-
tification of risk factors, or situations favoring their occurrence.
Also, data on voice disorders were not available from non-
responders, raising the concern that people with voice disorders
were either over- or underrepresented in the sample. Finally, as
cross-sectional data do not allow causes and consequences to
be distinguished, longitudinal research is needed to identify de-
termining factors of voice disorders.
CONCLUSIONS
In conclusion, voice disorders are frequent among female teach-
ers, and the significant predictors of vocal disorders are increased
work hours and work overload. Generally, there is a lack of knowl-
edge toward vocal care, hygiene, and different treatment
approaches. It was infrequent for them to seek medical advice
or treatment. High positive changes occurred in teachers’ knowl-
edge in most of the aspects of vocal hygiene tips after studying
the vocal hygiene educational program. Thus, the present study
stresses the need for regular screening programs, application of
a vocal hygiene awareness program on a wide scale to help in
eliminating this common problem, minimizing any permanent
impairments and/or disabilities, and raising the teacher’s per-
formance despite all the obstacles that they face in their work
settings.
Acknowledgments
The authors would like to thank all teachers for their coopera-
tion and participation. They also would like to thank the western
district directorate for their help in providing data on the number
of schools and teachers.
7
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