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2023 Nallamuthu Outcomes of Vocal Hygiene Program
2023 Nallamuthu Outcomes of Vocal Hygiene Program
Summary: 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 facili-
tating 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 sev-
enteen female teachers with voice concerns. All underwent a comprehensive voice assessment (subjective, objec-
tive, 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 improve-
ment 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 com-
parison of vocal metrics before & after the treatment provides information on changes that can be expected in
teachers after guiding them through a systematic VHP.
Key Words: Female school teachers−Vocal health−Vocal hygiene program−Vocal metrics.
vocal performance.7 In addition to the above, hormonal tension.17 The ultimate goal of VHP is to facilitate complete
changes during menstruation and pregnancy also affects the vocal health and enhance communicative effectiveness.18
laryngeal system9 resulting in vocal fatigue, decreased vocal However, it is essential to modify vocal hygiene practices to
range, and vocal instability.7 suit the clients’ day to day vocal need and improve vocal
The increased sensitivity of pain in females10 can be health.17 Specifically in teachers where they face challenges
related with the higher frequency of reported voice related to seek medical/professional help,19 VHP is crucial in pre-
problems among women. Behaviorally female teachers tend vention and treatment of voice related problems. The posi-
to vocalize 10 times more than their male counterpart at tive effects of VHP among teachers are evident on
work11 and are often compelled to use their voice for child- improving the knowledge of vocal health,6,7,12−14 decreasing
care at their homes.1 These factors indicate that females are at risk vocal behaviours20 and reducing the self-perception
more prone to voice related problems from puberty through of voice handicap (based on VHI scores).21 Though vocal
the child bearing ages. In addition to the physiological, hor- hygiene programs have positive effects on reducing the use
monal, and behavioral differences, several policy decisions of phono-traumatic vocal behaviors, its impact on facilitat-
of the governments (eg, in Tamil Nadu there is a preference ing efficient voice production and reduction of hyper func-
to employ female teachers than males in order to provide tion is limited.22 Contrary findings on the impact of vocal
gender equality and preference)1 may increase the risk for hygiene program indicates the need to incorporate actual
developing voice problems in females.12 Therefore the sus- observations instead of self-reported and survey methods.15
ceptibility of developing voice problems in female teachers In addition, though teachers gain the knowledge and aware-
coupled with increased number of women in teaching pro- ness of vocal health, they are often compelled and habitu-
fession in this locality results in higher incidence of voice ated to use phono-traumatic vocal behavior to meet their
related problems in female school teachers. Considering the occupational demand and other sociocultural factors in day
impact of voice problems on the overall functioning of the to day situation.1 Therefore, a formalized, structured (in
individual and in particular the voice use of the teachers,13 terms of knowledge, content, skill transfer, and attitudes to
it is essential to provide vocal education and intervention to monitor voicing behavior) and a socio-culturally relevant
prevent/ reduce the risk of vocal trauma and promote vocal vocal hygiene program might partially address the chal-
health in teachers. lenges faced by teachers in India. This will ensure expected
Vocal interventions include direct face-to-face vocal positive outcomes due to vocal hygiene education among
habilitation/therapy or indirect intervention like vocal teachers to self-perceive the subtle changes in voice and cor-
hygiene program (VHP). These vocal intervention rect their vocal behaviors in school, home environments
approaches are either used in isolation or in combination and day to day situations. To understand the impact of such
based on the client’s needs, logistic concerns, and other fac- sociocultural structured vocal hygiene program (VHP), the
tors.14 Despite the evidence of positive impact of direct present study aimed to investigate the outcomes of VHP in
voice therapy over VHP, teachers in India consider voice facilitating vocal health among female school teachers using
problems as an expected occupational difficulty/hazard in a comprehensive voice assessment protocol. The objectives
their profession and often restrict to "home remedies" and of the study were to investigate the effects of the developed
follow vocal hygiene program/tips as their first line of treat- VHP for teachers on clinical measures (perceptual & aero-
ment.1 Restriction in availing leave from school, compul- dynamic), instrumental (acoustic analysis & visual examina-
sion to complete the curriculum within stipulated time, tion of larynx) and self-perceptual vocal measures (V-DOP
travel, financial limitations for seeking treatment, and lack & VHI).
of support for child care limits them. These potentially delay
the time taken to seek treatment (direct voice therapy) for
2. MATERIALS AND METHODS
voice related problems. In such crucial situations, where the
The study was approved by the institutional ethical commit-
individuals have challenges in attending face to face inter-
tee of Sri Ramachandra Medical College & Research Insti-
vention, VHP could address partially to the problem and
tute (Reference number: IEC-NI/13/AUG/35/64). Similar to
facilitate a treatment option. 15
previous studies15,20,23−26, a single group pre- and post-test
Vocal hygiene program (VHP) is a client centered
research design was employed to estimate the impact of
approach that focus on education about normal processes
vocal hygiene program among female school teachers.
in voice production, identification and elimination of
phono-traumatic vocal practices and behaviors, emphasis
on adequate hydration, strategies to reduce of laryngo-pha- 2.1. Participants
ryngeal reflux, minimize the effects of environmental factors The participants were recruited across a period of one year
and inculcate healthy life style modifications.15 Studies have at different points of time. When the participants met the
shown the positive effects of VHP on prevention of voice inclusion and exclusion criteria, they were included in the
related problems and improvement in self-reported voice study. Teachers who reported of any pulmonary disease,
quality.16 VHP facilitates in providing awareness on the hypothyroidism, systemic illnesses, tinnitus/ hearing diffi-
impact of phono-traumatic vocal behaviors and which may culty, and those who had previously attended voice therapy
turn aid to reduce the hyper-function and laryngeal muscle were excluded from the study. Teachers in active teaching
Aishwarya Nallamuthu, et al Vocal Hygiene Program 295.e13
vada, appalam, paapad & chips) that may increase the opportunities to raise questions or ask for repetition. Fol-
chance of acid reflux affecting the vocal apparatus. Individ- lowing the face to face session, a checklist (that included all
uals with relatively sedentary physical occupation (including the components of the VHP explained in the face-to-face
teachers) may often lose the strength in the muscles of their session) was provided to the participants to remind them to
abdomen and back.50 Teachers in India predominantly follow on a regular basis. They were asked to follow the
practice black board teaching that requires overhead activ- vocal hygiene practices in day to day situation for 4 weeks
ity and twisting posture (torso twisted and head turned to duration. The participants were asked to mark a tick if they
talk to the students).51 In addition, they tend to strain their practiced each component every day. The reasons for not
shoulders and arms while reading/ dictating to pupil while being able to practice the vocal hygiene instruction were
holding books in hand.52 These in turn may affect their pos- also documented. The participants were periodically
ture compromising their breath support during speech/ reviewed & reminded to continue the vocal hygiene practice
teaching and increases the chance of developing musculo- through telephone calls once a week. At the end of 4 weeks,
skeletal tension disorder.52 To address the above, advice the participants were followed up and post-treatment voice
was given (with pictorial illustrations) on maintaining assessment was performed.
appropriate posture during standing (such as balancing
body weight in both feet, standing straight and tall without
bending or stretching back, keeping the feet at shoulder
width) and sitting (with proper lumbar/back support, main- 2.4. Vocal metrics & procedure to compare pre and
taining the height of the chair to place the feet plat on the post vocal hygiene program
ground & keeping the book at eye level while reading). Teachers who consented to participate in the study under-
These are routine advices provided for teachers. However, went a comprehensive voice assessment before and four
in addition, teachers were advised to use dust free chalk, weeks after the VHP. The metrics included:
and avoid the practice of speaking/ teaching while writing
or erasing on the blackboard to reduce inhaling of a. Sri Ramachandra vocal health questionnaire for
chalk dust. teachers:13
Next, importance of following appropriate vocal practice
to avoid/ reduce damage to vocal apparatus was discussed. The questionnaire collected details on demographic infor-
Teachers were advised to move close and face the listener mation, general health, voice use, vocal and nonvocal prac-
(students) while speaking, schedule classes with breaks to tices, self-perceived vocal symptoms, and impact of voice
avoid continuous voice use, and use microphone while problem in daily activity and participation and environmen-
addressing a large gathering. They were cautioned regarding tal factors that act as barriers and supporting elements.
inappropriate vocal use and strictly advised to limit loud
and continuous vocal use. In addition they were asked to b. Clinical vocal measures:
avoid the habit of throat clearing. Participants were also
guided on speaking/ teaching in ideal environment. These The clinical vocal measures included perceptual analysis
vocal hygiene practices for the teachers were explained using of voice (GRBAS), maximum phonation duration and s/z
pictures and animations (eg, avoiding speaking/teaching ratio. The recorded samples of reading and counting num-
while wiping the board, moving close to the students while bers from 1 to 10 were considered for perceptual voice anal-
teaching/ reading to them, facing the students and not ysis using GRBAS scale.53 The samples recorded (during
towards the board while teaching) to suit Indian context pre & post-treatment) for perceptual evaluation of voice
and for better understanding. were randomized and rated by two SLPs (clinicians who
The components of the VHP were verified by two speech work in the area of voice) who were not involved in deliver-
pathologists and one otolaryngologist (with a minimum of ing the vocal hygiene program. The evaluators were pro-
10 years of experience and specialization in the area of voice vided the freedom to listen the samples as many times as
assessment & management). The experts assessed the rele- they required.
vance of the selected vocal hygiene practices for school To assess the maximum phonation duration and s/z ratio,
teachers in the Indian context. With their inputs, the vocal the participants were instructed to sit upright and in a
hygiene program module for teachers was developed. relaxed posture. They were asked to sustain the vowel /a/, /i/
and /u/ at a comfortable pitch and loudness for as long as
possible on a single breath. The task was performed thrice
2.3. Administration of the VHP for school teachers for each sounds and the time was estimated using stop-
The vocal hygiene program was a clinician administered watch. The longest duration during the three trials was
module presented in the form of PowerPoint slides with ani- taken as maximum phonation time (in seconds) for the
mations to the participants. The rationale for each vocal respective sound. Similarly the participants were instructed
hygiene practice was explained to the participants in English to take a deep breath and sustain /s/ for as long as possible
and in Tamil during a single face to face session. During the twice. In the same way the MPT for /z/ was measured. Based
entire one-hour session, the participants were provided on the longest duration of two trials, the MPT for /s/ and /z/
Aishwarya Nallamuthu, et al Vocal Hygiene Program 295.e15
were estimated. Further s/z ratio was calculated by dividing It consisted of two divisions: the first part included a single
the sustained phonation time of /s/ by /z/. question on overall severity of voice problem and second
part comprised of 32 questions under three domains (physi-
a. Instrumental vocal measures: cal, emotional, and functional). All 33 questions were rated
on a 10 cm visual analog scale which ranged from normal
The acoustic analysis was performed in a sound treated (0) to always (10). Based on the severity rated by the partici-
room using Ling Waves Phonetogram Pro and signal analy- pants, the scores were categorized under overall severity,
sis module (Version 2.4). The samples were recorded using a physical, emotional and functional domain.
condenser microphone attached to a calibrated sound level Vocal fatigue index is a validated tool that can be used to
meter (Center 322) set in "A" weighting network mounted on assess the self-perception of vocal fatigue. It consisted of
a tripod stand. This enabled to adjust the height and maintain three sections with a total of 19 symptoms that are associ-
subjects’ mouth to mic distance as 30 cm. The participants ated with voice problems and fatigue. The symptoms are
were instructed to maintain upright sitting posture and per- rated on a five point scale (0-never; 1-almost never; 2-some-
form the following tasks: sustained phonation of vowel /a/ on times; 3-almost always, and 4-always) under each section of
a single breath at a comfortable loudness and pitch, sustained the tool. The comprehensive vocal assessments for the par-
phonation of /a/ at regular, loud and soft intensities, gliding ticipants were performed 5 days prior to or after their men-
of vowel /a/ from low to high pitch and high to low pitch, strual cycle. The vocal measures listed above were estimated
counting of numbers from 1 to 10 at varied intensities (nor- before the commencement of the vocal hygiene program
mal, soft, and loud) and reading a standardized passage or (pretreatment measurement) and after the completion vocal
general conversation as part of speaking profile. From the hygiene program for a period of one month (post-treatment
recorded samples, frequency (F0, high F0, low F0 & frequency measurement) without any specific order.
range), intensity (I0, high I0, low I0 & dynamic range), and
quality related parameters (jitter & shimmer) was calculated. 2.5. Definition of improvement in outcome measure
The dysphonia severity index (DSI) was estimated through (comparing pre- & post- treatment)
ling Waves software using the formula54 (DSI = 0.13 x The progressive changes in the scores while comparing the
MPT + 0.0053 x High F0- 0.26 x Low I0 x Jitter + 12.4). pre- and post-treatment assessments were operationally
The video-stroboscopic evaluation was performed jointly by defined as improvements in vocal measures after attending
the otolaryngologist and Speech Language Pathologist using the VHP. The improvement criteria established based on
ATMOS media strobe (Endo Stroboscope L). The partici- change in score or cut-off value was set for each measure
pants were given instructions about the procedure and were based on normative values, and a deemed clinically signifi-
sprayed with local anesthesia (10% lidocaine topic aerosol) cant change explained in Table 2.
prior to the procedure. Rigid endoscope (90⁰ and 70⁰) was
introduced transorally by the otolaryngologist to visualize the
larynx. The video-stroboscopic recordings were done during 2.6. Data and statistical analysis
sustained phonation of the vowel /i/ at a comfortable pitch The data obtained were tabulated and subjected to statisti-
and loudness, pitch gliding (from low to high & high to low), cal analysis using Statistical Package for the Social Sciences
interrupted /hi/, gentle cough, and normal breathing. Partici- (SPSS) version 19 (SPSS, Inc., Chicago, Illinois). The inter-
pants were restricted to consume food or any liquid for 30 rater reliability for perceptual evaluation and visual exami-
minutes following the procedure. The recorded samples were nation was estimated using Intra-Class Coefficient correla-
randomized and subsequently rated by another Speech Pathol- tion. Shapiro-Wilk test was used to estimate the normality
ogist and Otolaryngologist (who were not involved during the of data. The mean (SD) was considered for normally distrib-
recording of stroboscopy). The samples were assessed based uted variables and median was considered for variables
on the following parameters: morphology to indicate patho- which were not normally distributed. Wilcoxon signed ranks
logical changes and other observations, glottal closure (com- test was used to compare the pretreatment and post-treat-
plete/anterior gap/posterior gap/ irregular/bowing/hour glass ment measures of continuous variables (acoustic, MPT, s/z
pattern), and symmetry of vocal folds, mucosal wave, ampli- ratio, V-DOP, and VFI), and McNemar test was used with
tude and regularity of vocal fold vibration, presence/absence categorical variables (vocal health questionnaire, visual
of non-vibratory portion and hyper adduction of ventricular examination of larynx, and perceptual evaluation of voice).
folds. The evaluators were provided the freedom of reviewing
the samples as many as times they required. 3. RESULTS
TABLE 2.
Operational Definitions for Improvements in Vocal Measures After Attending the VHP
Voice tool metrics Definition of improvement
Vocal health questionnaire
- Practice of unhealthy vocal & non vocal habits - Change in the value of one point towards ‘never’ in a five point likert
scale
- Vocal symptoms reported by the teachers - Absence of the reported vocal symptom during post treatment mea-
surement
- Impact on activities of daily living - Absence of the specific activity limitation which was present during
pre-treatment
- Environmental factors as barrier - Presence of the specific factor that was absent during pre-treatment
- Environmental factors as support - Absence of the specific factor that was present during pre-treatment
Clinical vocal measures
- GRBAS rating - The improvement in each parameter of GRBAS was considered
when the scores improved towards normal by 1 point or greater
- MPT & s/z ratio - Quantified measures (values within normative range) 57
Instrumental vocal measures
- Acoustic analysis of voice - Quantified measures (values within normative range) 54,57,58
- Visual examination (stroboscopy) - Improvement in parameters such as complete glottal closure
(from any other incomplete closure pattern), presence of
symmetrical/periodic movement of vocal fold, with normal
amplitude and mucosal wave and absence of ventricular
fold hyper-adduction
Self-perceptual vocal measures
- V-DOP -Quantified measures (changes in scores/severity across domains) 55
- VFI - Quantified measures (changes in scores/severity across domains) 56
whispering, while three teachers (17.6%) increased the habit of Vocal symptoms reported by the teachers before and after
whispering. All the five teachers (29.4%) who reported the attending the VHP were explored. Significant improvement in
practice of mimicry during baseline, refrained themselves from vocal symptoms such sticky sensation/discomfort around the
mimicry during post treatment measure. The habit of scream- throat (P= 0.008), inadequate breath control while speaking
ing reported by 16 teachers (94.1%) during baseline assessment (P = 0.016) and sensation of heart burn (P = 0.031) were
had improved after the vocal hygiene program. reported. This in turn had a positive impact on teachers in feel-
On analyzing the nonvocal habits, intake of caffeinated ing less irritable (P = 0.031) and upset (P = 0.031). In addition,
drinks with a minimum of two to five cups/day was reported teachers who experienced limitations in executing activities in
by nine teachers (52.9%) during baseline. However, after the daily life situations reported significant improvement in using
VHP the frequency of coffee intake was reduced in five out of their voice for conversing with others via face to face (P=
the nine teachers. Three teachers (17%) who reported intake 0.031), and through telephone (P = 0.016). On exploring the
of soda stopped the habit during the outcome measure. The environmental factors, speaking in the presence of noise
practice of alcohol consumption and smoking was not (82.35%) and chalk dust (47.05%) were major barriers
reported by any teachers in this study. All teachers reported reported by teachers even after the VHP. Improvements were
of inadequate time interval (ranging from 30 to 60 minutes) reported in using communication devices (P = 0.004), use of
between intake of meals/dinner and sleep. However, after the their voice across the day (P = 0.008) and impact of changes
VHP, 13 teachers (76.4%) reported an improvement in the in weather such as rain/wind (P = 0.002). Though teachers
time interval (≥ 2 hours). The frequency of intake of oily/ reported improvement in the effect of seasonal changes in
spicy food reported by all teachers had reduced after the weather on their voice, this could probably be a bias as the
VHP. Ten teachers (58.8%) who had the habit of chewing participants were assessed only between the time frame of one
throat lozenges completely stopped the habit post treatment. month pre- and postvocal hygiene program.
To stay hydrated, teachers drank a minimum of 2 glasses of Teachers reported a perception of positive attitude from
water/day during baseline. However, post-treatment, an their family (94.11%), colleagues (88.23%), and doctors
improved intake of 6−8 glasses (of approximately 240 ml/ (100%) after the VHP. In addition, teachers felt that the pol-
glass) of water (47%) and >8 glasses (53%) were noticed. icies and school systems (70.58%) in India was still a barrier
Vapor/steam inhalation was sparsely (23.5%) practiced by to their voice problems. Speaking in the presence of noise,
teachers during baseline. However, all the teachers reported exposure to chalk dust, higher number of students in a class
to follow steam inhalation along with adequate intake of were inevitable barriers for teachers in Indian scenario.
water to keep them hydrated. Nearly 94% of teachers reported imposed restrictions on
Aishwarya Nallamuthu, et al Vocal Hygiene Program 295.e17
availing leave for medical treatments when they had voice TABLE 3.
problems. Comparison in Acoustic Measures Obtained Before and
After Vocal Hygiene Program
3.2. Perceptual analysis of voice & simple Acoustic Pre-treatment Post-treatment P-value
parameters
aerodynamic measures
Mean SD Mean SD
The perceptual analysis of voice using GRBAS scale was
performed by two speech pathologists. The Intra-class Cor- F0 (Hz) 216.69 32.41 219.81 26.29 0.630
relation Coefficients (ICC) was 0.8 and this indicated good High F0 (Hz) 316.27 76.07 358.87 65.65 0.006*
Low F0 (Hz) 177.64 28.07 167.01 14.19 0.064
inter rater reliability. On analyzing the baseline (pretreat-
Freq. range 10.06 4.53 12.94 3.82 0.004*
ment) perceptual measures, 82.35% of subjects had abnor-
(Semitones)
mal vocal quality (overall grade). However, the percentage I0 (dBSLP) 72.38 4.12 72.13 2.55 0.757
dropped to 52.94% post treatment. Significant changes in High I0 (dBSLP) 93.54 5.71 93.79 4.59 0.901
other parameters (such as roughness, breathiness, asthenia Low I0 (dBSLP) 66.89 4.99 63.52 5.28 0.044*
& strain) of voice were also noticed (Figure 1). Dynamic range 26.88 5.92 30.25 8.16 0.186
The functioning and coordination of the respiratory system (dBSLP)
with the laryngeal system was estimated using maximum pho- Jitter (%) 0.27 0.16 0.31 0.63 0.233
nation time (MPT) and s/z ratio. The MPT values during base- Shimmer (%) 6.19 2.86 4.24 1.82 0.017*
line (Mean: 9.38 sec, SD: 3.43) and post VHP (Mean: 9.57 sec, DSI -2.55 1.76 -1.38 1.60 0.013*
SD: 3.04) revealed no significant difference. Similarly, the s/z
values were within the normal range during pretreatment
intensity stability. While, the overall scores on dysphonia
(Mean: 0.97, SD: 0.11) and post-treatment (Mean: 1.01, SD:
severity index (DSI) improved during outcome assessment,
0.04) with no significant difference between the measurements.
they were higher than the normative values.54
During the post-treatment assessment, five out of 17
teachers did not consent to undergo the stroboscopy proce-
3.3. Instrumental vocal measure (acoustic analysis
dure. The samples obtained before (pretreatment) and after
and stroboscopy)
(post-treatment) the VHP were randomized and evaluated
The acoustic parameters obtained during pre- and post-
by two raters (otolaryngologist & speech pathologist). The
treatment were compared against the normative values
inter-rater reliability obtained using Intra-class Correlation
obtained from previous literature.54,57,58 The values in
Coefficients (ICC) indicated good agreement across the
acoustic measures after attending the vocal hygiene pro-
parameters of stroboscopy (ICC scores >0.7) thus ruling
gram is presented in Table 3.
out the need of another evaluator to judge the samples. The
On analyzing the frequency related parameters, the fun-
improvement in stroboscopic parameters before and after
damental frequency values during pre- and post-treatment
VHP is presented in Figure 2. There were changes in all
were within the normal range.57 Significant change was
parameters of stroboscopic evaluation other than non-
observed in frequency range of the teachers after attending
vibratory portion and ventricular fold hyper-adduction.
the vocal hygiene program. Frequency related perturbation
measure (jitter) was within normal limits.54 Intensity related
parameter indicated that the Low I0 value further reduced 3.4. Self-perceptual evaluation of voice (V-DOP &
significantly after attending the VHP. Though shimmer val- VFI)
ues significantly reduced after treatment, the values were Voice Disorder Outcome Profile (V-DOP) was administered
still higher than normal range58 indicating deviation in to estimate the impact of voice problem on physical,
FIGURE 1. Comparison of the baseline and outcome measure using GRBAS scale after VHP
295.e18 Journal of Voice, Vol. 37, No. 2, 2023
FIGURE 2. Comparison between the pre and post VHP using parameters of visual examination of larynx.
TABLE 4. TABLE 5.
Comparison in V-DOP Scores Obtained Before and After Comparison in VFI Scores Obtained Before and After
Vocal Hygiene Program Vocal Hygiene Program
Parameters Pre-treatment Post-treatment P-value Parameters Pre-treatment Post-treatment P-value
Mean SD Mean SD Mean SD Mean SD
Overall severity 5.46 2.66 3.76 2.81 0.002* Part 1 26.18 8.17 23.12 8.78 0.066
Physical domain 48.33 22.16 38.16 23.25 0.003* Part 2 10.76 5.58 9.59 4.19 0.231
Emotional domain 29.72 33.14 23.52 30.95 0.060 Part 3 4.71 2.54 4.06 2.27 0.048*
Functional domain 30.18 26.74 24.28 25.48 0.034*
Total scores 108.24 72.46 85.98 70.32 0.006*
TABLE 6.
Summary of Outcome of VHP in Facilitating Vocal Health in School Teachers
Metric Improvement observed No change Interpretation
Vocal health Reduction in unhealthy Speaking in the presence of VHP has facilitated in improving the
vocal & non vocal noise knowledge & awareness of phono-trau-
practices matic behaviors
Vocal and related Sensation of heart burn, dis- No deterioration in other Indicative of minimal improvement/ main-
symptoms comfort in the throat, feel- vocal symptoms observed tenance of voice during the VHP
ing upset, feeling
reserved, struggling for
breath while speaking
Perceptual Minimal improvement in Roughness breathiness Minimal change in voice quality could be
evaluation overall quality of voice asthenia, strain due to the cut off score for improvement.
VHP was not facilitative in reducing devi-
ations in vocal quality
Aerodynamic MPT & s/z ratio were within No significant change The duration of the VHP was minimal to
measure normal ranges observed indicate significant change in MPT val-
ues (that can be expected as an indirect
benefit of VHP)
Acoustic analysis Frequency range, Low I0, F0, Dynamic range, Jitter VHP had positive effect on maintaining
Shimmer, DSI frequency range, frequency stability and
reduction in lower I0. However, deviation
in intensity stability was noticed
Stroboscopy Minimal improvement in Non vibratory portion, ven- Improvement in glottal closure could
glottal closure, symmetry, tricular fold reflect effects of morphological changes
periodicity hyperadduction. such as reduction in vocal cord edema.
However persistence of ventricular fold
hyperadduction indicates that teachers
continued to use faulty vocal production
even after VHP.
Self-perception Reduction in self-perception Impact of voice related Teachers perceived that they used their
of voice of overall severity of voice problems on emotional voice with reduced effort despite their
problems and its impact domain. vocal demands.
on physical and functional Symptoms associated with VHP did not provide resistance to vocal
domain. Improvement in tiredness of voice & physi- fatigue and improve the vocal endurance
voice following voice rest cal discomfort in teachers.
instructions in a real-life situation and thus reducing the identifying voice quality changes in voice disorders.66−68
vocal symptoms. These changes in self-perceived vocal In this study, positive changes in voice were observed in
symptoms had a positive impact on the teachers in using teachers after attending the VHP. This could be because
their voice in day to day situations over telephone and the improvement in GRBAS parameters was considered
during face to face interactions. However, they faced when there was at least a reduction in one score of sever-
major barrier to speak in the presence of noise and chalk ity. However, significant difference was not observed in
dust. The support from the educational institutions in overall grade after VHP. This finding is justified consider-
India is minimal that the teachers are compelled to speak/ ing significant changes in voice quality could be expected
teach in a large classroom with minimal or no amplifica- when the treatment was continued for a longer duration
tion devices.1 This in turn make them susceptible to of time.66,69
develop intermittent or sometimes more permanent voice Studies evaluating the efficacy of voice treatment had
related problems.65 indicated positive effect on aerodynamic measures.66,70
However, in the present study significant changes were not
observed in MPT and s/z ratio after attending the VHP. The
4.1. Effect of VHP on perceptual voice quality and VHP did not directly focus on improving the breath support
aerodynamic measures for speech other than some instructions about breathing
Perceptual evaluation of voice using GRBAS scale has been during production of sound and indirect measures to reduce
considered as one of the gold standard method for difficulties in breathing such as smoking, need for regular
295.e20 Journal of Voice, Vol. 37, No. 2, 2023
physical exercises, etc. The probable other reason could be demands. Similar results were reported by Timmermans
that increases in phonation duration is always a challenge et al69, where the authors indicated that improvements in
immediately after any vocal treatment.71 Including a vocal the self- perceptual scores were with time rather than the
loading task during assessment, where the teachers can use effects of vocal treatment. On the other hand, significant
their maximum potential for breath support could have improvement was not observed in part 1 & 2 of vocal fatigue
shown a difference after VHP. 66 index. This indicated that teachers did not feel considerable
improvement in vocal symptoms associated with tiredness
of voice and physical discomfort in voice use. However, sig-
4.2. Effect of VHP on instrumental measures
nificant change in part 3 (improvement of voice after voice
(acoustic & visual examination of larynx)
rest) scores indicated vocal recovery after a period of voice
The frequency range in teachers improved after the comple-
rest. These self-perceptual measures point out that the VHP
tion of VHP. Though significant changes were not observed
is effective in improving their awareness of inappropriate
in the dynamic range, the results indicated that the teachers
vocal behavior and reduced their effortful feel during voice
showed reduction in the value of Low I0 indicating a posi-
production. However, the VHP did not facilitate to provide
tive change after attending the VHP. In addition, shimmer
resistance to vocal fatigue or improve vocal endurance in
values indicated deviation in intensity stability even after
teachers.74
attending the VHP. The findings of this study parallel other
previous literature.72 The possible reason could be that
though the teachers gain the knowledge and awareness of
5. CONCLUSION
phono-traumatic vocal behaviors, they are often compelled
The vocal hygiene program for teachers was developed con-
to use loud voice for teaching 1 to meet their occupational
sidering the socio cultural aspects, lifestyle factors and occu-
demand. The structure and the functions of the laryngeal
pational needs of school teachers in India. Considering the
system were estimated by the visual examination of larynx
multifactorial aspects of vocal health in teachers, the current
through stroboscopy. Though positive changes were
study estimated the outcome of VHP using a comprehensive
observed in few parameters such as glottal closure, symme-
voice assessment protocol. The results indicate that the
try, periodicity, amplitude and mucosal wave movement,
VHP is potential in improving the teachers’ knowledge and
these were not significant. In addition, ventricular fold
awareness of at risk phono-traumatic behaviors and vocal
hyper adduction was persistent in all the teachers (who con-
health. However, its efficiency is limited in producing physi-
sented for stroboscopy) even after the completion of VHP.
ological improvement in teachers’ voice. This outcome
This clearly indicates that teachers continue to use an inap-
study of vocal hygiene program across the range of vocal
propriate/faulty voice production even after the VHP.73 In
metrics provides the voice clinician with some guidance
addition, though VHP is efficient in reducing the practice of
regarding the possible changes that can be expected after
at risk vocal/ phono-traumatic behaviors (based on self-
instituting a VHP to teachers.
report questionnaire), its impact on changing the vocal func-
tioning is limited. However in places like India where there
are restriction/constraints to seek direct therapy, vocal
6. LIMITATION
hygiene programs could be an option. However, the changes
The present study facilitated to understand the outcome of
in the vocal functioning as a result of VHP is not sufficient
VHP in facilitating vocal health among female school teach-
and is recommended to be followed in combination with
ers. Including a larger sample would have helped to
direct vocal treatment in teachers with voice related prob-
strengthen and generalize the findings to all teachers. The
lems.
challenges faced in monitoring the vocal hygiene practices
in day to day situation can be aided by developing mobile
4.3. Effect of VHP on self-perceptual evaluation of applications and reminders for teachers. In future studies,
voice measures (V-DOP & VFI) vocal task simulating the class room teaching (vocal loading
In teachers, the impact of compromised vocal health is not in the presence of noise) could be investigated as a part of
just restricted to observable voice symptoms, or laboratory vocal measures to understand the impact of the voice treat-
measures. It further affects the teachers’ day to day func- ment in facilitating endurance in vocally demanding profes-
tioning and their quality of life.13 Therefore, it is vital to sionals such as teachers.
understand the impact of voice related problems from the
teachers’ perspective (using self-perceptual vocal measures).
The scores obtained from V-DOP indicate a significant ETHICAL APPROVAL
change in overall severity, physical and functional domain. Institutional Ethics Committee approval obtained prior to
Though significant change was not observed in the function- the commencement of the study
ing of the vocal system and acoustics measures, these self-
perceptual measures showed that teachers felt an improve-
ment in their voice. This indicated that teachers felt they CONFLICT OF INTEREST
used their voice with reduced effort despite their vocal The authors declare that they have no conflict of interest.
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