ARTICLE IN PRESS

Vocal Health, Voice Self-concept and Quality of Life in German

School Teachers
1X X
*DManfred NusseckD2X X, *D3X XClaudia SpahnD4X X, *,†D5X XMatthias EchternachD6X X, *D7X XAnna ImmerzD8X X, and *D9X XBernhard RichterD10X X, *Freiburg, and
yMunich, Germany

Summary: Objectives. For school teachers, the voice is a mandatory occupational tool during teaching.
Several studies, however, proved that teachers are at high risk of developing voice disorders. The aim of this study
was to investigate the voice health, voice self-concept, and quality of life in German teachers.
Methods. In a cross-sectional study 536 German school teachers had a laryngeal examination, acoustic voice
measurements to determine the Dysphonia Severity Index and filled in a self-reporting questionnaire with the
Voice Handicap Index-12), the voice self-concept (Fragebogen zur Erfassung des Stimmlichen Selbstkonzepts),
and the general quality of life (SF-12).
Results. A total of 58.3% of the teachers reported that they had experienced a voice problem at least once in
their career. Female teachers had more often experienced voice problems than male teachers. Twenty-five percent
showed a current considerable voice abnormality of vocal fold oscillation pattern. Such voice abnormalities were
observed more in male teachers than female teachers. The Dysphonia Severity Index also differed between gender
with higher values in the female teachers and a steadily decreasing value over age. The voice self-concept showed
differences between gender and age of the teachers. Teachers who experienced a voice problem had higher Voice
Handicap Index and lower voice self-concept values compared to those without experienced voice problems.
Teachers with voice abnormalities had lower values in the quality of life scales.
Conclusions. The findings confirm the high risk of voice health problems among German teachers and illus-
trate the complexity of vocal health and quality of life issues in teachers associated with gender, age, and the
history of experienced voice problems. This study strengthens the necessity for vocal training programs to pre-
pare teachers for a professional and healthy voice use to maintain vocal health.
Key Words: Teachers−Vocal health−Voice quality−Voice self-concept−Wellbeing.

INTRODUCTION level in the classroom and the habitual use of a loud

School teachers use their voice not only to address their
class and verbally convey the lessons’ content but also as a
means of expression. However, they were identified as hav-
ing high prevalence rates of occupational voice disorders.1
Studies showed that teachers are at greater risk of develop-
ing voice problems compared to nonteachers or to the gen-
eral population.2−5 Teachers listed voice disorders as the
fifth most frequent health problem behind tiredness, eye-
strain, anxiety, and sleep problems.6 Vocal problems not
only have a significant impact on the work capacity of
teachers,7−9 they can also lead to a reduction in content
processing and a decrease in the learning ability of the
pupils.10,11 Therefore, teachers should develop more aware-
ness of their own voice and take care of vocal health.
There are various risk factors for the development of
voice problems in teachers. In particular, a high noise
Accepted for publication November 14, 2018.
Funding: The study was funded by the ministry of science and arts and the ministry
of culture, youth, and sports in Baden-W€ urttemberg, Germany.
From the *Freiburg Institute of Musicians’ Medicine, Faculty of Medicine, Medi-
cal Center University of Freiburg, University of Music Freiburg, University of
Freiburg, Germany; and the yDivision of Phoniatrics and Pediatric Audiology,
Department of Otorhinolaryngology, Munich University Hospital (LMU), Munich,
Germany.
Address correspondence and reprint requests to Manfred Nusseck, Freiburg Insti-
tute of Musicians’ Medicine, Faculty of Medicine, Medical Center University of Frei-
burg, University of Music Freiburg, University of Freiburg, Els€asserstr. 2m, Freiburg
79110, Germany. E-mail: manfred.nusseck@uniklinik-freiburg.de
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2018.11.008
voice were associated with high vocal load in teachers.4,9
Kristiansen et al12 showed that teachers spoke with a
voice sound pressure level of more than 80 dB (A) in
61% of lesson time measured with a microphone
mounted on their shoulders. Using a voice accelerome-
ter, Nusseck et al13 found that teachers spoke with a
mean voice level of 80.2 dB (A) during teaching (calcu-
lated for a microphone distance of 30 cm). Speaking
repetitively with high vocal intensity is considered an
essential risk factor for developing voice problems.1
On average, more than 50% of teachers reported a
voice problem at least once in their teaching career.8,14−17
In a study on teachers in Latvia, the prevalence of voice
problems during a teaching career was 66%.9 Prevalence
differs across the type of school and changes over the life-
span of the teacher. Russel et al18 claimed that the preva-
lence of voice problems increases with age and that the
highest prevalence rates can be found in teachers over
50 years old. In a national survey in New Zealand, 33%
of teachers had a voice problem during their career and
prevalence was highest for teachers 50−59 years old.19
In Brazil, 63% of teachers reported voice problems during
their lifetime with the highest prevalence for teachers
40−49 years old (about 70%), with a considerable increase
over the previous age group of 30−39 year old teachers.3
Female teachers have generally been found to have a
higher prevalence of voice problems compared to male
teachers.3,5,9,19−21 A study specifically of primary school
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2018
teachers, however, did not find a difference between
genders.17
By analyzing recordings of preschool teachers, S€ odersten
et al22 claimed that teachers in earlier school levels−such as
primary schools−have greater vocal demands than in higher
school levels−such as high schools−due to higher noise
exposures in these classes. Leao et al19 found the highest
prevalence of voice problems for teachers working in pri-
mary schools, stating that especially for this type of school
the demands of classroom control and repeated use of the
voice led to more vocal stress. In contrast, Thibeault et al23
did not find higher risks for developing a voice disorder for
elementary school teachers. In addition, they found that the
lowest risk was shown by the teachers of special and voca-
tional education schools.
Several studies used the Voice Handicap Index (VHI24) as
an instrument to evaluate voice problems of teachers. This
self-assessment questionnaire indicates the possibility of
having a voice handicap. Generally, teachers with voice
self-complaints have been found to have significantly
higher VHI values than teachers without voice com-
plaints.15,20,21,25,26 Whilst Lu et al20 did not find a difference
in the VHI value between genders, Albustan et al21 did find
a difference as well as that teachers working in elementary
schools had higher VHI values than teachers of other types
of school. Kooijman et al25 did not find a change in VHI
across age.
In addition to vocally demanding factors there are also
psychological aspects such as high workload and stress that
were associated with developing voice complaints. Chen et
al7 identified a clear relationship between vocal health and
psychosocial and occupational stress in teachers. Teachers
with self-reported voice problems claimed to have more
stress and experienced more negative emotional states such
as anger than teachers without voice problems. Similarly,
Alva et al27 found that teachers with self-reported voice
problems were more likely to change their teaching style,
were more often thinking of changing the job or retire soon,
got easily upset, diminished their social activities, and were
more dissatisfied with the job compared to teachers without
a voice disorder. Rantala et al28 claimed certain associations
between occupational stress and the occurrence of vocal
symptoms. They found that teachers in poor working envi-
ronments and with certain stress experiences tend to have
destructive postures and use louder voices than healthy
teachers.
A clear connection has been found between voice com-
plaints and the Voice-Related Quality of Life (V-RQOL29).
Teachers with self-perceived voice problems showed a lower
quality of life than teachers without voice complaints.20,26,30
Furthermore, good correlations between the VHI and the
V-RQOL were affirmed.20,26 Where Hummel et al30 found
that female teachers were lower on the V-RQOL than men
Lu et al20 observed no differences between genders.
As an acoustically determinable dysphonia profile the
Dysphonia Severity Index (DSI31) provides an acoustic
voice quality measure with higher values representing
healthier voice functionality. The DSI value has been shown
for nonteachers to be correlated with age, where a higher
age was associated with lower DSI values and no significant
differences between genders.32 In contrast, Hummel et al30
did show for voice patients that men have a significantly
lower DSI value than women. They also showed that
patients with organic dysfunctions had a lower DSI than
teachers with functional dysfunction and that there was no
correlation between the DSI and the V-RQOL. In female
elementary school teachers, Aghadoost et al33 found signifi-
cantly higher DSI values for teachers who denied the ques-
tion of having experienced a voice problem at the time of
the assessment or during the last year than for teachers with
an experienced voice problem. So far, a large cross-sectional
sample of teachers has not been investigated using the DSI
as measure.
In this study, a combination of voice health and qual-
ity of life measurements was investigated in German
school teachers. This included different aspects of voice
health such as a laryngeal examination, the DSI, the
VHI-12, and the general quality of life measured with
the SF-12 questionnaire.34 The SF-12 is a standardized
instrument for physical and psychological health. In
addition, the questionnaire for the assessment of the
voice self-concept (Fragebogen zur Erfassung des Stim-
mlichen Selbstkonzepts [FESS]35) was inserted. This
questionnaire evaluates personal appraisals of the voice
such as the relationship with one's own voice, the
awareness of the voice usability, and the connection
between voice and emotional states. It was shown to be
a reliable measure and was used in student teachers to
investigate the effectiveness of a voice training pro-
gram.36 An intervention group with voice training
increased their relationship with and the awareness on
how to use their own voice significantly in contrast to a
control group. Both groups, however, showed that the
first teaching phase, which terminates after 1.5 years in
a teaching exam, was certainly vocally and emotionally
demanding.
These different measures were specifically analyzed
in relation to the age of the teachers to identify possi-
ble age-related changes. In addition to the prevalence
rates of voice problems, coherences with the experi-
ence of a voice problem and with recognizable voice
dysfunctions were investigated. From that, there were
four main research questions with additional interac-
tions of self-reported voice problems and voice
dysfunctions:
- Are there differences in vocal health and voice quality
of teachers across the age?
- Does the self-perception of their own voice differ
across the age?
- Is the quality of life of teachers different with different
ages?
- Are there variations in the previous questions across
the types of school?
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Manfred Nusseck, et al Vocal Health, Voice Self-concept and Quality of Life in Teachers 3

TABLE 1.
Distribution of the Participants, the Amount of Female Teachers, and Experienced Voice Problem During the Teaching
Career Across the Types Of School and the Age Groups
Amount % Female Experienced
Voice Problem
Type of school All Females Males
Primary school 26.5% 90.1% 70.2% 73.2% 42.9%
Junior high school 11.4% 77.0% 67.2% 70.2% 57.1%
High school (gymnasium) 41.4% 67.6% 56.3% 60.7% 47.2%
Special school 8.8% 87.2% 40.4% 41.5% 33.3%
Vocation-oriented school 11.9% 53.1% 43.8% 47.1% 40.0%
Age groups
<35 y 23.7% 75.4% 36.5% 36.8% 35.5%
35−44 y 29.1% 77.4% 63.2% 65.8% 54.3%
45−54 y 29.5% 70.1% 66.2% 75.5% 44.7%
55+ y 17.7% 75.5% 66.0% 71.8% 47.8%
Total 100% 74.6% 58.3% 62.7% 45.6%

MATERIAL AND METHODS
Participants
A sample of 536 teachers participated in this study. There
were no student teachers of the first teaching phase
included. All participants were already active teachers.
They taught in different types of school such as primary
school, junior high school, high school, special school, and
vocation-oriented school. The special school is particularly
for children with attention and learning difficulties and
potential developmental disorders which follow a regular
school curriculum. The vocation-oriented schools are regu-
lar high schools with an emphasis on specific occupational
lesson subjects. The distribution of the sample across the
types of school is shown in Table 1. The dispersal is in
accordance with the representative amount of these types of
school in the region.
The study was announced on different information por-
tals for teachers such as emails or in regular teacher meet-
ings. At first, the principal was asked for permission to
provide details of the study to the teachers. When granted,
the teachers were asked to come to the institute to be exam-
ined. All participants gave their agreed consent for partici-
pation. The study was approved by the ethical committee of
the Medical Center University of Freiburg (367/11).
In total, 74.6% were female teachers (Table 1). There was
a significant difference in the gender distribution across the
different types of school (chi square [5364] = 46.653;
P < 0.001) with the most female teachers in the primary
schools. This represents a typical gender distribution for
each type of school.
The mean age of the sample was 43.7 years (SD = 9.9).
Four teachers did not provide their age. The mean age dif-
fered significantly between the types of school (F
[4,530] = 5.688; P < 0.001). The youngest teachers were at
the special schools (M = 38.6 years; SD = 9.8) and the oldest
at the primary schools (M = 45.5 years; SD = 9.9). There
was no significant difference in age between genders. For
later analyses, the teachers were categorized into four differ-
ent age groups: younger than 35 years (<35), between 35
and 44 years, between 45 and 54 years and 55 years, and
older (55+; Table 1).
The teachers had on average 15.1 years of teaching expe-
rience (SD = 10.2 years; Min: 1 year; Max: 43 years). Both
the age and the years of teaching experience correlated with
Pearson's r = .90 (P < 0.001).
Measuring procedure
The participants had to follow a multidimensional voice
assessment protocol including a voice examination by an
experienced otolaryngologist, an acoustic measurement of
the voice, a vocal loading test, and filling in a questionnaire.
Besides gender, age, and years of teaching practice the ques-
tionnaire contained the below mentioned standardized
questionnaires.
The teachers were asked if they had at least once in their
career experienced a voice problem (Yes/No question). The
question also included the possibility of having a present
voice problem. In this article, the answers of this question
are stored in the variable of having an “experienced voice
problem.”
The participants were also asked if they have called in
sick at work due to a voice problem (Yes/No question). If
so, they were additionally asked to specify the total amount
of days absent from work due to voice problems.
Vocal measurements
All participants were analyzed using a multidimensional
voice assessment protocol of the European Laryngologi-
cal Society.37 It contains an examination of the vocal
fold oscillatory characteristics using rigid videolaryngos-
troboscopy. The examinations have been performed by
experienced laryngologists and all subjects tolerated the
laryngoscopy.
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2018
The results of the examination were afterwards catego-
rized into four symptomatic groups: (1) without any oscil-
latory abnormality of irregularity of the vocal folds, (2)
slight but detectable presence of at least one abnormality
concerning vocal fold oscillations (ie left-right asymmetries,
aperiodicities, impairment of oscillatory amplitudes, ante-
rior−posterior phase differences, and impairment of vocal
fold closure) without vocal fold mass lesions, which were
considered as “functional dysfunction,” (3) slightly recog-
nizable vocal fold mass lesions causing vocal fold irregulari-
ties (“organic dysfunction”), and (4) recognizable “serious
vocal disorders,” when a functional or organic dysfunction
reached a serious symptomatic level with a considerable
need to be medically treated. A laryngeal examination of
905 teachers in Spain found 29% functional, 20% organic,
and 8% chronical dysfunctions.16
In the acoustic measurement, the participants did a vocal
performance in which the highest fundamental frequency
(ƒo max), the lowest phonation intensity, the jitter (by use of
the sustained vowel [aː], measured over an interval of one
second, starting 1 second after the voice onset), and the
maximum phonation time (MPT; vowel [aː], comfortable
pitch and loudness, best of three attempts) were determined.
The lingWAVES software (WEVOSYS, Forchheim, Ger-
many) with a sound level meter (Voltcraft 322, Conrad
Electronic AG, Wels Austria) at a distance of 30 cm was
used. The acoustic measurements have been performed by
two examiners. They were previously trained to follow simi-
lar measuring instructions and to establish consistency and
reliability across the measurements.
From the above mentioned voice parameters the DSI31
has been calculated. The DSI is a compound value and rep-
resents an acoustic voice quality measure with higher values
indicating a generally better and healthier voice functioning.
A regular healthy voice has been found to be at a value of
4.2 or higher.38
Finally, the VHI24 was included to investigate the self-
perceived degree of having a voice handicap. In this study,
the short form of the German version with 12 items was
used.39 The higher the value, the higher the potential for a
voice handicap. The first threshold for having a light dys-
function was reported at the value of seven.38
Self-judgment of the own voice
The questionnaire for the assessment of the voice self-con-
cept (FESS, “Fragebogen zur Erfassung des Stimmlichen
Selbstkonzepts”35) investigates personal approaches to the
subject's own voice. It focuses on three dimensions: (1) the
“Relationship with the own voice” (eg “I like my voice”),
(2) the “Awareness of voice use,” ie, the awareness of how
to use the own voice and what the voice can provoke (eg, “I
take care of how my voice affects others”), and (3) the con-
nection between changes of “Voice and Emotion” (eg, “For
me, voice and emotion are strongly connected”). The indi-
vidual self-perception of the own voice is an important abil-
ity linked with personality aspects. Higher values in the
“Relationship with the own voice” and “Awareness of voice
use” indicate a better understanding of and connection to
the own voice. The scale “Voice and Emotion” in contrast
can respond with higher values for people perceiving higher
levels of psychological stress. The questionnaire consists of
17 items to be answered on a five-point scale. Internal con-
sistencies were between Cronbach's alpha of 0.69 and 0.82.
Quality of life measurement
The assessment of the quality of life of the teachers was
done with the SF-12 Health Survey (34German version40).
This is a short version of the SF-3641 with 12 items. The
questionnaire measures the functional health and well-being
in a four-week recall period. It distinguishes between two
scales: the physical health scale and the mental health scale.
Low values in the physical scale indicate the experience of
physical limitations in daily activities. Low scores on the
mental scale refer to nervousness and a high risk of depres-
sion.42 A study on 101 voice patients using the SF-3643
found relationships between both scales and the VHI with
higher values in the health scales correlating with lower val-
ues in the VHI.
Statistics
The analyses have been performed with SPSS 25 (SPSS Inc.,
Armonk, NY, USA). A multifactor multivariate variance
of analysis (MANOVA) was used with the dependent varia-
bles DSI, VHI, all three FESS scales, and both scales of the
SF-12. As independent variables the gender, age groups,
type of school, experienced voice problem, and the laryngo-
scopic result of having a voice dysfunction was included. To
avoid overloading the analysis, a user-defined model with
all main effects and the two-way interactions between age
groups and the other factors has been calculated. Nonpara-
metric comparisons were performed with Pearson's chi
square tests. The level of significance was set to P = 0.05.
RESULTS
In total, 58.3% of the teachers had answered positively to
the question of having experienced a voice problem at least
once in their career (Table 1). Female teachers reported
experienced voice problems significantly more often than
male teachers (chi square [5351] = 12.156; P < 0.001). There
was a significant distribution effect across types of school
for all teachers (chi square [5354] = 22.340; P < 0.001) with
the highest report in the primary school and the lowest in
the special school. However, this effect differed between
genders with a significant distribution effect for the female
teachers (chi square [3994] = 18.873; P = 0.001) and without
a significant effect for the male teachers (chi square
[1364] = 1.614; P = 0.806).
For the age groups, there was a significant distribution
effect for experienced voice problems (chi square
[5323] = 32.494; P < 0.001) that was mainly found between
the youngest age group (<35 years) with the lowest amount
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Manfred Nusseck, et al Vocal Health, Voice Self-concept and Quality of Life in Teachers 5

TABLE 2.
Distribution of the results of the laryngostroboscopic examination for gender and experienced voice problem.
Normal Functional Organic Serious Voice
Function Dysfunction Dysfunction Disorder
Total 75.1% 15.5% 7.5% 1.9%
Gender
Female 78.2% 13.5% 6.5% 1.8%
Male 65.9% 21.5% 10.4% 2.2%
Experienced
voice problem
No 80.1% 10.4% 9.0% 0.5%
Yes 71.8% 18.9% 6.4% 2.9%

in comparison to the other age groups, which had rather
similar report rates. Similar to the types of school, for the
female teachers the distribution difference was significant
(chi square [3963] = 37.816; P < 0.001) whereas for the male
teachers it was not significant (chi square [1363] = 2.405;
P = 0.493). The increase between the youngest and the sec-
ond age group found in the main effect was larger in the
female teachers than in the male teachers.
In total, 24.1% of the teachers called in sick at work due
to a voice problem. The 55.7% of the teachers who said that
they have experienced a voice problem did not stay away
from work. The mean absenteeism was 20.7 days
(SD = 45.4 days) with a range between 1 day and several
weeks. Since this answer was referring to the individual's
whole teaching career, for every teacher the absenteeism
was divided by their years of teaching practice to calculate
the mean absenteeism per year. The teachers who became
sick at work due to a voice problem did so on average for
1.2 days in a year (SD = 2.2 days).
The videostroboscopy yielded that 25% of the teachers had
a current recognizable abnormality of vocal fold oscillatory
characteristics (Table 2). Two percent even presented with a
serious voice disorder. Table 2 shows the distributions of the
laryngostroboscopic results divided by gender and reported
experienced voice problem. For the following analyses, the
laryngostroboscopic results were dichotomously grouped
into participants without and with stroboscopic abnormali-
ties. The three categories with recognizable abnormalities
(functional, organic, and serious) where combined into a sin-
gle group. In the following, this will be referred to as “physio-
logic voice problem” in contrast to the subjective assessment
of experienced voice problem.
Female teachers had significantly less physiologic vocal
problems than male teachers (chi square [5341] = 8.119;
P = 0.004). Furthermore, the teachers with experienced
voice problems had physiologic voice problems significantly
more often than the teachers without experienced voice
problems (chi square [5331] = 4.778; P = 0.029). However,
19.9% of the teachers who reported having never experi-
enced a voice problem had an observed abnormality of
vocal fold oscillatory characteristics. There were no signifi-
cant distribution differences for physiologic voice problems
in the types of school and in the age groups.
Table 3 shows the results of the multivariate analysis
(MANOVA) by listing the P values of the main effects. The
mean DSI value was significantly higher for female teachers
(M = 4.1; SD = 1.9) than for male teachers (M = 3.1;
SD = 2.1). As shown in Figure 1, this was mainly an effect
in the mid-age groups where for the youngest age group
there was no significant difference in the DSI values

TABLE 3.
P values of the Main Effects in the Multivariate Analysis
Gender Age Group Type of Experienced Physiologic
School Voice Problem Voice Problem
Dysphonia severity index (DSI) <0.001 0.007 0.671 0.564 0.090
Voice handicap index (VHI) 0.069 0.015 0.153 <0.001 0.119
Relationship with the 0.014 0.014 0.593 0.001 0.514
own voice (FESS)
Awareness of voice use (FESS) 0.038 0.002 0.298 0.451 0.504
Voice and emotion (FESS) 0.770 0.045 0.017 <0.001 0.260
Physical health (SF-12) 0.905 0.130 0.022 0.032 0.038
Mental health (SF-12) 0.002 0.087 0.893 0.017 0.015
Bold: P < 0.05.
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6 Journal of Voice, Vol. &&, No. &&, 2018
FIGURE 1. DSI mean values (with standard error) across age
groups and gender of the teachers (*: P < 0.05; **: P < 0.01). DSI,
Dysphonia Severity Index.
between genders. In both genders the mean DSI value
reduced significantly over the age groups. However, there
was no significant interaction effect found for gender and
age group.
For the VHI, significant differences were found across
the age groups and between previous voice problems. In
the age groups, the lowest VHI value was found in the
youngest age group (M = 5.9; SD = 4.87), which was sig-
nificantly below the first threshold of a light voice handi-
cap (t [124] = ¡2.518; P = 0.013), and the highest in the
age group 45−55 years (M = 7.4; SD = 5.74), which was
not significantly above the first threshold (t [155] < 1.0).
Teachers who reported an experienced voice problem
showed a higher mean VHI (M = 7.7; SD = 5.4) compared
to teachers without experienced voice problem (M = 5.1;
SD = 4.8). The VHI value with an experienced voice
problem was significantly above the first threshold of a
FIGURE 2. Mean values (with standard error) of the VHI-12 across age groups and physiologic voice problem (*: P < 0.05; bold line:
threshold of having a voice handicap). VHI, Voice Handicap Index.
light voice handicap (t [308] = 2.127; P = 0.034) and the
VHI without an experienced voice problem was signifi-
cantly below this threshold (t [222] = ¡5.795; P < 0.001).
Furthermore, there was a significant two-way interaction
effect between age groups and physiologic voice problem
(F [3,519] = 3.111; P = 0.026). Figure 2 shows the mean
VHI values for teachers without and with a physiologic
voice problem across the age groups. In the two oldest
age groups, the VHI value was considerably higher for
the teachers with a physiologic voice problem and above
the first threshold of a voice handicap.
In the FESS scale “Relationship with the own voice”
there were significant main effects found for gender, age
group, and experienced voice problem. Female teachers had
a lower mean value (M = 3.6; SD = 0.6) than male teachers
(M = 3.8; SD = 0.6). The mean values split by age groups
and experienced voice problem are shown in Figure 3. On
average, the teachers with an experienced voice problem
had a lower mean value (M = 3.6; SD = 0.6) compared to
the teachers without an experienced voice problem
(M = 3.8; SD = 0.6). Across the age groups the highest scale
value was found for the oldest age group (55+; M = 3.8;
SD = 0.6) and the lowest in the age group 35−44 years
(M = 3.6; SD = 0.6). The interactions showed no significant
effects.
The “Awareness of voice use” scale (FESS) showed
significant effects of age group and gender. In Figure 4
the mean values across the age groups and spilt by gen-
der are shown. The highest value was found in the oldest
group (55+; M = 3.4; SD = 0.8) and the lowest in the age
group 35−44 years (M = 3.0; SD = 0.7). The other two
groups showed rather similar values around M = 3.1.
Generally, male teachers had significantly higher values
(M = 3.3; SD = 0.7) than female teachers (M = 3.1;
SD = 0.7).
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Manfred Nusseck, et al Vocal Health, Voice Self-concept and Quality of Life in Teachers 7

FIGURE 3. Mean values (with standard error) of the FESS scale “Relationship with the own voice” across age groups and experienced
voice problem (*: P < 0.05; **: P < 0.01). FESS, Fragebogen zur Erfassung des Stimmlichen Selbstkonzepts.

For the “Voice and Emotion” scale (FESS), teachers with
an experienced voice problem showed significantly higher
values (M = 3.2; SD = 0.8) compared to the teachers with-
out an experienced voice problem (M = 2.7; SD = 0.8).
Figure 5 shows the mean values across the age groups split
by experienced voice problem. The mean value of all teach-
ers steadily increased over the age groups from M = 2.8
(SD = 0.7) in the youngest group up to M = 3.1 (SD = 0.8)
in the oldest group.
The type of school showed for this scale a significant main
effect. The highest value was found for the primary school
(M = 3.2; SD = 0.8) and the lowest for high school (M = 2.8;
SD = 0.9). In the other types of school there were similar
mean values of M = 3.0 (SD = 0.8).
The quality of life was measured with the SF-12 ques-
tionnaire and Figure 6 shows the physical and the men-
tal scale split by experienced and physiologic voice
problems. For both voice problems, the absence of a

FIGURE 4. Mean values (with standard error) of the FESS scale “Awareness of voice use” across age groups and gender (*: P < 0.05).
FESS, Fragebogen zur Erfassung des Stimmlichen Selbstkonzepts.
 ARTICLE IN PRESS
8 Journal of Voice, Vol. &&, No. &&, 2018

FIGURE 5. Mean values (with standard error) of the FESS scale “Voice and Emotion” across age groups and experienced voice problem
(*: P < 0.05; **: P < 0.01). FESS, Fragebogen zur Erfassung des Stimmlichen Selbstkonzepts.

voice problem showed higher values in both SF-12 DISCUSSION

scales. There was no significant interaction between both
conditions. Female teachers had also significantly lower
values in the mental scale (M = 49.5; SD = 8.3) than
male teachers (M = 52.1; SD = 7.4).
In the physical scale of the SF-12 there was a significant
effect found for type of school. The highest value was shown
by the vocation-oriented school (M = 54.5; SD = 4.5). The
lowest value was in the primary school (M = 51.2; SD = 6.6)
followed by the high school (M = 51.3; SD = 6.8). The val-
ues of the junior high school (M = 51.8; SD = 7.1) and the
special school (M = 52.7; SD = 5.6) lay in between.
In this study, a large sample of German school teachers was
examined for vocal health, quality of life, and voice self-
concept. In total, 58% of the teachers reported that they had
at least once experienced a voice problem in their career.
This amount is in a similar range of the findings of other
studies regarding the prevalence of voice problems in teach-
ers.3,8,17,44 Female teachers indicated an experienced voice
problem more frequently than men. This result was also in
agreement with previous studies.2,8,14,25
An age-related effect on the prevalence of experienced
voice problems was found with the lowest rate for the young

FIGURE 6. Mean values (with standard error) of the SF-12 scales for experienced and physiologic voice problem (*: P < 0.05; **: P <
0.01). FESS, Fragebogen zur Erfassung des Stimmlichen Selbstkonzepts.
 ARTICLE IN PRESS
Manfred Nusseck, et al Vocal Health, Voice Self-concept and Quality of Life in Teachers
teachers (<35 years). This primarily confirms the suggestion
of Russel et al18 that with age the prevalence rate increases.
However, in contrast to Leao et al19 the prevalence rate
jumped abruptly to the age group of 35−44 years and
stayed there even for the older teachers, confirming the find-
ings of Behlau et al.3 If the voice problems occur randomly
over a teaching career, the prevalence rate would continu-
ously increase over age as previous reports accumulate. The
results indicate that voice problems seem to be experienced
more often within the first 10−15 years of the teaching
career. Nonetheless, to systematically verify this statement
a longitudinal study on the experience of voice problems
during a teaching career would be necessary.
The videostroboscopic examination revealed that 25% of
the teachers had a considerable abnormality of vocal fold
oscillatory patterns. Teachers with self-reported experience
of voice problems had more physiologic voice problems
than teachers who had not experienced voice problems.
About 20% of the teachers who reported to have never expe-
rienced a voice problem presented a considerable physio-
logic voice problem. Even if they did not have previous
voice issues, they should have recognized the current vocal
abnormality. They seem to have not perceived the voice as
being restricted in its functioning. An apparent physiologi-
cal abnormality may not always directly produce a subjec-
tive sense of a voice problem. The difficulty with this is that
those teachers probably continue with their usual voice use
at work and could cause a higher risk of developing a
chronic voice disorder. Furthermore, studies that only relate
the prevalence of voice problems based on subjective inter-
rogation should consider the potential discrepancy between
self-reported experience and the existence of physiologic
voice problems.
The results also showed that female teachers have less
physiologic voice problems than male teachers. This finding
is in opposition with the amount of self-reported experi-
enced voice problems, for which men reported having less
voice problems than female teachers. Male teachers seem to
recognize a serious voice alternation as a potential voice
problem to a lesser extent than female teachers. This finding
is in accordance to the literature about the gender difference
on self-reported symptoms.45 Women seem to be more sen-
sitive in interpretation and reporting of symptoms. The spe-
cific differences between subjective and objective voice
problems between genders should be investigated in more
detail to be properly considered in future research.
For the acoustic voice quality, male teachers showed in
total a lower DSI than female teachers. This result supports
the findings of Hummel et al rather than the lack of gender
differences observed by Hakkesteegt et al.32 The DSI value
for both genders reduced with statistical similarity over the
age groups confirming the age-related loss of acoustic voice
quality claimed by Hakkesteegt et al.32 However, both gen-
ders had a rather similar mean DSI value in the youngest
age group (<35 years). Moreover, where the male teachers
showed a large decrease of the DSI in the age group of 35
−45 years, the female teachers stayed rather at the same
9
mean value and decreased in the DSI value considerably in
the age group 55+ years. A possible explanation for the
female DSI reduction could be the loss of high frequencies
in postmenopausal women.46 Nevertheless, the results show
that both genders start with a rather similar acoustic voice
quality and then seem to diverge within the first 10 years of
their teaching career.
In the VHI, the results go along with several other studies
showing lower VHI for teachers without voice self-com-
plaints. Thus, the VHI increased in total over age, which is
in contrast to Kooijman et al.25 Between genders there was
only a tendency of being different with lower values for the
male teachers. Therefore, in accordance with the findings of
Lu et al20 and Albustan et al,21 it can be suggested that
male teachers generally rate their voice health slightly better
than female teachers.
Interestingly, there was no difference in the VHI for phys-
iologic voice problems. However, the interaction between
age group and physiologic voice problem showed that
within the older age groups (45−54 and 55+ years) and with
existing physiologic voice problem the VHI was over the
threshold of a light voice handicap. The younger age groups
revealed a similar distribution of physiologic voice problems
but without differences in the VHI. It seems that for these
teachers the physiologic voice problem was not perceived as
a serious voice problem where for the older teachers the
vocal abnormality seem to have a higher emphasis and may
lead to a higher amount of consequential restrictions in spe-
cific job activities. This study, however, did not include
work-related changes. The interaction between age, voice
problem, and work situation should be investigated in
future studies.
For the voice self-concept, the “Relationship with the
own voice” seems to increase in total over age indicating
that the teachers getting more familiar with the voice with
more teaching experience. The results also showed large dif-
ferences between the teachers with and without an experi-
enced voice problem. Teachers with an experienced voice
problem had continuously lower values in this scale than
the teachers who had not experienced voice problems. Hav-
ing an experienced voice problem, therefore, is associated
with a certain negative effect on their relationship with their
own voice. The causality of this interaction, however, can-
not be reconstructed.
An experienced voice problem showed no difference in
the scale “Awareness of voice use.” Thus, over the age
groups this scale steady increases. This suggests that the
teachers seem to learn how to use their voice and how effec-
tive the voice can be with increasing teaching experience.
This, however, stands in contrast to the decreases of the
acoustic voice quality with age. It could be possible that the
teachers seem to have learned to deal with their own voice
and to compensate possible voice constraints. This is possi-
bly connected with the increase in the scale “Relationship
with the own voice.” The data of this study only provides
indications of this interaction. Further research, possibly
with a longitudinal design, are necessary.
 ARTICLE IN PRESS
10
In the third FESS scale “Voice and Emotion” describing
the connection between emotional stress and voice changes,
the mean value also increased over the age groups. This
indicates that age and the sensibility of emotional and vocal
changes are positively entwined. The scale has shown a posi-
tive correlation with the scale “Awareness of voice use”35
suggesting that as understanding of how to use the voice
improves, the conscious connection between emotion and
vocal changes increases as well. This result and the finding
in the scale “Awareness of voice use” may indicate that
younger teachers seem to have less general awareness of
their voice which increases with teaching experiences.
Understanding and self-awareness of which aspects of the
voice influence others is, however, not possible to determine
with the presented data.
The results for the general quality of life did not change
significantly over age. Where Bullinger and Kirchberger40
found a negative correlation of the physical health scale
with increased age, this was not the case in this study. The
teachers showed a steady physical health over age. Only the
female teachers had significantly lower mental scale values
than the male teachers, confirming the gender differences in
this scale.40
However, teachers with an experienced or physiologic
voice problem were significantly lower in both health scales
than teachers without voice problems. This finding agrees
with the study of Chen et al7 who found a correlation
between general psychological health conditions and voice
disorders and presumed that both health issues are associ-
ated with each other. The results additionally showed that
this seems to be true also for the physical condition. Never-
theless, the findings cannot clarify which of both, the quality
of life or the voice complaint, influenced the other. An inter-
vention study with a voice training program showed that
both vocal and mental health improved with the training
simultaneously,36 indicating that there is a clear relationship
between both.
Across types of school, there was a significant distribution
effect of the prevalence of experienced voice problems. The
highest rates were found in the primary and the junior high
school. It is unclear if this effect was provoked by the higher
number of female teachers in these types of school, which
could have been overpowered by the gender difference, and
age influence, with slightly older teachers in these types of
school, or a higher vocal load which is generally claimed for
these types of school.19,22 However, the teachers of these
types of school did not differ in the acoustic voice quality or
the amount of physiologic voice problems compared to the
other types of school. It seems that the schools with younger
year groups evoke a higher subjective impression of voice
problems, which may be caused by the specific work-related
vocal demands in classes of these types of school. Neverthe-
less, the results of this study cannot yield much insight to
this topic. More work-related research of vocal load and
subjective voice experiences are necessary.
The absenteeism from work due to voice problems of 24%
was in a similar range to the reports of other studies (20%15;
Journal of Voice, Vol. &&, No. &&, 2018
23%3,17; 36%19). Furthermore, the average duration of
absenteeism of 1.2 days per year was also comparable to
other studies who found a range of 1−2 days. The educa-
tional system relies on a consistency of teaching. Every hia-
tus in continuous teaching is reflected in educational loss for
the pupils. As voice problems can be diminished with voice
training programs,47 it should be considered for teachers to
take more care of their vocal health to minimize voice-
related vocational absences.
CONCLUSION
Generally, the results of this study confirm that school
teaching is an extremely voice demanding occupation.
About six out of 10 teachers had experienced voice prob-
lems in their teaching careers at least once. Young teachers
showed a lower prevalence of experienced voice problems
and a higher acoustic voice quality. The acoustic voice qual-
ity decreased with age, which is a common finding also in
the general population. However, they also had a lower
voice self-concept with less awareness of the voice compared
to older teachers. While the age of the teachers was a major
factor of influence on voice-related parameters, the quality
of life was nearly unaffected by age.
Additionally, the simultaneous measuring of physiologic,
acoustic, and subjective voice parameters yielded a fair
amount of inconsistencies. Some teachers who were diag-
nosed with a considerable physiologic voice problem did
not identify it as a subjective voice problem. This finding
demonstrates the complexity and contradiction between
subjective and objective voice measures.
An experience of a voice problem reduced the self-percep-
tion of the voice health, the voice self-concept, and the men-
tal well-being. This indicates that experiencing a voice
problem has a clear effect on life and work. Therefore, it is
important for teachers to recognize severe signals of vocal
and mental health problems as soon as they appear and to
seek professional voice counseling. The results of this study
strengthen the necessity for vocal training programs for
teachers to prevent the development of voice problems, to
prepare the voice for highly demanding occupational use,
and to maintain vocal health in long-term.
ACKNOWLEDGMENTS
The authors would like to thank Nisma Bux-Cherrat,
Juliane Stein-Vogel, Dr. Louisa Traser, and Dr. Sebastian
Dippold for providing the measuring procedure and the
examinations.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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