Voice Problems and Teachers

Voice Problems of Classroom Teachers: Incidence, Symptoms, and Associated Factors

Daniel E. Phillips, MA, CCC-SLP
fdphillips16@juno.com
Ashley A. Gillespie, BS
Jessica D. Thompson
Communication Science and Disorders
University of Montevallo

Introduction
Teaching is an occupation with a high incidence of voice problems (Herrington-Hall, Lee, Stemple, Niemi, McHone, 1988; Rantala, & Vilkman, 1999; Smith, Gray, Dove, Kirchner, & Heras, 1997; Titze, Lemka, Montequin, 1997). Smith and colleagues found that while teachers comprise only 2% of the working population, they constitute 16% of hospital voice clinic populations diagnosed with a voice disorder. Twenty percent of the teacher population analyzed by Smith reported missing work as a result of a voice problem. Research findings in Europe, led by Rantala, concluded that “as many as 50% to 80% of teachers experience or have experienced voice problems” (p.484). Eustace (1996) determined that teachers are the second largest occupational group reporting chronic laryngeal fatigue.

Participants
Teachers from four school systems participated in this study.  Data were collected in 2001 and 2002 from approximately 500 teachers from elementary, middle, and secondary schools. The current data are based on the results of 230 teachers who reported experiencing voice problems related to classroom teaching. One hundred ninety seven (86%) were female and thirty three (14%) were male. The mean number of years teaching was 14 with a range of one to 35 years.

Method
Data were collected via questionnaire to obtain information on 29 areas of voice problems and associated factors, including: school setting, subject area, voice use, gastroesophageal reflux, sinus/allergy problems, caffeine intake, hydration, presence, symptoms, type and severity of voice problems experienced, if the problem has affected teaching, and the number of days missed from work.

Results
More than 47% of the teachers surveyed (230 out of 480) thought that they currently had a voice problem or had experienced a voice problem in the past year.

School Setting  
The 230 teachers reporting voice problems in different school settings:
Kindergarten:   5%,  12/230
Elementary:   35%,  79/230
Middle:          22%,  50/230
Secondary:    27%,  61/230
Two or more:  11%,  25/230

Teaching Situation
The 220 teachers reporting voice problems represented a variety of instructional areas and situations:
79% were Classroom teachers
13% were Music teachers   
4% were PE teachers
4% were Band teachers

Vocal Demands
Time speaking:             9.57 hours/day
Teaching:                     6.57 hours/day, 5.03 days/week
Outside vocal activities: 6.31 hours/week, 2.74 times/week

Teachers Rated Voice Problems as Mild, Moderate, or Significant
Mild:         63%, 140/230
Moderate:  31%,  68/230
Significant:  7%,  15/230

The Five Most Common Voice Symptoms Reported by Teachers:
Hoarseness:                             87%, 201/230
Frequent throat clearing:            41%,   95/230
Effort or strain to speak :           38%,   88/230 
Voice ‘gives out’ during the day: 31%,   71/230
Weak, tired voice:                     27%,   61/230

Most Common Voice Problems Reported by Teachers:
Quality:        47%, 107/230
Durability:     41%, 96/230
Loudness:     36%, 83/230
Consistency: 21%, 49/230
Pitch:            18%, 43/230

Water intake
Teachers with voice problems drank 3.81 glasses/day
Teachers without voice problems drank 3.24 glasses/day

Caffeine intake
Teachers with voice problems drank 2.15 caffeinated beverages/day
Teachers without voice problems drank 3.22 caffeinated beverages/day

Voice Problems Affect Teaching
52% of teachers (115/222) feel that problems with their voice have mildly to moderately affected their ability to teach. 9% of teachers (19/222) feel that problems with their voice have moderately to greatly affected their ability to teach. 21% of the teachers (48/227) or 10% of the total number surveyed missed work within the past year due to problems with their voice.

Discussion
The results indicate that 47% of teachers experience or have experienced problems with their voice, which is greater than the 16% found by Smith. Elementary teachers (40%) were most likely to experience voice problems, followed by Secondary teachers (27%), Middle School teachers (22%).  Teachers were asked to rate the severity of voice problems.  63% rated their voice problem mild, 31% moderate, and 7% significant. 52% think that voice problems have mildly to moderately affected their ability to teach and 9% think that problems with their voice have moderately to greatly affected their ability to teach. 21% of the teachers or 10% of the total number surveyed missed work within the past year due to problems with their voice. Those teachers  missing work missed an average of 2.4 days per teacher per year due to voice problems. Clearly, teachers are likely to develop voice problems which can affect their ability to teach. Teachers who complain of sinus problems, throat problems, have vocal activities outside the classroom are more likely to develop problems. Further research to identify those teachers most likely to develop problems is necessary.
If problems develop recent work by Roy, N., Gray,S., Simon, M., Dove, H., Corbin-Lewis, K., & Stemple, J.(2001) and Roy, N., Weinrich, B., Gray,S., Tanner, K., Toledo, S., Dove, H., Corbin-Lewis, K., & Stemple, J.(2002) has demonstrated effective measures, such as vocal function exercises or the use of amplification in the classroom, to improve voice production in the classroom. 

In light of the information obtained from this survey of Alabama teachers, we recommend the following:

Voice Conservation Suggestions for Classroom Teachers
Analyze schedules & vocal demands
Obtain amplifier for classroom
Reduce ambient noise
Reduce environmental irritants
Schedule student teacher
Understand recommendations made by physician or therapist
Instructional suggestions to reduce vocal strain

Suggestions to Help Prevent Voice Problems
Know if your voice changes
Try not to push or strain to speak
If your voice tires, rest it
Do not clear your throat unless necessary - determine why you are clearing your throat, if from vocal strain take a sip of water.
Drink sips of water throughout the day (6-8 glasses /day)
Limit caffeine intake to 2-3 drinks/day or less
Monitor reflux, control if a problem
Videotape classroom teaching to evaluate teaching style and voice use
Use over the counter medications  (antihistamines, decongestants) with caution
Use amplification if necessary - may be temporary or long term
Warm up voice before teaching
     Vocal function exercises are helpful to strengthen, stretch, and energize the vocal folds.
Begin vocal exercises 2-3 weeks before school starts and continue doing them 1-2 times/day throughout the year.
If you notice voice problems ask the speech pathologist in your school for ideas or suggestions. Consult an ENT physician

Preventing Voice Problems:
Questions to Ask:
Develop awareness of your voice quality (how it sounds): smooth, hoarse, rough, raspy, gravelly
Develop awareness of vocal effort (how it feels to talk): no effort, strain, or push to speak
Does your voice last all day?
Does it tire or give out during the day?
Do you clear your throat before speaking?
Do you have laryngitis during the school year? If yes, how often?
If you get laryngitis, do you rest your voice or continue teaching?
Do you drink water during the teaching day?

Analysis
T-tests were conducted on dependent measures to assess the differences as a function of self-reported sinus and reflux symptoms. One significant finding showed that subjects reporting sinus problems were more likely to report higher scores of the ‘voice problem’ variable, T(218) = -2.76, p < .0063, with means of 1.81 and 2.59 and ‘throat problems’ variable, T(177) = -14.099, p < .0001, with means of 3.16 and 4.66, two tailed. Subjects reporting reflux were more likely to report lower scores of the ‘voice problem’ variable, T(190) = -2.67, p < .0082, with means of 2.36 and 2.98. Correlation analyses were conducted to assess the relationship between several independent variables measured. A positive correlation trend was found between the presence of ‘throat problems’ and problems teaching  r = 0.367, p < 0.0095. A positive correlation trend was also found between the presence of ‘throat problems’ and vocal activities outside of the classroom teaching r = 0.169, p < 0.0248.

References
Eustace, C., Stemple, J., Lee, L. (1996). Objective measures of voice production in patients complaining of laryngeal fatigue. Journal of Voice, 10, 146-154.

Herrington-Hall, B., Lee, L., Stemple, J., Niemi, K., & McHone, M. (1988). Description of laryngeal pathologies by age, sex, and occupation in a treatment-seeking     sample. Journal of Speech and Hearing Disorders, 53, 57-64.

Rantala, L., & Vilkman, E. (1999). Relationship between subjective voice complaints and  acoustic parameters in female teachers’ voices. Journal of Voice, 13, 484-495.

Roy, N., Gray,S., Simon, M., Dove, H., Corbin-Lewis, K., & Stemple, J. (2001). An  evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. Journal of Speech and Hearing Research, 44, 86-296.

Roy, N., Weinrich, B., Gray,S., Tanner, K., Toledo, S., Dove, H., Corbin-Lewis, K., & Stemple, J. (2002). Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study. Journal of Speech and Hearing Research, 45, 625-638.

Smith, E., Gray, S., Dove, H., Kirchner, L., & Heras, H. (1997). Frequency and effects of  teachers’ voice problems. Journal of Voice, 11, 81-87.

Titze, I., Lemke, J., Montequin, D. (1997). Populations in the U.S workforce who rely on voice as a primary tool of trade: A preliminary report. Journal of Voice, 11,  254-259.