Voice Care Knowledge Among Clinicians and People

With Healthy Voices or Dysphonia

*Helen M. Fletcher, †Michael J. Drinnan, and ‡Paul N. Carding

*Dumfries, Scotland, and †‡Newcastle-upon-Tyne, United Kingdom

Summary: An important clinical component in the prevention and treatment

of voice disorders is voice care and hygiene. Research in voice care knowl-
edge has mainly focussed on specific groups of professional voice users
with limited reporting on the tool and evidence base used. In this study,
a questionnaire to measure voice care knowledge was developed based on
‘‘best evidence.’’ The questionnaire was validated by measuring specialist
voice clinicians’ agreement. Preliminary data are then presented using the
voice care knowledge questionnaire with 17 subjects with nonorganic dys-
phonia and 17 with healthy voices. There was high (89%) agreement among
the clinicians. There was a highly significant difference between the dys-
phonic and the healthy group scores (P 5 0.00005). Furthermore, the dys-
phonic subjects (63% agreement) presented with less voice care knowledge
than the subjects with healthy voices (72% agreement).
The questionnaire provides a useful and valid tool to investigate voice care
knowledge. The findings have implications for clinical intervention, voice
therapy, and health prevention.
Key Words: Dysphonia—Healthy voices—Voice care—Vocal hygiene—
Voice therapy.

INTRODUCTION explanation of vocal tract care and voice hygiene.1

In the management and treatment of voice dis-
orders, importance is placed on education and
Accepted for publication August 30, 2005.
From the *Speech and Language Therapy Service, Dumfries
& Galloway Royal Infirmary, Dumfries, Scotland; †Regional
Medical Physics Department, Freeman Hospital, Newcastle-
upon-Tyne, United Kingdom; and ‡Department of Speech,
Voice and Swallowing, Freeman Hospital and Medical School,
University of Newcastle-upon-Tyne, United Kingdom.
Address correspondence and reprint requests to Professor
Paul Carding, Department of Speech, Voice and Swallowing,
Otolaryngology, Freeman Hospital, Newcastle-upon-Tyne,
UK NE7 7DN. E-mail: paul.carding@ncl.ac.uk
Journal of Voice, Vol. 21, No. 1, pp. 80–91
0892-1997/$32.00
Ó 2007 The Voice Foundation
doi:10.1016/j.jvoice.2005.09.002
Voice care knowledge includes an understanding of
issues of vocal hygiene,2 limiting vocal hyperfunc-
tion, and reducing vocally abusive behaviors.3
However, few attempts have been made to examine
the general knowledge base of voice and voice care
in either people with dysphonia or with healthy
voice. Knowledge of what people believe influen-
ces their voice may provide insight into who
presents with, or is at greater risk of presenting
with, dysphonia. This may highlight the need for
providing preventative education or health promo-
tion to the wider population. On an individual basis,
documenting existing voice care knowledge pro-
vides a baseline for interventions4 and is a starting
point for designing appropriately targeted treatment
programs.

80
 VOICE CARE KNOWLEDGE
To date, research has looked at voice knowledge
and care in specific populations of professional
voice users, for example, actors5 and singers.6,7
Most studies reported low levels of voice care
knowledge.5,8 Chan9 and Yui10 examined voice
knowledge in teachers, with Yui10 reporting no
significant differences in voice care knowledge
between groups of teachers. We are not aware of
any studies on the voice care knowledge of non-
professionally grouped voice users or between peo-
ple with dysphonia and those with healthy voices.
A further problem with existing studies is the
lack of a validated and evidence-based tool to in-
vestigate levels of voice care knowledge. Previous
studies have relied on self-reporting using either in-
formal means8,9 or questionnaires.5,7,10,11 Most of
these studies reported a minimal evidence base
for the voice care items used. The evidence is pre-
dominately based on expert opinion, descriptive
studies, or reports from expert committees,12 with
several notable exceptions, such as hydration13,14
and amplification.15–17 Furthermore, previous stud-
ies demonstrated a limited means of measuring
responses, often relying on yes/no answers.
The aims of this study were as follows:
- To develop a ‘‘best evidence’’ tool to measure
voice care knowledge
- To validate the tool by measuring specialist
clinicians’ agreement
- To present some preliminary data comparing
people with healthy voices and those with non-
organic dysphonia.
METHOD
Developing the voice care knowledge
questionnaire
Because no suitable questionnaire on voice care
knowledge was available in the current literature,
a new self-administered questionnaire was designed
and validated as a measurement tool. Factors in the
questionnaire reflect assumptions or perceived
wisdom identified in the published literature about
vocal care. A summary is presented in Table 1.
1,2,6,9,10,13,15–54
The questionnaire (in Appendix 1)
was designed with 28 factors that might or might
not influence the voice. The factors were presented
81
as short unambiguous statements, with an approxi-
mate balance between likely negative factors (eg,
‘‘smoking’’), positive factors (eg, ‘‘resting my tired
voice’’) and factors that could be perceived as hav-
ing no influence (eg, ‘‘drinking warm soup’’). As
the evidence base about specific voice care is limit-
ed, with few ‘‘rights’’ and ‘‘wrongs,’’ the question-
naire was designed to reveal perceptions.55 Each
factor was measured using a direct estimation meth-
od that combined a visual analog scale (100-mm
line) with a Likert attitude scale.56 The questionnaire
gave instructions followed by an example. The de-
sign incorporated symbols and labels to reinforce
the continuous nature of the scale (left ‘‘positive,’’
middle ‘‘no influence,’’ right ‘‘negative’’).
The questionnaire was piloted on two specialist
voice clinicians and four consenting volunteers
(two dysphonic, two healthy voices) to ensure its
ease of use for the target groups. They were asked
to complete the questionnaire and to report any dif-
ficulties. All gave favorable responses and found it
simple to understand and easy to complete. The
questionnaire was then validated by 10 practicing
specialist voice clinicians throughout the United
Kingdom who are experts in the topic of interest.57
The specialist clinicians reported a mean of 12.3
years within the speciality (range of experience
was 2–33 years).
Subjects
We used a prospective comparative study design
with two groups of subjects; a dysphonic voice
group (DVG) and a healthy voice group (HVG).
All subjects were informed and consenting adults.
Groups were matched for age, sex, smoking habits,
and predicted IQ. A summary of the subjects is pre-
sented in Table 2.58 In the DVG, five of the sub-
jects’ occupations could be classified as requiring
substantive voice (4 teachers, 1 telephonist) com-
pared with two (teachers) in the HVG.
The DVG consisted of patients with a diagnosis
of nonorganic dysphonia (defined as dysphonia of
behavioral hyperfunctional etiology only and did
not include dysphonia of an organic or psychogenic
etiology1). Exclusion criteria were previous therapy
for voice problems, formal singing or acting train-
ing, registered medical professionals, or an inability
to comprehend written English.
Journal of Voice, Vol. 21, No. 1, 2007
82 HELEN M. FLETCHER ET AL
TABLE 1. Voice Care Knowledge Factors, the Assumptions, Evidence Base, and/or Reporting in the Literature
Voice Care Factor and Assumption
1. Being happy
Emotion is reflected in the voice, with positive emotions having
a positive effect.
2. Being overweight
No generally accepted assumption, although poor dietary habits
may lead to reflux, a major risk factor in dysphonia, and/or
being overweight may constrict breath support for voice.
3. Coughing
That the collision forces acting on the vocal folds during
coughing have a negative effect on voice.
4. Drinking alcohol
Alcohol potentially acts as a laryngeal irritant and leads to
dehydration, which puts the vocal folds at risk of damage.
5. Being relaxed
General body relaxation has positive effects on the voice by
allowing the muscles to function optimally.
6. Loud singing
Could be considered a strenuous vocal activity, which may be
negative, or alternatively, singing may have some positive
psychological benefits.
7. Sucking fruit sweets or chewing gum
No generally accepted assumption for or against.
8. Eating warm food
No generally accepted assumption for or against.
9. Smoking
Smoking is generally agreed to be a negative, as the smoke leads
to inflammation and swelling of the pharyngeal and laryngeal
mucosa and dehydration leaving the vocal folds prone to
damage.
10. Drinking coffee, tea or coke
These may be regarded as having a negative effect on the voice,
due to the diuretic effects of caffeine intake leading to
dehydration.
11. Swimming
No generally accepted assumption for or against.
12. Whispering
May be negative for the voice, as the anterior two thirds of the
vocal folds often continue to approximate, resulting in effort
and irritation.
Journal of Voice, Vol. 21, No. 1, 2007
Evidence Base and/or Reporting in Literature
Emotional stability is an ingredient in healthy voice use.9
Murry and Rosen20 advise ‘‘be happy.’’ Emotional state can be
reflected in the voice1,21–23
Opera singers’ needing to be obese is a myth.22 Hoarseness is
a symptom of gastroesophageal reflux.24 General fitness will
assist breath support.25
Severe coughing can cause damage to the epithelium of the
vocal folds.26 Excessive collision may damage tissue.27
Avoiding coughing is recommended for good vocal
care.9,18–20,25,28,29
Drinking alcohol is related to an increased risk of laryngeal
cancer.30 Avoiding or limiting drinking alcohol is often
advised for voice care.6,19,25
Blood31 included a self-reported relaxation scale in a voice
treatment for two women with hyperfunctional voice
disorders. Findings indicated that the use of relaxation showed
no clinically significant improvements, although it may assist
and complement the overall treatment. Relaxation is
commonly recommended for voice care.1,32,33
Sataloff34 refers to singing as athletic activity. Yiu35 suggests
that vocal fatigue can follow high-intensity karaoke singing.
Avoiding singing has been advocated to help the voice.1,9,19,29
Froeschels [2] observed that bus drivers chewing gum were
more likely to have a normal voice. Possibly a placebo
factor.
Potentially a neutral factor.
Smoking is related to an increased risk of laryngeal
cancer.30 The adverse effects of smoking on the voice are
indisputable.22 The cessation of smoking is usually advised for
voice care.1,6,18,19,25,28,32
Akhtar et al36 studied eight subjects after ingesting a moderate
amount of caffeine. Voice quality was measured by EGG and
findings indicated voice changes with marked intrasubject
variability. Avoiding caffeine drinks may be recommended for
voice care.1,9,18,25,33,37
Potentially a neutral factor.
Tsunoda et al38 reported constriction and suppression of the
larynx during whispering. Voice care suggests not whispering
or not using forced or excessive whispering.1,9,20,25,34
(Continued )
 VOICE CARE KNOWLEDGE
TABLE 1. Continued
Voice Care Factor and Assumption
13. Shouting
That shouting can have a negative influence on the voice. It may
result in laryngeal edema and increased tension in the vocal
folds due to hyperadduction and the effect of collision forces.
14. Resting my tired voice
That resting a tired voice is positive as it allows fatigued muscles
to recover, prevents any further potential trauma, and avoids
risk of further damage.
15. Warming up my voice before talking
This is perceived as having a positive influence on the voice,
especially before extended periods of voice use.
16. Using an amplifier or microphone
This has a positive influence on voice, augmenting the voice,
thereby reducing the vocal load on the vocal mechanism and
may prevent hyperfunction by reducing the demands placed
on the voice.
17. Walking
No generally accepted assumption for or against.
18. Throat clearing
Is considered negative and damaging to the vocal folds due to
the collision forces and habitual use.
19. Steam inhalation
Steam inhalation is perceived as positive for the voice as it is
a source of hydration that facilitates easier voice production
by decreasing the viscosity of vocal fold tissue that thereby
reduces the energy used in the vibratory cycle of the vocal
folds.
20. Drinking warm soup
No generally accepted assumption for or against.
21. Not talking if my voice is sore
Not talking if the voice is sore is generally positive for voice
care.
83
Evidence Base and/or Reporting in Literature
Boone32 describes yelling as one of the most common vocal
abuses. The avoidance of shouting is often recommended for
voice care.1,20,28,29
Yiu and Chan35 reported vocal rest may conserve the function
and quality of voice during karaoke singing. Postoperative
voice rest is potentially recommended, although there is
varied opinion and practice regarding the type and duration.39
Specific voice rest can have both advantages and
disadvantages19 and although resting may help renew a tired
voice,32 it will not cure a dysphonia.40 A degree of voice rest
or reducing the amount of talking may be advised as being
beneficial to voice care.1,6,20,25,28
Sataloff34 compares voice warm-up to stretching before
undertaking exercise. Warming up in other fields is considered
vital for optimum performance despite lack of evidence.41
With singers42 suggested pitch changes following warm-up.
Voice care may include advice on warming-up the
voice.20,33,43
Amplification has shown to be beneficial in a number of
studies with teachers and students.15–17,44–48 Yiu19 reported
that teachers suggested amplifiers as a strategy to avoid voice
problems. Voice care may include recommending the use of
an amplifier or microphone.32,43
Potentially a neutral factor.
Throat clearing is traumatic to the epithelium.26 Voice care
advises the avoidance of throat clearing.1,9,18–20,28,29,32
Verdolini-Marston et al13 used a double-blind placebo
controlled study of six women with voice disorders. Findings
indicated significant improvement in both the control and the
treatment group, with greater improvement following
hydration treatment. Generalization to the clinical situation is
cautioned, although recommended as a supportive benefit for
dysphonics. Steam inhalation can be recommended as part of
voice care.1,13,20,28
Potentially a neutral factor.
Reducing the amount of talking, especially if the voice is
sore, may be beneficial to voice care.1,32,34 Refer also to 14
above (although similar to 14, this factor uses negative
wording and is included as a commonly expressed opinion of
those who present with voice disorders that they should ‘‘just
keep talking’’ and ‘‘the voice will come back’’).
(Continued )
Journal of Voice, Vol. 21, No. 1, 2007
84 HELEN M. FLETCHER ET AL
TABLE 1. Continued
Voice Care Factor and Assumption
22. Sucking medicated throat lozenges
No generally accepted assumption for or against.
23. A noisy environment
Has a negative influence on the voice as raising volume may lead
to increased laryngeal tension, vocal fold trauma, and
irritation.
24. Speaking gently
Speaking gently may be considered positive or possibly as
having no influence on the voice.
25. Breathing through my nose
May be considered positive as the nose warms, humidifies, and
acts as a natural filtration system to airborne irritants that may
irritate the vocal tract.
26. Plants in the office/home
No generally accepted assumption for or against.
27. Good posture
Appropriate alignment and muscle movement of the laryngeal
structures is necessary to facilitate optimum voice.
28. Eating chocolate
No generally accepted assumption for or against.
The HVG subjects were recruited from a variety
of public institutions. Exclusions were as per the
criteria above, with one additional exclusion criteri-
on: previous self-reported voice difficulties.
Subjects could withdraw from the study at
any time by withdrawing consent. The local re-
search ethics committee approved this research
project as following ethical guidelines and
protocols.
Evaluation of voice care knowledge
Each subject completed the voice care knowl-
edge questionnaire in a quiet room. Instructions
Journal of Voice, Vol. 21, No. 1, 2007
Evidence Base and/or Reporting in Literature
Although throat lozenges are beneficial in relieving in sore
throats49 they also mask pain, which is a protective
physiological function for the voice.26
Ternstrom et al50 demonstrated the effects of noise on a variety
of voice measurements, with subjects reporting voice strain in
loud conditions. Voice care recommends avoiding voice use in
noisy environments.1,6,19,20
Prater and Swift19 advise avoiding strained voice use, and Yiu10
reported that teachers suggested speaking softly as a strategy
to avoid voice problems. Voice care may1 or may not
specifically advise the use of speaking gently.
Nasal breathing heats, humidifies, and partially cleans
inspired air before it passes through the remaining
respiratory tract.51 Sivasankar and Fisher52 report the
adverse effects of short-term oral breathing and suggest
a possible link that oral breathing may predispose people to
vocal pathology. Nose breathing is recommended for voice
use rather than mouth breathing.22
Although Mathieson1 recommends having a moist atmosphere,
for example, having plants to assist the voice, Andrews43
suggests removing plants due to mold.
Vintturi et al53 reported standing posture during vocal use was
associated with improved vocal recovery. The Alexander
Technique is advocated to improve posture and voice.18,25,54
Appropriate body posture is essential to efficient voice use.34
Chocolate as a solid caffeine may be detrimental to the
voice.6,18,25,36
were given to complete the questionnaire, and
an example was given to aid completion. For the
DVG, the questionnaire was completed before the
patient was treated to prevent any newly acquired
knowledge being reflected in their responses.
Statistical analysis
Each factor was measured on the visual analog
scale along the 100-mm line. These values were
converted to a score in the range 21 to 11; 21 cor-
responded to an extreme negative influence; 11
corresponded to an extreme positive influence;
a score of 0 indicated no influence on voice.
 VOICE CARE KNOWLEDGE
TABLE 2. Subject Characteristics
DVG n 5 17 HVG n 5 17
Age (yrs)
Mean 45.8 44.3
Range 32 to 50 34 to 50
Sex
Male 2 2
Female 15 15
Smokers 2 3
Standard predicted IQ
Mean 110 110
Range 94–126 95–122
Note: IQ was predicted using the National Adult Reading
Test.58
Validation of the voice care knowledge
questionnaire
A total of 280 ratings (10 raters 3 28 items) were
made by the clinicians. The mean score across the
10 specialist clinicians was calculated for each fac-
tor. This became the benchmark ‘‘correct’’ answer
for the measurement of agreement.
An error score was calculated for each factor to
examine specialist clinician agreement. Error was
defined as the difference between the rater’s score
and the benchmark correct answer. The standard
deviation across the 10 specialist clinician raters
was calculated. Agreement was defined as 1 minus
the standard deviation and presented as percentage
agreement. This could range from 0 (complete
agreement for all clinicians) to 11 (clinicians are
equally divided at opposite ends of the scale).
For summary, the raw ratings were classified as
‘‘positive influence’’ (a score from 10.33 to
11.0), ‘‘no influence’’ (a score from 20.33 to 1
0.33), and ‘‘negative influence’’ (a score from
20.33 to 21.0). To analyze levels of clinicians’
agreement, the kappa score was calculated; kappa
shows the level of strength of agreement beyond
chance. A kappa score of 1 5 complete agreement,
O0.8 excellent, 0.6–0.8 good, 0.4–0.6 moderate,
!0.4 poor, and 0 no better than chance.59
Evaluation of voice care knowledge
in HVG and DVG
To evaluate the DVG and HVG score, each factor
(n 5 28) for every subject (n 5 17) of each group
85
(n 5 2) was measured to yield a total of 952 scores.
The error for each factor was calculated as the dif-
ference between the subject’s score and the bench-
mark correct answer from the specialist clinicians.
The standard deviation across the 17 subjects
(around the benchmark score) was calculated, and
agreement (1 minus standard deviation) was pre-
sented as a percentage for the HVG and the DVG
groups separately. Agreement across the 28 factors
in the questionnaire was compared between the
HVG and DVG groups using the Student paired
t test.
RESULTS
Validation of the voice care knowledge
questionnaire
The overall average response to the 28 factors in
the questionnaire was 0.02 (0 5 no influence),
which demonstrates a balance of positive and
negative items in the voice care knowledge
questionnaire.
Figure 1 shows a summary of agreement on each
of the factors in the voice care questionnaire. These
values represent the degrees of consensus among
the 10 specialist clinicians. The range was from
77% to 99% with mean agreement of 89% for the
specialist clinicians.
The strength of agreement across each factor of
the questionnaire was summarized using Kappa,
as illustrated in Table 3.59 Sixteen of the 28 factors
on the questionnaire scored 1, indicating complete
agreement among all 10 clinicians. Five of the 28
factors scored 0.7, indicating good agreement.
One of the 28 factors (11, swimming) scored 0.4,
which indicates moderate agreement. The remain-
ing six factors scored less than 0.4, which indicates
poor agreement.
Evaluation of voice care knowledge
in HVG and DVG
The HVG agreement with the specialist clini-
cians is shown in Figure 2. Twenty-five of the 28
factors demonstrated agreement above 50%. The
remaining three were 12, whispering (49%); 18,
throat clearing (46%); and 22, sucking medicated
throat lozenges (47%). The highest agreement
was for factor 21, not talking if my voice is sore
Journal of Voice, Vol. 21, No. 1, 2007
86 HELEN M. FLETCHER ET AL
100%
90%
Agreement
80%
70%
60%
50%
40%
1 4 7 10 13 16 19 22 25
Factor on Voice Care Knowledge Questionnaire
FIGURE 1. Specialist clinicians agreement of all 28 factors
of the Voice Care Knowledge Questionnaire.
(91%). Mean agreement for the HVG with the spe-
cialist clinicians was 72% (95% confidence interval
68% to 76%).
Agreement for the DVG is in Figure 3. Twenty-
one of the 28 factors demonstrated agreement
above 50%. The remaining seven factors were 3,
coughing (43%); 4, drinking alcohol (46%); 6,
loud singing (49%); 12, whispering (41%); 13,
shouting (49%); 18, throat clearing (23%); and
22, sucking medicated throat lozenges (48%). The
highest agreement was for factor 2, being over-
weight (80%). Mean agreement for the DVG with
the specialist clinicians was 63% (95% confidence
interval 5 58%–68%).
There was a highly significant difference be-
tween the HVG and the DVG groups (Student
paired t test, t 5 4.8, df 5 27, P 5 0.00005). The
three factors that showed less than 50% agreement
with the HVG also showed less than 50% agree-
ment in the DVG. There was no difference in the
mean age or mean IQ between the groups (Student
unpaired t test, P 5 0.44 and 0.96, respectively).
DISCUSSION
Developing the voice care questionnaire
The first aim of this study was to develop a ques-
tionnaire to investigate voice care knowledge. The
questionnaire attempted to measure voice care
knowledge systematically and with explicit as-
sumptions and links to the evidence base. However,
certain limitations were imposed by use of the scale
chosen.56 Attempts to minimize these were made
through random ordering, non-emotive wording,
and use of neutral factors. Results showed an aver-
age balance of negative and positive responses
across the total number of items. This finding
Journal of Voice, Vol. 21, No. 1, 2007
supports the validity of the questionnaire. Intrarater
validation was not considered as part of this study,
although it would add valuable information to fur-
ther research in this area. The factors presented in
the questionnaire were in the form of statements
that did not allow for degrees of interpretation.
28
For example, the response to factor 10 could have
been influenced by the amount of coffee, tea, or
soda consumed. An attempt was made to include
the majority of factors that may influence voice.
Hydration was represented (by factor 19, steam in-
halation). Although there is evidence to support
systemic hydration14,60 drinking water, which is
frequently recommended for voice care,1,18,61 was
not included. Modification of the voice care knowl-
edge questionnaire could be considered as several
other factors may be included, for example, drink-
ing water, avoiding dust,19 gargling,1 or the use of
peppermints.11
Validation of the voice care knowledge
questionnaire
This study showed high specialist agreement
among clinicians for factors that influence voice
care knowledge as measured by the voice care
knowledge questionnaire. Professional consensus,
although not an unexpected outcome, exceeded
the de facto 75% acceptance level.59
The specialist clinicians were not asked to re-
spond with regard to a specific client group. It is
possible that clinicians may provide different ad-
vice for different clinical conditions,62 thereby rat-
ing voice care knowledge influences differently for
healthy voices than for nonorganic or organic voice
disorders. All clinicians were speech and language
therapists. As other professional groups such as ear,
nose, and throat colleagues frequently provide
voice care advice, benchmarking their consensus
would further validate the tool.
According to Glenton,63 advice given by profes-
sionals is frequently a mixture of tradition, intui-
tion, and research. It is of interest to consider the
clinicians’ agreement (Table 2) in the context of
the evidence base in the literature (Table 1).
Some factors with a strong evidence base (for ex-
ample, factor 16, using an amplifier or microphone
and factor 19, steam inhalation) showed excellent
clinician agreement. However, other factors with
 VOICE CARE KNOWLEDGE 87

TABLE 3. Specialist Clinicians Agreement Summary of Factors Influencing Voice and Kappa Scores
Specialist Clinician Raters

Voice Care
Knowledge Questionnaire 1 2 3 4 5 6 7 8 9 10 Kappa

1 Being happy U U U U U U U U U U 1.00

2 Being overweight 3 3 3 3 3 0.16
3 Coughing 3 3 3 3 3 3 3 3 3 3 1.00
4 Drinking alcohol 3 3 3 3 3 3 3 3 3 3 1.00
5 Being relaxed U U U U U U U U U U 1.00
6 Loud singing 3 3 3 3 3 3 3 3 3 0.70
7 Sucking fruit U U U U U U U 0.29
sweets or chewing gum
8 Eating warm food 1.00
9 Smoking 3 3 3 3 3 3 3 3 3 3 1.00
10 Drinking coffee, 3 3 3 3 3 3 3 3 3 0.70
tea or coke
11 Swimming 3 3 0.46
12 Whispering 3 3 3 3 3 3 3 3 3 3 1.00
13 Shouting 3 3 3 3 3 3 3 3 3 3 1.00
14 Resting my tired voice U U U U U U U U U U 1.00
15 Warming up my voice U U U U U U U U U U 1.00
before talking
16 Using an amplifier or microphone U U U U U U U U U U 1.00
17 Walking U 0.70
18 Throat clearing 3 3 3 3 3 3 3 3 3 3 1.00
19 Steam inhalation U U U U U U U U U U 1.00
20 Drinking warm soup 1.00
21 Not talking U U U U U U U U 1.00
if my voice
is sore
22 Sucking medicated 3 3 3 3 3 3 0.19
throat lozenges
23 A noisy environment 3 3 3 3 3 3 3 3 3 3 1.00
24 Speaking gently U U U U U U U U U 0.70
25 Breathing through U U U U U 0.16
my nose
26 Plants in the office/home U U U U U 0.16
27 Good posture U U U U U U U U U 0.70
28 Eating chocolate 3 3 3 0.29

U 5 positive influence, blank 5 no influence, 3 5 negative influence

Notes: Kappa scores show the strength of agreement; hence a kappa value of 0 corresponds to agreement of no more than chance.59

an evidence base (for example, 25, breathing
though my nose and 28, eating chocolate) showed
the lowest levels of agreement. Clinicians may dif-
fer in their views of the evidence, and this indicates
the need for further research.
As illustrated in Figure 3, it is clinically reassur-
ing that specialist clinicians seem to show no abso-
lute contradiction.
Evaluation of voice care knowledge
with HVG and DVG
This research demonstrated a significant differ-
ence in voice care knowledge (as measured by the
voice care questionnaire) between adults presenting
with nonorganic dysphonia and those with healthy
voices. Those with dysphonia demonstrated a lower
level of voice care knowledge. At this stage, it is

Journal of Voice, Vol. 21, No. 1, 2007

88 HELEN M. FLETCHER ET AL

100%
that the clinician and the voice patients’ beliefs of
90%
what influences voice care are diametrically op-
Agreement

80%
70%
60%
50%
40%
1 4 7 10 13 16 19 22 25
Factor on Voice Care Knowledge Questionnaire
FIGURE 2. Healthy voice group agreement with specialist
clinicians of all 28 factors of the Voice Care Knowledge
Questionnaire.
not possible to fully explain why this is the case as
this is the first study to assess the effect of voice
care knowledge. The finding does raise questions
as to whether lower voice care knowledge makes
people more susceptible to voice difficulties. How-
ever, due to the relatively small group of subjects,
this is a preliminary impression. A larger popula-
tion sample of healthy and dysphonic subjects is
required to investigate this further.
Of greater clinical interest are the factors that
showed the least agreement between the subject
groups and the specialist clinicians. The specialist
clinicians rated coughing, drinking alcohol, loud
singing, whispering, shouting, and throat clearing
as having a negative effect on the voice. However,
the dysphonic group generally rated these as posi-
tive for the voice. This has important implications
for the therapeutic process, delivering education
and health promotion. Considering this finding in
relation to prior reports yields important clinical
implications. Prior research suggests that the level
of acceptance of new information depends on
how closely it is aligned with previously held
beliefs or information.64 Yet this study illustrates
100%
90%
Agreement
posed on key factors. As a consequence, this may
place challenges to the therapeutic process64 and
offer some explanation of low levels of patient
compliance.65,66
28
Neither age nor IQ explains the differences in
voice care knowledge. Other predictive factors as-
sociated with voice care knowledge (such as gen-
der, ethnic background, or level of education)
may warrant further investigation. Recognizing
that there are significant differences in voice care
knowledge provides justification for the inclusion
of vocal education and voice care programs in voice
therapy. Furthermore, it highlights the need to pro-
mote health through providing voice care knowl-
edge to at-risk groups (for example, professional
voice users) as an integral part of service provision.
CONCLUSION
Although limitations may restrict generalization
of this study, the findings highlight a consensus
among clinicians and a clear difference in voice
care knowledge between people with healthy voice
and those with nonorganic dysphonia. The voice
care questionnaire provides a useful and valid tool
to investigate voice care knowledge. However,
there is a need for refinement of the questionnaire
and larger empirical studies to investigate this
area further.
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 VOICE CARE KNOWLEDGE 91

APPENDIX 1. Voice Care Knowledge Questionnaire

Factors that I think influence voice
Please place a cross on the line to indicate what influence you think each statement has:
e.g., Shopping Positive No influence Negative

1. Being happy Positive No influence Negative

2. Being overweight Positive No influence Negative
3. Coughing Positive No influence Negative
4. Drinking alcohol Positive No influence Negative
5. Being relaxed Positive No influence Negative
6. Loud singing Positive No influence Negative
7. Sucking fruit sweets or chewing gum Positive No influence Negative
8. Eating warm food Positive No influence Negative
9. Smoking Positive No influence Negative
10. Drinking coffee, tea, or soda Positive No influence Negative
11. Swimming Positive No influence Negative
12. Whispering Positive No influence Negative
13. Shouting Positive No influence Negative
14. Resting my tired voice Positive No influence Negative
15. Warming up my voice before talking Positive No influence Negative
16. Using an amplifier or microphone Positive No influence Negative
17. Walking Positive No influence Negative
18. Throat clearing Positive No influence Negative
19. Steam inhalation Positive No influence Negative
20. Drinking warm soup Positive No influence Negative
21. Not talking if my voice is sore Positive No influence Negative
22. Sucking medicated throat lozenges Positive No influence Negative
23. A noisy environment Positive No influence Negative
24. Speaking gently Positive No influence Negative
25. Breathing through my nose Positive No influence Negative
26. Plants in the office/home Positive No influence Negative
27. Good posture Positive No influence Negative
28. Eating chocolate Positive No influence Negative

Journal of Voice, Vol. 21, No. 1, 2007