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Outcomes of Vocal Hygiene Program in Facilitating Vocal Health in Female

School Teachers With Voice Problems

Article in Journal of Voice · January 2021

DOI: 10.1016/j.jvoice.2020.12.041

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 ARTICLE IN PRESS
Outcomes of Vocal Hygiene Program in Facilitating Vocal
Health in Female School Teachers With Voice Problems
*Aishwarya Nallamuthu, *Prakash Boominathan, †Ravikumar Arunachalam, and ‡Pushpavathi Mariswamy,
*Chennai, yKattankulathur, and zMysuru, India

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.

1. INTRODUCTION classroom setting, disciplinary problems among students in

An individual is considered to be vocally healthy, if he/she
has the capacity to produce voice with ease to meet his/her
personal, social and occupational demand.1 When the vocal
health of the individual is compromised, it leads to voice
related problems. These voice problems are more prevalent
in professionals who use their voice for a prolonged dura-
tion2 such as politicians, vendors, singers and teachers.3 Spe-
cifically, teachers suffer greater impacts of voice problems
due to continuous loud speaking/teaching in incongruous
Accepted for publication December 23, 2020.
The study was self-funded.
From the *Department of Speech Language & Hearing Sciences, Sri Ramachandra
Institute of Higher Education & Research, Chennai, Tamil Nadu, India; yPro-Vice
Chancellor (Medical & Health Sciences), SRM Medical College Hospital & Research
Centre, Kattankulathur, Tamil Nadu, India; and the zAll India Institute of Speech
and Hearing, (Ministry of Health & Family Welfare, Govt. of India), Manasagango-
thri, Mysuru, India.
Address correspondence and reprint requests to Prakash Boominathan, Depart-
ment of Speech Language & Hearing Sciences, Sri Ramachandra Institute of Higher
Education & Research, Chennai, Tamil Nadu, India.
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.12.041
the classroom, neglect of care for personal health and a few
other contributing factors (including environmental, indi-
vidual, and work related issues).4 These occupational
demand increases the amount of vocal load (stress laid on
the vocal mechanism) in teachers resulting in voice disor-
ders. In addition to the occupational demand, the physio-
logical gender differences increase the chance of voice
problems among female teachers.5 The various physiologi-
cal factors in the larynx include higher fundamental fre-
quency,6 thinner vocal folds,7 increased mechanical stress in
anterior third of the vocal fold that result in developing
vocal nodules, and variation in tissue property of the vocal
folds in females that reduce the protection from phono-
trauma.7 Furthermore, women use increased respiratory
muscular effort for speaking compared to men.7 The gender
differences in the digestive system results in increased inci-
dence of laryngopahryngeal reflux in woman during upright
and supine (while sleeping) posture.8 Additionally, the
reduced systemic tissue hydration in women makes them
more vulnerable to laryngeal injuries during compromised
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2021
vocal performance.7 In addition to the above, hormonal
changes during menstruation and pregnancy also affects the
laryngeal system9 resulting in vocal fatigue, decreased vocal
range, and vocal instability.7
The increased sensitivity of pain in females10 can be
related with the higher frequency of reported voice related
problems among women. Behaviorally female teachers tend
to vocalize 10 times more than their male counterpart at
work11 and are often compelled to use their voice for child-
care at their homes.1 These factors indicate that females are
more prone to voice related problems from puberty through
the child bearing ages. In addition to the physiological, hor-
monal, and behavioral differences, several policy decisions
of the governments (eg, in Tamil Nadu there is a preference
to employ female teachers than males in order to provide
gender equality and preference)1 may increase the risk for
developing voice problems in females.12 Therefore the sus-
ceptibility of developing voice problems in female teachers
coupled with increased number of women in teaching pro-
fession in this locality results in higher incidence of voice
related problems in female school teachers. Considering the
impact of voice problems on the overall functioning of the
individual and in particular the voice use of the teachers,13
it is essential to provide vocal education and intervention to
prevent/ reduce the risk of vocal trauma and promote vocal
health in teachers.
Vocal interventions include direct face-to-face vocal
habilitation/therapy or indirect intervention like vocal
hygiene program (VHP). These vocal intervention
approaches are either used in isolation or in combination
based on the client’s needs, logistic concerns, and other fac-
tors.14 Despite the evidence of positive impact of direct
voice therapy over VHP, teachers in India consider voice
problems as an expected occupational difficulty/hazard in
their profession and often restrict to "home remedies" and
follow vocal hygiene program/tips as their first line of treat-
ment.1 Restriction in availing leave from school, compul-
sion to complete the curriculum within stipulated time,
travel, financial limitations for seeking treatment, and lack
of support for child care limits them. These potentially delay
the time taken to seek treatment (direct voice therapy) for
voice related problems. In such crucial situations, where the
individuals have challenges in attending face to face inter-
vention, VHP could address partially to the problem and
facilitate a treatment option. 15
Vocal hygiene program (VHP) is a client centered
approach that focus on education about normal processes
in voice production, identification and elimination of
phono-traumatic vocal practices and behaviors, emphasis
on adequate hydration, strategies to reduce of laryngo-pha-
ryngeal reflux, minimize the effects of environmental factors
and inculcate healthy life style modifications.15 Studies have
shown the positive effects of VHP on prevention of voice
related problems and improvement in self-reported voice
quality.16 VHP facilitates in providing awareness on the
impact of phono-traumatic vocal behaviors and which may
turn aid to reduce the hyper-function and laryngeal muscle
tension.17 The ultimate goal of VHP is to facilitate complete
vocal health and enhance communicative effectiveness.18
However, it is essential to modify vocal hygiene practices to
suit the clients’ day to day vocal need and improve vocal
health.17 Specifically in teachers where they face challenges
to seek medical/professional help,19 VHP is crucial in pre-
vention and treatment of voice related problems. The posi-
tive effects of VHP among teachers are evident on
improving the knowledge of vocal health,6,7,12−14 decreasing
at risk vocal behaviours20 and reducing the self-perception
of voice handicap (based on VHI scores).21 Though vocal
hygiene programs have positive effects on reducing the use
of phono-traumatic vocal behaviors, its impact on facilitat-
ing efficient voice production and reduction of hyper func-
tion is limited.22 Contrary findings on the impact of vocal
hygiene program indicates the need to incorporate actual
observations instead of self-reported and survey methods.15
In addition, though teachers gain the knowledge and aware-
ness of vocal health, they are often compelled and habitu-
ated to use phono-traumatic vocal behavior to meet their
occupational demand and other sociocultural factors in day
to day situation.1 Therefore, a formalized, structured (in
terms of knowledge, content, skill transfer, and attitudes to
monitor voicing behavior) and a socio-culturally relevant
vocal hygiene program might partially address the chal-
lenges faced by teachers in India. This will ensure expected
positive outcomes due to vocal hygiene education among
teachers to self-perceive the subtle changes in voice and cor-
rect their vocal behaviors in school, home environments
and day to day situations. To understand the impact of such
sociocultural structured vocal hygiene program (VHP), the
present study aimed to investigate the outcomes of VHP in
facilitating vocal health among female school teachers using
a comprehensive voice assessment protocol. The objectives
of the study were to investigate the effects of the developed
VHP for teachers on clinical measures (perceptual & aero-
dynamic), instrumental (acoustic analysis & visual examina-
tion of larynx) and self-perceptual vocal measures (V-DOP
& VHI).
2. MATERIALS AND METHODS
The study was approved by the institutional ethical commit-
tee of Sri Ramachandra Medical College & Research Insti-
tute (Reference number: IEC-NI/13/AUG/35/64). Similar to
previous studies15,20,23−26, a single group pre- and post-test
research design was employed to estimate the impact of
vocal hygiene program among female school teachers.
2.1. Participants
The participants were recruited across a period of one year
at different points of time. When the participants met the
inclusion and exclusion criteria, they were included in the
study. Teachers who reported of any pulmonary disease,
hypothyroidism, systemic illnesses, tinnitus/ hearing diffi-
culty, and those who had previously attended voice therapy
were excluded from the study. Teachers in active teaching
 ARTICLE IN PRESS
Aishwarya Nallamuthu, et al Vocal Hygiene Program
TABLE 1.
Laryngeal Conditions (During Baseline) Initial
Measurement
Laryngeal conditions Number Percentage
Primary muscle tension 06 35.28
dysphonia
Secondary muscle tension dys- 10 58.83
phonia (co-occurring vocal
nodule)
Laryngopharyngeal reflux 01 5.89
were included and those who were in any vacation/ school
breaks were excluded in the study. Visual examination of
the larynx (stroboscopy) was done by otolaryngologist
along with a speech pathologist. Based on the visual exami-
nation, individuals diagnosed with hyperfunctional voice
disorder recommended for conservative treatment (such as
medication & vocal intervention) were included. On the
other hand, teachers diagnosed with morphological changes
in the vocal fold that required surgical management were
also excluded.
Seventeen female school teachers in the age range of 28 to
45 years (Mean: 38.70; SD: 4.57) with a varied years as
teaching experience (Mean 10.41 years; SD: 5.09) who used
their voice for a minimum of 4 hours/day for teaching
(Mean: 6.05; SD: 1.02) were included. Eleven teachers
(64.7%) handled primary grades, five (29.4%) taught high
school students and one (5.88%) handled higher secondary
students. Written informed consent was obtained from all
participants included in the study. The laryngeal conditions
identified in the participants during baseline are presented
in Table 1.
On administrating the vocal health questionnaire for
school teachers,13 participants reported of vocal symptoms
such as changes in voice quality (100%), vocal tiredness
(88%), inability to speak softly (76%), pain in the throat
(71%), gasping for breath while speaking (53%), sensation
of heartburn (47%), voice breaks while speaking (47%) and
clenched speech (41%). In addition they reported sleep dis-
turbances (24%), feeling upset (41%), and irritable (47%).
The duration of reported symptoms were between one
month to five years (Mean: 10.35 months; SD: 14.50).
2.2. Description of the VHP for school teachers
Vocal hygiene program to facilitate vocal health in teachers
were compiled based on information published in
literature.7,14,16,17,23,26 The VHP included the following
components:
2.2.1. Anatomy and physiology of normal voice
production15,20,23,27−31
The physiology of voice production was explained using a
video portraying the structures of voice box and how the air
moves upwards through the wind pipe and sets the vocal
3
fold in to vibration. This video was constructed using ani-
mations of two dimensional images drawn by the investiga-
tor along with a video stroboscopic sample of normal vocal
fold movement.
2.2.2. Differences in normal and abnormal voice
production1,15,20,27,32−36
The participants were explained that a voice that meets an
individual’s professional/ occupation demand, personal,
emotional and social needs for day to day communication
were considered as normal voice. In addition, the partici-
pants were explained regarding the vocal pathology and
deviancy from normal voice.
2.2.3. Risk factors and causes of voice problems in
teachers15,17,20,27,29,31,37
In this segment, the various risk factors/ causes of voice
problems were included. It included unhealthy vocal practi-
ces (eg, throat clearing, yelling, shouting, talking for long
time &nd speaking too loud), improper dietary habits (eg,
intake of oily/spicy foods, skipping of meals) that may result
in reflux related problems, life style habits (eg, smoking &
excessive consumption of alcohol), uncompensated psycho-
logical stress and work pressure, nerve related issues, hor-
mone related problems (such as hyper- or hypo-thyroidism),
and birth defects. These factors were explained using pic-
tures and animations related to Indian context.
2.2.4. Practices to be followed to maintain vocal
health1,20,42,43,23,27−29,38−41
Vocal hygiene practices emphasizing on adequate hydra-
tion, healthy vocal diet, posture and alignment while teach-
ing, vocal practices to be followed while teaching and ideal
speaking environment were recommended. The rationale
for each vocal hygiene practice, instruction was explained in
the program. To maintain adequate hydration, the partici-
pants were instructed to drink/sip water frequently (approxi-
mately once in every 30 minutes)44 amounting to a
minimum of 8−10 glasses (approximately 2 liters/65 ounces)
of water per day,45 and were instructed to perform vapor
inhalation for three minutes twice a day.38 In addition, par-
ticipants were instructed to avoid intake of carbonated
drinks (eg, cola & soda), coffee/caffeinated drinks, smoking,
and consumption of alcohol, and reduce the exposure to air
conditioning for long duration to avoid dehydration of
vocal folds.42
Secondly, the participants were given instructions on
maintaining healthy vocal diet. They were educated regard-
ing the practice of eating healthy foods at regular inter-
vals.46 They were also advised to avoid consumption of
oily/spicy food47 (eg, pickles, karakozhambu, pulikoz-
hambu−−a south Indian cuisine), sour foods48 (eg, fer-
mented yogurt, items made exclusively using tamarind/
tomato), citrus fruits49 (eg, lemon, mosambi, pineapple &
grapes) and junk foods47 (eg, deep fried item such a varuval,
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2021
vada, appalam, paapad & chips) that may increase the
chance of acid reflux affecting the vocal apparatus. Individ-
uals with relatively sedentary physical occupation (including
teachers) may often lose the strength in the muscles of their
abdomen and back.50 Teachers in India predominantly
practice black board teaching that requires overhead activ-
ity and twisting posture (torso twisted and head turned to
talk to the students).51 In addition, they tend to strain their
shoulders and arms while reading/ dictating to pupil while
holding books in hand.52 These in turn may affect their pos-
ture compromising their breath support during speech/
teaching and increases the chance of developing musculo-
skeletal tension disorder.52 To address the above, advice
was given (with pictorial illustrations) on maintaining
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-
taining the height of the chair to place the feet plat on the
ground & keeping the book at eye level while reading).
These are routine advices provided for teachers. However,
in addition, teachers were advised to use dust free chalk,
and avoid the practice of speaking/ teaching while writing
or erasing on the blackboard to reduce inhaling of
chalk dust.
Next, importance of following appropriate vocal practice
to avoid/ reduce damage to vocal apparatus was discussed.
Teachers were advised to move close and face the listener
(students) while speaking, schedule classes with breaks to
avoid continuous voice use, and use microphone while
addressing a large gathering. They were cautioned regarding
inappropriate vocal use and strictly advised to limit loud
and continuous vocal use. In addition they were asked to
avoid the habit of throat clearing. Participants were also
guided on speaking/ teaching in ideal environment. These
vocal hygiene practices for the teachers were explained using
pictures and animations (eg, avoiding speaking/teaching
while wiping the board, moving close to the students while
teaching/ reading to them, facing the students and not
towards the board while teaching) to suit Indian context
and for better understanding.
The components of the VHP were verified by two speech
pathologists and one otolaryngologist (with a minimum of
10 years of experience and specialization in the area of voice
assessment & management). The experts assessed the rele-
vance of the selected vocal hygiene practices for school
teachers in the Indian context. With their inputs, the vocal
hygiene program module for teachers was developed.
2.3. Administration of the VHP for school teachers
The vocal hygiene program was a clinician administered
module presented in the form of PowerPoint slides with ani-
mations to the participants. The rationale for each vocal
hygiene practice was explained to the participants in English
and in Tamil during a single face to face session. During the
entire one-hour session, the participants were provided
opportunities to raise questions or ask for repetition. Fol-
lowing the face to face session, a checklist (that included all
the components of the VHP explained in the face-to-face
session) was provided to the participants to remind them to
follow on a regular basis. They were asked to follow the
vocal hygiene practices in day to day situation for 4 weeks
duration. The participants were asked to mark a tick if they
practiced each component every day. The reasons for not
being able to practice the vocal hygiene instruction were
also documented. The participants were periodically
reviewed & reminded to continue the vocal hygiene practice
through telephone calls once a week. At the end of 4 weeks,
the participants were followed up and post-treatment voice
assessment was performed.
2.4. Vocal metrics & procedure to compare pre and
post vocal hygiene program
Teachers who consented to participate in the study under-
went a comprehensive voice assessment before and four
weeks after the VHP. The metrics included:
a. Sri Ramachandra vocal health questionnaire for
teachers:13
The questionnaire collected details on demographic infor-
mation, general health, voice use, vocal and nonvocal prac-
tices, self-perceived vocal symptoms, and impact of voice
problem in daily activity and participation and environmen-
tal factors that act as barriers and supporting elements.
b. Clinical vocal measures:
The clinical vocal measures included perceptual analysis
of voice (GRBAS), maximum phonation duration and s/z
ratio. The recorded samples of reading and counting num-
bers from 1 to 10 were considered for perceptual voice anal-
ysis using GRBAS scale.53 The samples recorded (during
pre & post-treatment) for perceptual evaluation of voice
were randomized and rated by two SLPs (clinicians who
work in the area of voice) who were not involved in deliver-
ing the vocal hygiene program. The evaluators were pro-
vided the freedom to listen the samples as many times as
they required.
To assess the maximum phonation duration and s/z ratio,
the participants were instructed to sit upright and in a
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
for each sounds and the time was estimated using stop-
watch. The longest duration during the three trials was
taken as maximum phonation time (in seconds) for the
respective sound. Similarly the participants were instructed
to take a deep breath and sustain /s/ for as long as possible
twice. In the same way the MPT for /z/ was measured. Based
on the longest duration of two trials, the MPT for /s/ and /z/
 ARTICLE IN PRESS
Aishwarya Nallamuthu, et al Vocal Hygiene Program
were estimated. Further s/z ratio was calculated by dividing
the sustained phonation time of /s/ by /z/.
a. Instrumental vocal measures:
The acoustic analysis was performed in a sound treated
room using Ling Waves Phonetogram Pro and signal analy-
sis module (Version 2.4). The samples were recorded using a
condenser microphone attached to a calibrated sound level
meter (Center 322) set in "A" weighting network mounted on
a tripod stand. This enabled to adjust the height and maintain
subjects’ mouth to mic distance as 30 cm. The participants
were instructed to maintain upright sitting posture and per-
form the following tasks: sustained phonation of vowel /a/ on
a single breath at a comfortable loudness and pitch, sustained
phonation of /a/ at regular, loud and soft intensities, gliding
of vowel /a/ from low to high pitch and high to low pitch,
counting of numbers from 1 to 10 at varied intensities (nor-
mal, soft, and loud) and reading a standardized passage or
general conversation as part of speaking profile. From the
recorded samples, frequency (F0, high F0, low F0 & frequency
range), intensity (I0, high I0, low I0 & dynamic range), and
quality related parameters (jitter & shimmer) was calculated.
The dysphonia severity index (DSI) was estimated through
ling Waves software using the formula54 (DSI = 0.13 x
MPT + 0.0053 x High F0- 0.26 x Low I0 x Jitter + 12.4).
The video-stroboscopic evaluation was performed jointly by
the otolaryngologist and Speech Language Pathologist using
ATMOS media strobe (Endo Stroboscope L). The partici-
pants were given instructions about the procedure and were
sprayed with local anesthesia (10% lidocaine topic aerosol)
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
sustained phonation of the vowel /i/ at a comfortable pitch
and loudness, pitch gliding (from low to high & high to low),
interrupted /hi/, gentle cough, and normal breathing. Partici-
pants were restricted to consume food or any liquid for 30
minutes following the procedure. The recorded samples were
randomized and subsequently rated by another Speech Pathol-
ogist and Otolaryngologist (who were not involved during the
recording of stroboscopy). The samples were assessed based
on the following parameters: morphology to indicate patho-
logical changes and other observations, glottal closure (com-
plete/anterior gap/posterior gap/ irregular/bowing/hour glass
pattern), and symmetry of vocal folds, mucosal wave, ampli-
tude and regularity of vocal fold vibration, presence/absence
of non-vibratory portion and hyper adduction of ventricular
folds. The evaluators were provided the freedom of reviewing
the samples as many as times they required.
b. Self-perceptual vocal measures:
The self-perceptual evaluation of voice was obtained by
using Voice Disorder Outcome Profile (V-DOP)55 and
Vocal Fatigue Index (VFI)56. V-DOP was used to obtain
individual’s self-perception of the severity of voice problem.
5
It consisted of two divisions: the first part included a single
question on overall severity of voice problem and second
part comprised of 32 questions under three domains (physi-
cal, emotional, and functional). All 33 questions were rated
on a 10 cm visual analog scale which ranged from normal
(0) to always (10). Based on the severity rated by the partici-
pants, the scores were categorized under overall severity,
physical, emotional and functional domain.
Vocal fatigue index is a validated tool that can be used to
assess the self-perception of vocal fatigue. It consisted of
three sections with a total of 19 symptoms that are associ-
ated with voice problems and fatigue. The symptoms are
rated on a five point scale (0-never; 1-almost never; 2-some-
times; 3-almost always, and 4-always) under each section of
the tool. The comprehensive vocal assessments for the par-
ticipants were performed 5 days prior to or after their men-
strual cycle. The vocal measures listed above were estimated
before the commencement of the vocal hygiene program
(pretreatment measurement) and after the completion vocal
hygiene program for a period of one month (post-treatment
measurement) without any specific order.
2.5. Definition of improvement in outcome measure
(comparing pre- & post- treatment)
The progressive changes in the scores while comparing the
pre- and post-treatment assessments were operationally
defined as improvements in vocal measures after attending
the VHP. The improvement criteria established based on
change in score or cut-off value was set for each measure
based on normative values, and a deemed clinically signifi-
cant change explained in Table 2.
2.6. Data and statistical analysis
The data obtained were tabulated and subjected to statisti-
cal analysis using Statistical Package for the Social Sciences
(SPSS) version 19 (SPSS, Inc., Chicago, Illinois). The inter-
rater reliability for perceptual evaluation and visual exami-
nation was estimated using Intra-Class Coefficient correla-
tion. Shapiro-Wilk test was used to estimate the normality
of data. The mean (SD) was considered for normally distrib-
uted variables and median was considered for variables
which were not normally distributed. Wilcoxon signed ranks
test was used to compare the pretreatment and post-treat-
ment measures of continuous variables (acoustic, MPT, s/z
ratio, V-DOP, and VFI), and McNemar test was used with
categorical variables (vocal health questionnaire, visual
examination of larynx, and perceptual evaluation of voice).
3. RESULTS
3.1. Description of outcomes from vocal hygiene
questionnaire − inventory of non-vocal & vocal
behaviors
On comparing the baseline and outcome measures, 11 teachers
(64.7%) reported a reduction in frequency of throat clearing
and coughing. Six teachers (35.2%) reduced the frequency of
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2021

TABLE 2.
Operational Definitions for Improvements in Vocal Measures After Attending the VHP
Voice tool metrics
Vocal health questionnaire
- Practice of unhealthy vocal & non vocal habits
- Vocal symptoms reported by the teachers
- Impact on activities of daily living
- Environmental factors as barrier
Definition of improvement
- Change in the value of one point towards ‘never’ in a five point likert
scale
- Absence of the reported vocal symptom during post treatment mea-
surement
- Absence of the specific activity limitation which was present during
pre-treatment
- 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
whispering. All the five teachers (29.4%) who reported the
practice of mimicry during baseline, refrained themselves from
mimicry during post treatment measure. The habit of scream-
ing reported by 16 teachers (94.1%) during baseline assessment
had improved after the vocal hygiene program.
On analyzing the nonvocal habits, intake of caffeinated
drinks with a minimum of two to five cups/day was reported
by nine teachers (52.9%) during baseline. However, after the
VHP the frequency of coffee intake was reduced in five out of
the nine teachers. Three teachers (17%) who reported intake
of soda stopped the habit during the outcome measure. The
practice of alcohol consumption and smoking was not
reported by any teachers in this study. All teachers reported
of inadequate time interval (ranging from 30 to 60 minutes)
between intake of meals/dinner and sleep. However, after the
VHP, 13 teachers (76.4%) reported an improvement in the
time interval (≥ 2 hours). The frequency of intake of oily/
spicy food reported by all teachers had reduced after the
VHP. Ten teachers (58.8%) who had the habit of chewing
throat lozenges completely stopped the habit post treatment.
To stay hydrated, teachers drank a minimum of 2 glasses of
water/day during baseline. However, post-treatment, an
improved intake of 6−8 glasses (of approximately 240 ml/
glass) of water (47%) and >8 glasses (53%) were noticed.
Vapor/steam inhalation was sparsely (23.5%) practiced by
teachers during baseline. However, all the teachers reported
to follow steam inhalation along with adequate intake of
water to keep them hydrated.
Vocal symptoms reported by the teachers before and after
attending the VHP were explored. Significant improvement in
vocal symptoms such sticky sensation/discomfort around the
throat (P= 0.008), inadequate breath control while speaking
(P = 0.016) and sensation of heart burn (P = 0.031) were
reported. This in turn had a positive impact on teachers in feel-
ing less irritable (P = 0.031) and upset (P = 0.031). In addition,
teachers who experienced limitations in executing activities in
daily life situations reported significant improvement in using
their voice for conversing with others via face to face (P=
0.031), and through telephone (P = 0.016). On exploring the
environmental factors, speaking in the presence of noise
(82.35%) and chalk dust (47.05%) were major barriers
reported by teachers even after the VHP. Improvements were
reported in using communication devices (P = 0.004), use of
their voice across the day (P = 0.008) and impact of changes
in weather such as rain/wind (P = 0.002). Though teachers
reported improvement in the effect of seasonal changes in
weather on their voice, this could probably be a bias as the
participants were assessed only between the time frame of one
month pre- and postvocal hygiene program.
Teachers reported a perception of positive attitude from
their family (94.11%), colleagues (88.23%), and doctors
(100%) after the VHP. In addition, teachers felt that the pol-
icies and school systems (70.58%) in India was still a barrier
to their voice problems. Speaking in the presence of noise,
exposure to chalk dust, higher number of students in a class
were inevitable barriers for teachers in Indian scenario.
Nearly 94% of teachers reported imposed restrictions on
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Aishwarya Nallamuthu, et al Vocal Hygiene Program 7

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
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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*

vocal needs and overcome the challenges faced by the school

emotional and functional domain using a visual analog
scale. The range of improvement in V-DOP scores (Table 4)
indicated positive change in the overall severity, physical,
and functional domain. However, in emotional domain, the
changes were not significantly evident.
The Vocal Fatigue Index (VFI) was administered to
assess the symptoms associated with tiredness of voice (part
1), physical discomfort during voice usage (part 2) and
improvement of voice following voice rest (part 3). Though
the scores improved in part 1 & 2 of the VFI, significant
change was observed only in part 3 indicating that teachers
had reported positive changes in voice after a period of
voice rest (Table 5). The outcomes of VHP across different
vocal metrices have been summerized in Table 6.
4. DISCUSSION
The objective of this study was to estimate the outcome of a
structured vocal hygiene program (VHP) in facilitating vocal
health among female school teachers with voice problems.
Single group pretest-post treatment research design was used
to analyze the impact of VHP using multi-parametric vocal
measures. Considering the susceptibility and high incidence of
voice problems in females,1,59−62 the study involved female
school teachers from Chennai city. The vocal hygiene pro-
gram (VHP) was culturally customized/ adapted to suit the
teachers in India. The vocal hygiene program focused on
increasing the knowledge on the voice production mechanism,
improving their awareness on good vocal health and voice dis-
orders, reducing/eliminating inappropriate or unhealthy vocal
and non-vocal behaviors that result in voice disorders and
facilitating the practice of healthy vocal habits. The program
also highlighted the vocal practices and strategies to be fol-
lowed while teaching in the classrooms. The information pro-
vided in the VHP were tailored to the Indian school teachers
considering their knowledge on vocal health, lifestyle pattern,
dietary habits, classroom conditions, attitude to seek treat-
ment, and vocal training.1,42 Earlier studies have estimated
the outcome of vocal hygiene/ vocal education programs
using survey methods and subjective evaluations 20,63,64. How-
ever, it is crucial to validate the reported behavioral changes
as a result of VHP using comprehensive vocal metrics.15
The administration of vocal health questionnaire for
teachers facilitated to understand the impact of voice prob-
lems from a bio-psychosocial perspective.13 As a result of
gaining knowledge regarding the healthy/unhealthy vocal
behaviors, teachers reduced the counterproductive vocal
and non-vocal practices. The knowledge and awareness of
phono-traumatic and unhealthy practices in-turn facilitated
in good vocal health.15 Checklist of these behaviors along
with telephone follow up and reminders every week made
them 100% compliant to follow these vocal hygiene
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Aishwarya Nallamuthu, et al Vocal Hygiene Program 9

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
vocal symptoms. These changes in self-perceived vocal
symptoms had a positive impact on the teachers in using
their voice in day to day situations over telephone and
during face to face interactions. However, they faced
major barrier to speak in the presence of noise and chalk
dust. The support from the educational institutions in
India is minimal that the teachers are compelled to speak/
teach in a large classroom with minimal or no amplifica-
tion devices.1 This in turn make them susceptible to
develop intermittent or sometimes more permanent voice
related problems.65
4.1. Effect of VHP on perceptual voice quality and
aerodynamic measures
Perceptual evaluation of voice using GRBAS scale has been
considered as one of the gold standard method for
identifying voice quality changes in voice disorders.66−68
In this study, positive changes in voice were observed in
teachers after attending the VHP. This could be because
the improvement in GRBAS parameters was considered
when there was at least a reduction in one score of sever-
ity. However, significant difference was not observed in
overall grade after VHP. This finding is justified consider-
ing significant changes in voice quality could be expected
when the treatment was continued for a longer duration
of time.66,69
Studies evaluating the efficacy of voice treatment had
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
VHP did not directly focus on improving the breath support
for speech other than some instructions about breathing
during production of sound and indirect measures to reduce
difficulties in breathing such as smoking, need for regular
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10 Journal of Voice, Vol. &&, No. &&, 2021

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.
 ARTICLE IN PRESS
Aishwarya Nallamuthu, et al Vocal Hygiene Program
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