ARTICLE IN PRESS

Prevalence and Risk Factors of Voice Problems Among

Primary School Teachers in India
*Usha Devadas, †Rajashekhar Bellur, and †Santosh Maruthy, *Manipal, India, and †Mysore, India

Summary: Objectives. Teachers are more prone to develop voice problems (VPs) when compared with other pro-
fessional voice users. The aim of present study was to investigate the prevalence and risk factors of VPs among primary
school teachers in India.
Study design. Epidemiological cross-sectional survey.
Methods. Self-reporting questionnaire data were collected from 1082 teachers.
Results. Out of 1082 teachers who participated in the present study, 188 teachers reported VPs that account for a
prevalence rate of 17.4%. Tired voice after long hours of talking was the most frequently reported symptom, followed
by sore/dry throat, strain in voice, neck muscle tension, and difficulty in projecting voice. The adjusted odds ratio values
showed number of years of teaching, high background noise levels in the classroom, experiencing psychological stress
while teaching classes, improper breath management (holding breath while speaking), poor focus of the tone (clench-
ing jaw/teeth while speaking), upper respiratory tract infection, thyroid problems, and acid reflux as significant risk
factors for the development of VPs in the current cohort of teachers.
Conclusions. Current results suggest that teachers develop VPs due to multiple risk factors. These factors may be
either biological, psychomotor, or environment-related factors. A holistic approach (which could include educating teach-
ers about voice care during their training, and if they develop VP during their career, then managing the VP by taking
into consideration different risk factors) addressing all these factors needs to be adopted to prevent VPs in primary
school teachers.
Key Words: primary school teachers–voice problems–prevalence–phonotrauma–risk factors.

INTRODUCTION intestinal reflux, repeated exposure to upper respiratory tract

Teachers depend on their vocal endurance and voice quality for
their livelihood. Unlike the other professional voice users, teach-
ing requires frequent voice use with elevated volume for long
hours. Hence, teachers are more prone to develop voice prob-
lems (VPs). In the literature, multiple studies have reported that
teachers experience VPs more frequently than the general
population.1–5 The prevalence rates of VPs in teachers range
between 11% and 81%.1,3,4,6–10 This wide range in prevalence rates
may be mainly because of differences in the study population,
type of methods used, and the definition of the VP.1 In most
studies, questionnaires have been commonly used in studying
the prevalence of VPs in teachers. However, some were supple-
mented with laryngoscopic examinations.8
VPs in teachers can manifest as vocal fatigue, hoarseness, throat
pain, or discomfort, weak voice, dryness, and lower pitch.1,4,9–11
Among the different risk factors, the most frequently reported
one is phonotrauma.4,12 In teachers phonotrauma may occur
because they need to speak for long hours.1,4,10,11,13–16 Other re-
ported risk factors include being female, poor acoustic
environment due to noise generated in and around the class-
room, speaking without amplification devices and using excessive
loudness levels, systemic illnesses, hormonal problems, gastro-
Accepted for publication February 12, 2016.
From the *Department of Speech and Hearing, School of Allied Health Sciences, Manipal
University, Manipal, India; and the †Department of Speech-Language Sciences, All India
Institute of Speech and Hearing, Manasagangothri, Mysore, India.
Address correspondence and reprint requests to Santosh Maruthy, All India Institute of
Speech and Hearing, Naimisham Campus, Manasagangothri, Mysore, Karnataka 570006,
India. E-mail: santoshm79@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.03.006
infections, stress, anxiety, and psychological factors.1,17 Person-
ality factors, diet issues like untimely food intake, skipping
breakfast, fast-food culture, consumption of alcohol and tobacco,
caffeinated and carbonated drinks are also other reported risk
factors.17
VPs in teachers can significantly impact their quality of life.17
Due to VPs, teachers may need to go for longer periods of sick
leave which can have financial consequences.1 Hence, it is im-
portant to provide professional voice care for teachers by
establishing the relationship between their VPs, teaching demands,
and different risk factors. Unfortunately, in Indian context, there
are no published research evidence regarding the prevalence of
VPs in primary school teachers. Like other countries, even in
India, teachers during their training do not receive any formal
instructions or training about appropriate voice use or knowl-
edge about vocal hygiene. However, unlike other developed
countries, in India primary school teachers may face different
demands. First, number of classes per day, number of students
in each class, and background noise level may be different when
compared with teachers from other countries. Second, other en-
vironmental issues like dust, dry weather, and higher temperature
and humidity may also add to the development of VPs. Hence,
the prevalence of VPs may be different in Indian teachers when
compared with teachers in other countries. Estimating the prev-
alence will help in planning the prevention and management of
VPs. In this context, there is a need to establish prevalence of
VPs and identify different risk factors for the same. Hence, ob-
jectives of the study include the following: (a) to investigate
prevalence of self-reported VPs in primary school teachers, and
(b) to identify the potential risk factors associated with VPs in
primary school teachers in India.
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016
METHOD
Study design and data collection
The present cross-sectional survey targeted primary school teach-
ers of Mysore District of Karnataka state, India. Approval from
institutional ethical committee was obtained to conduct the study
prior to data collection. Eighty government schools and 24 private
schools were randomly selected. The researchers contacted the
head teachers of these schools during the period of September
2012 to October 2013, and were requested to distribute the ques-
tionnaires to the teachers working in their school. In each school
the questionnaires were distributed depending on the number
of teachers. The questionnaire included a cover letter explain-
ing the purpose of the study and a consent form. The participation
of the teachers in the study was voluntary. All the teachers,
regardless of which subjects they were teaching, participated
in the present study. However, physical education teachers, music
teachers, mathematics teachers, and those who were involved
more in administrative activities were excluded from the study
as their vocal demands will be different from those of the target
population. The individual school head teachers distributed the
questionnaires in their school, collected, and returned them after
15 days. There were 1500 questionnaires distributed across 104
primary schools. Among the 1500 questionnaires, 1100 filled
questionnaires were returned with a response rate of 73%. Of
these, 18 were incomplete questionnaires. Hence, these were
excluded and responses from the remaining 1082 question-
naires were analyzed and discussed. Follow-up of non-
responders was not done due to inability to contact them
individually.
Self-reported questionnaire
A self-reporting questionnaire was developed which included
questions to determine the prevalence of the VPs in primary school
teachers, to identify the variables associated with the risk of VPs
in teachers, vocal symptoms experienced by the teachers, phy-
sician or speech language pathologist (SLP) consultation by the
teachers for their VPs, the effect of VPs in teachers, and knowl-
edge of voice care among teachers (Appendix). This questionnaire
was designed in Kannada language based on the other previ-
ously published literature on VPs in teachers. 1,10,17,18 The
questionnaire addressing the above-mentioned issues was dis-
tributed among five experienced SLPs, and were asked to give
their comments on the content of the questionnaire. Their sug-
gestions and comments were incorporated in the questionnaire.
The questionnaire was then distributed to 30 primary school teach-
ers for the familiarity check, and they were asked to answer (1)
whether this questionnaire includes relevant information related
to teaching profession? (2) did the researchers miss anything that
is important for teachers? (3) were there any questions teach-
ers were not sure how to answer? If yes, why were teachers not
sure? As there was no ambiguity or difficulty in understanding
the terminologies as reported by the teachers, it was accepted
for use as the final version.
The questionnaire included the following sections: (1) de-
mographic details (age and gender), (2) teachers’ work
organization at school (number of years as a teacher, average
number of classes per day, duration of each class, average number
of students in the class, vocal loudness while teaching (whether
soft, loud, or too loud), use of amplification devices if any, whether
they are trained singers, and if yes, then number of years of train-
ing and type of singing), (3) work environment (presence of
background noise, level of noise in the classroom, measures taken
to reduce noise level in the classroom, stress experienced by the
teachers), (4) vocal behaviors exhibited by the teachers in the
classroom (yelling/shouting, holding breath while talking, clench-
ing jaw while talking, starting the class by ignoring background
noise, singing, or mimicry, stop speaking when voice gets tired),
(5) vocal symptoms experienced by teachers (loss of voice, ex-
cessive coughing, frequent throat clearing, shortness of breath,
sore/dry throat, neck muscle tension, vocal fatigue, difficulty
raising the voice, strained voice, husky/hoarse voice, difficulty
projecting the voice, monotone voice, and need to put extra effort
to talk), (6) seeking help from physician or SLP (whether they
had consulted a physician for their voice problem? whether they
had consulted an SLP for their voice problem? if yes how many
times? whether their voice improved after consultation with an
SLP? did teachers attend any voice care related programs?), (7)
health-related factors (whether they had any major illnesses in
the past? whether they had any major surgeries in the past?
whether they suffer from any allergy? or whether they suffered
from any medical condition associated with voice disorder such
as pharyngitis, laryngitis, thyroid problems, etc, and whether they
had taken any medication or treatment in the past that may have
an effect on voice like anti-histamines, steroids, hormone re-
placement therapy etc)? (8) lifestyle factors (smoking cigarettes,
consumption of beverages like alcohol, tea, and coffee, water
consumption per day, and participation in physical activities like
exercise, (9) knowledge about voice care, (10) effect of voice
problem on job performance (how many days were they func-
tionally impaired due to voice problem? the number of missed
working days due to voice problem, and the degree of impair-
ment to which voice limits or makes them unable to perform
certain tasks or work-related activities). To identify the preva-
lence of voice problems, teachers were asked to answer yes or
no pertaining to the question “Any time your voice does not work,
perform, or sound as it normally should, so that it interfered with
communication and job performance”.1 Further, teachers were
asked to describe their VP: history of frequent VP, when did they
notice the problem, onset of the VP, and any variation of the
problem (getting worse or better).
Statistical analysis
Statistical analysis was done using Statistical Package for Social
Sciences 16.0 (IBM, Inc., Austin, TX) software. Percentage was
used to summarize the prevalence of VPs. Pearson chi-square
test was used to compare the differences between teachers with
and without VPs for different risk factors. Further, adjusted odds
ratio (OR) with corresponding 95% confidence intervals with
multiple logistic regression using Wald forward selection crite-
ria was used to assess the association between reporting VP
and different risk factors. The significance level was set at
(α = 0.05).
 ARTICLE IN PRESS
Usha Devadas et al Voice Problems Among Primary School Teachers in India 3

RESULTS Further in this article, teachers reporting VP (n = 188) are in-

Prevalence of VP
The teachers were considered to have VP if any time their voice
does not work, perform, or sound as it normally should, so that
it interfered with their communication and job performance.1 Ac-
cording to this operational definition, 188 of 1082 teachers who
participated in the study were identified to have VP with a prev-
alence rate of 17.4%. Out of 188 teachers who reported to have
VP, 43% (n = 82) reported they noticed VP since more than a
year, 27% (n = 50) of them noticed it since 1 year, and 30%
(n = 56) of them indicted they had noticed VP since last 6 months.
Further, when teachers were asked to indicate the onset of the
VP, 37% (n = 69) of them reported it as intermittent, 34% (n = 65)
of them reported it as gradual, and 29% (n = 55) of them re-
ported it as sudden onset. Since the onset, there was not much
of a variation in VP for 41% (n = 78) of teachers, voice was
getting better for 33% (n = 60), and voice was becoming worse
for 26% (n = 50) of the teachers.
dicated as VP group, and teachers who did not report VP (n = 894)
are indicated as no VP (NVP) group. Out of 894 NVP partici-
pants, 744 participants were randomly selected to maintain a ratio
of 1:4 between the VP and NVP groups for further analysis (com-
paring two groups). The results of the study are presented by
comparing differences between the VP and NVP groups using
chi-square analysis.
Demographic, vocational, and work
environment characteristics
Comparisons of demographic, vocational, and work environ-
ment details between the VP and NVP groups are shown in
Table 1. Overall, there were 781 (83.7%) female teachers and
151 (16.5%) male teachers between the age range of 20–69 years
(mean age of 37.5 years, standard deviation = 10.7 years). There
was no significant difference between two groups of teachers
(VP and NVP) with respect to age and gender. A significantly

TABLE 1.
Comparison of Demographic, Vocational, and Work Environment Details Between Teachers with VP and NVP
Characteristics VP (n = 188) NVP (n = 744) χ2 P Value
N (%) N (%)
Gender Male 29 (19.2%) 122 (80.8%) 0.15 0.746
Female 159 (20.4%) 622 (79.6%)
Age 20–29 y 53 (28) 223 (30) 7.08 0.131
30–39 y 60 (32) 213 (29)
40–49 y 36 (19) 191 (26)
50–59 y 35 (19) 111 (15)
60–69 y 4 (2) 6 (0.8)
Teaching experience <10 y 96 (51) 403 (54) 7.26 0.026
10–20 y 51 (27) 237 (32)
>20 y 41(21) 104 (14)
No. of classes per day <5 classes 53 (28) 224 (30) 0.26 0.608
>5 classes 135 (72) 520 (70)
Duration of each class <45 min 182 (97) 704 (95) 1.52 0.217
>45 min 6 (3) 40 (5)
Average student <50 students 134 (71) 564 (76) 1.63 0.201
strength >50 students 54 (29) 180 (24)
Medium of instruction Kannada 87 (46) 353 (47) 0.082 0.774
English 101 (54) 391 (53)
Presence of No 24 (13) 144 (19) 10.63 0.014
background noise Yes, students noise 127 (68) 452 (61)
Yes, external noise 34 (18) 108 (15)
Yes, fan or airconditioning noise 3 (2) 40 (5)
Noise level in Low 82 (44) 432 (58) 39.11 <0.001
classrooms Medium 91 (48) 305 (41)
High 15 (8) 7 (1)
Vocal loudness while Low 3 (2) 16 (2) 5.48 0.064
teaching Medium 145(77) 621 (83)
High 40 (21) 107 (14)
Stress feeling while Yes 96 (51) 155 (21) 69.69 < 0.001
teaching No 92 (49) 589 (79)
Training in singing No 164 (87) 681 (92) 10.12 0.006
Yes, <5 y 13 (7) 50 (7)
Yes, >5 y 11 (6) 13 (1)
Data are number (percentage) of teachers with VP and NVP unless otherwise specified. Percentages were calculated with the number of respondents in
each group. P values were derived from the chi-square test. Boldface values indicate statistical significance (P < 0.05).
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016
TABLE 2.
Comparison of Vocal Behaviors Exhibited by Two Groups of Teachers in the Classroom
VP
Vocal Behaviors N (%)
Stop speaking Yes 134 (71%)
No 54 (29%)
Yelling and shouting Yes 131 (70%)
No 57 (30%)
Holding breath Yes 47 (25%)
No 141 (75%)
Clench teeth Yes 37 (20%)
No 151 (80%)
Mimicking sounds Yes 101 (54%)
No 87 (46%)
Data are number (percentage) of teachers with VP and NVP unless otherwise specified. Percentages were calculated with the number of respondents in
each group. P values were derived from the chi-square test. Boldface values indicate statistical significance (P < 0.05).
(P < 0.05) higher number of teachers who had more than 20 years
of teaching experience reported having VP compared with the
teachers in the NVP group. The presence of background noise
was found to have significant influence on the teachers report-
ing the VP. Higher percentage of teachers in the VP group reported
higher level of the student noise in the classroom and were
stressed while teaching in the classroom than the teachers in the
NVP group. Reporting of VPs were also found to be higher in
teachers who were involved in singing for more than 5 years.
There was no significant difference between two groups of teach-
ers for other vocational-related factors such as number of classes
per day, average number of students in the class, medium of in-
struction, and vocal loudness while teaching.
Vocal behaviors exhibited by the teachers during
classroom teaching
Teachers were asked to explain the different vocal behaviors they
exhibited while teaching in the classroom. The responses ob-
tained from the teachers are shown in Table 2. The comparison
between the vocal behaviors exhibited by the two groups of teach-
ers indicated that teachers in the VP group shouted in the
classroom to get the attention of the students, held their breath
before they begin to speak, clenched their teeth while teach-
ing, and stopped speaking because of tired voice at significantly
higher rate than the NVP group.
Prevalence of vocal symptoms experienced by
the teachers
Teachers were asked to identify if they were experiencing any
symptoms of vocal attrition listed in the questionnaire. Out of
14 symptoms listed in Table 3, the prevalence of vocal symp-
toms such as tired voice after long hours of talking (52%), sore/
dry throat (34%), strain in voice (29%), neck muscle tension
(19%), and difficulty in projecting the voice (14%) were ob-
served to be higher in the VP group than the NVP group of
teachers. Even though teachers in the NVP group reported ex-
periencing few of those symptoms, the teachers in the VP group
reported experiencing loss of voice, sore/dry throat, shortness
of breath, neck muscle tension, tired voice, excessive cough-
NVP
N (%) χ2 P Value
416 (56%) 14.64 <0.001
328 (44%)
384 (52%) 19.81 <0.001
360 (48%)
62 (8%) 40.36 <0.001
682 (92%)
41 (6%) 39.29 <0.001
703 (94%)
358 (48%) 1.88 0.170
386 (52%)
ing, strain in voice, throat clearing, husky/hoarse voice, difficulty
in projecting voice, monotone voice, and increased effort while
talking at significantly higher rate than the NVP group.
Personal lifestyle and health-related conditions
There was no significant difference between two groups with
respect to lifestyle factors except intake of medicine (Table 4).
However, teachers in the VP group reported experiencing re-
spiratory system-related problems, thyroid problems, and Gastro-
esophageal reflex disorder (GERD) at significantly higher rate
than teachers in the NVP group (Table 5).
Functional impairment and missing of work
When the teachers in the VP group were asked for how many
days they experienced functional impairment due to their VP,
38% (n = 71) reported for less than 7 days, 11% (n = 21) re-
ported for 8–15 days, 2% (n = 3) reported for 16–30 days, and
7% (n = 13) reported for more than 30 days. Further, when these
teachers were asked to indicate whether they missed their work
because of their VP, 27% (n = 50) of them reported they missed
work for less than 7 days, 5% (n = 9) reported for 8–15 days,
0.5% (n = 1) reported 16–30 days, and 2% (n = 4) reported for
more than 30 days.
Awareness/identification of the VP and Physician/
SLP Consultation
When the teachers with VP were asked to indicate whether they
were aware of the VP (identify early symptoms of vocal attri-
tion), and whether they had consulted SLP/physician for the same,
47 (25%) teachers said that they had consulted SLPs for their
VP. Among them, 35 (74.5%) teachers reported their voice im-
proved after their consultation with SLP. Only 10 teachers reported
that they received voice care programs during their teacher train-
ing program.
Risk factors associated with the presence of VP
The association between VP and different risk factors were as-
sessed using adjusted (using Wald forward selection criteria) OR
with 95% confidence intervals. The results suggested that work
 ARTICLE IN PRESS
Usha Devadas et al Voice Problems Among Primary School Teachers in India 5

TABLE 3.
Frequency of Vocal Symptoms Reported by VP and NVP Group of Teachers
VP (N = 188) NVP (N = 744)
Symptoms N (%) N (%) χ2 P Value
Loss of voice Yes 23 (12) 8 (1) 58.116 <0.001
No 165 (88) 736 (99)
Sore/dry throat Yes 63 (34) 81 (11) 58.800 <0.001
No 125 (66) 663 (89)
Shortness of breath Yes 35 (11) 44 (6) 31.217 <0.001
No 153 (89) 700 (94)
Neck muscle tension Yes 35 (19) 44 (6) 31.217 <0.001
No 153 (81) 700 (94)
Tired voice Yes 97 (52) 160 (22) 68.040 <0.001
No 91 (48) 584 (79)
Excessive coughing Yes 24 (13) 18 (2) 37.334 <0.001
No 164 (87) 726 (98)
Difficulty raising the Yes 20 (11) 50 (7) 3.316 0.069
voice No 168 (89) 694 (93)
Strain in voice Yes 54 (29) 43 (6) 84.727 <0.001
No 134 (71) 701 (94)
Throat clearing Yes 20 (11) 16 (2) 29.115 <0.001
No 168 (89) 728 (98)
Husky or Yes 21 (11) 4 (1) 64.994 <0.001
hoarse No 167 (89) 740 (99)
Unsteady voice Yes 5 (3) 7 (1) 3.488 0.062
No 183 (97) 737 (99)
Difficulty projecting the Yes 26 (14) 16 (2) 47.570 <0.001
voice No 162 (86) 728 (98)
Monotone voice Yes 15 (8) 12 (2) 21.619 <0.001
No 173 (92) 732 (98)
Increased effort while Yes 18 (10) 1.2 9 (1) 37.329 <0.001
talking No 170 (90) 735 (99)
Data are number (percentage) of teachers with VP and NVP unless otherwise specified. Percentages were calculated with the number of respondents in
each group. P values were derived from the chi-square test. Boldface values indicate statistical significance (P < 0.05).

TABLE 4.
Comparison of Lifestyle Factors Between VP and NVP Group of Teachers
Factors VP (188) NVP (744) χ2 P Value
Smoking Yes 3 (2) 5 (1) 1.421 0.491
No 185 (98) 738 (99)
Alcohol Yes 5 (3) 8 (1) 2.739 0.098
No 183 (97) 736 (99)
Caffeinated drinks <3 times 122 (65) 430 (58) 3.513 0.173
>3 times 9 (5) 34 (5)
No consumption 57 (30) 280 (38)
Physical activities <30 min 62 (33) 266 (36) 0.524 0.770
>30 min 27 (14) 105 (14)
Not applicable 99 (53) 373 (50)
Water intake <4 L 154 (82) 562 (76) 3.428 0.064
>4 L 34 (18) 182 (25)
Taking medicine Yes 18 (10) 13 (2) 39.50 <0.001
No 170 (90) 731 (98)
Data are number (percentage) of teachers with VP and NVP unless otherwise specified. Percentages were calculated with the number of respondents in
each group. P values were derived from the chi-square test. Boldface values indicate statistical significance (P < 0.05).
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 5.
Health-Related Conditions of VP and NVP Group of Teachers
VP (N = 188) NVP (N = 744)
Health-related factors N (%) N (%) χ2 P Value
Respiratory system- Yes 43 (23) 68 (9) 26.97 <0.001
related problem No 145 (77) 676 (91)
Thyroid problem Yes 13 (7) 18 (2) 9.43 0.002
No 175 (93) 726 (98)
GERD Yes 12 (6) 12 (2) 13.61 <0.001
No 176 (94) 732 (98)
Respiratory allergy Yes 4 (2) 10 (1) 0.62 0.430
No 184 (98) 734 (99)
Neurologic diseases Yes 3 (2) 6 (1) 0.97 0.323
No 185 (98) 727 (99)
Diabetes Yes 5 (3) 17 (2) 0.90 0.762
No 183 (97) 727 (98)
Data are number (percentage) of teachers with VP and NVP unless otherwise specified. Percentages were calculated with the number of respondents in
each group. P values were derived from the chi-square test. Boldface values indicate statistical significance (P < 0.05).

experience of more than 20 years (OR 1.7 [95% CI 1.0; 2.8]),
high noise level in the classroom (OR 4.4 [95% CI 1.5;12.9]),
being stressed while teaching (OR 3.1 [95% CI 21.;4.5]), holding
breath while speaking in the classroom (OR 2.26 [95% CI
1.4;4.4]), clenching jaw/teeth while speaking (OR 2.5 [95%
CI 1.4;4.4]), upper respiratory tract infections (OR 2.2 [95% CI
1.3;3.7]), thyroid problems (OR 3.7 [95% CI 1.6;8.6]), and acid
reflux (OR 4.8 [95% CI 1.8;12.6] are found to be significant risk
factors associated with higher prevalence of self-reported VPs
in teachers (Table 6).
DISCUSSION
The main objective of the present study was to investigate the
prevalence and risk factors of VP among primary school teach-
ers in Mysore District, India. For this purpose, teachers from
both government and private schools were included consider-
ing their similar working environment in the classroom, number
of working hours per week, as well as number of students in
the classroom. Thus, these teachers were considered homoge-
nous and representative. Generally, the literature suggests that
there are more female teachers compared with male teachers in
primary schools.5,19,20 A similar trend was observed in the present
study. There were 781 (83%) female teachers and 151 (17%)
male teachers in the total sample of 1082 teachers.
Prevalence of VP
In the present study, the prevalence of VP was measured on the
basis of an operational definition given by Roy et al as “Any time
your voice does not work, perform, or sound as it normally should,
so that it interfered with communication and job perfor-
mance.” As per the definition, 188 teachers out of 1082 reported
that they experienced VP with a prevalence rate of 17%. In the

TABLE 6.
Factors Having Significant Association with Voice Problems
Unadjusted Odds Adjusted Odds
Ratio (95% CI) P Value Ratio (95% CI) P Value
Teaching experience <10 y 1.00 1.00
10–20 y 1.411 (0.395–2.924) 0.020 0.827 (0.542–1.262) 0.378
>20 y 2.338 (0.841–3.875) 0.012 1.739 (1.062–2.848) 0.028
Noise level in the Low 1.00 1.00
classroom Medium 1.523 (0.432–7.542) 0.191 1.299 (0.898–1.879) 0.164
High 4.302 (2.506–10.582) 0.002 4.488 (1.559–12.924) 0.005
Stressed while teaching 3.965 (2.833–5.550) <0.001 3.125 (2.152–4.538) <0.001
Holding breath while speaking in the classroom 3.667 (2.409–5.582) <0.001 2.268 (1.438–4.432) 0.001
Clenching jaw/teeth while speaking 4.201 (2.605–6.776) <0.001 2.524 (1.438–4.432) 0.001
Medical conditions Upper respiratory tract 1.927 (1.216–3.658) 0.004 2.287 (1.377–3.798) 0.001
infections (cold, laryngitis,
pharyngitis, etc)
Thyroid problems 1.974 (1.739–6.254) 0.026 3.734 (1.667–8.364) 0.001
Acid reflux 3.520 (1.947–12.210) 0.041 4.897 (1.892–12.676) 0.001
Boldface values indicate statistical significance (P < 0.05).
 ARTICLE IN PRESS
Usha Devadas et al Voice Problems Among Primary School Teachers in India
literature, different studies have reported wide range in preva-
lence of VP in teachers, and it varies between 15% and 80% in
preschool, elementary, and high school teachers.1,3,5,19–21 Major-
ity of these studies reported prevalence rates closer to 50%. This
wide range in values in different studies may be attributed to
the differences in the definitions of VP and methods used to collect
the sample. Hence, it is difficult to compare the findings of dif-
ferent studies. In general, teachers may develop VP as they need
to constantly use their voice at inappropriate loudness levels for
long periods.
Demographic, vocational, and work
environment information
When teachers with VP and NVP are compared, there was no
significant relationship observed between VP and age and gender
(Table 1). Most of the studies in the literature have identified
higher prevalence of VP in the female teachers than in males.,1,3,5
In the current study, the unequal distribution of male and female
teachers across different age groups could have influenced our
findings related to age and gender. However, relationship between
age and reporting of VP in teachers is not very consistent in the
literature. Only few studies have identified higher VP in teach-
ers above 50 years of age.1,3,10 Further studies to specifically
investigate the effects of age and gender on reporting of VP in
teachers may reveal more facts. Apart from age and gender, there
was no significant difference between the two groups of teach-
ers (VP and NVP) with respect to medium of instruction, number
of classes per day, duration of each class, and average number
of students in the class, suggesting that these factors probably
have less influence on the VP in our teachers.
However, significant relationship was observed between teach-
ers reporting VP and teaching experience, noise levels in the
classroom, experiencing psychological stress while teaching
classes, yelling, shouting, inappropriate breath management while
speaking, speaking with clenched jaw, and singing. Associa-
tion between teaching experience and VP experienced by teachers
was also reported in few studies in the literature.1,5,10,20,22 However,
current study results are not in consonance with Russell et al3
and Chen et al18 investigations, who did not find any relation-
ship between teaching experience and VP.
Teachers with VP reported that they experienced signifi-
cantly higher background noise (especially the students’ noise
in the classroom) when compared with NVP teachers.9,12,23 Studies
have reported that noise levels in the classroom should be below
35–40 dB(A) for a good communication.24 However, in the past,
it is reported that very few primary schools meet these require-
ments, and most classrooms have high background noise levels
which is at least 10–15 dB higher than the recommended
standards.25–27 In the present study exact noise levels in the class-
room were not measured. However, teachers reported that there
was medium to high levels of noise in the classroom. Current
results also suggested the relationship between psychological stress
experienced by the teachers while teaching and the VP which
is consistent with several studies in the literature.7,8,12,14,18,21,22 In-
creased stress levels in teachers is associated with the teaching
demands, curriculum revision, inappropriate behaviors of stu-
dents, and background noise levels in the classroom.28
7
Vocal behaviors exhibited by the teachers during
classroom teaching
Teachers with VP were more likely (P < 0.001) to yell and shout
in the classroom, have inappropriate breath management (holding
breath) and were clenching their jaw, and were involved in singing
apart from teaching than teachers with NVP. These findings
suggest that teachers with the VP group were involved in strain-
ing their voice by inappropriate speaking style and vocal abusive
behaviors. All these vocal behaviors are considered to have neg-
ative influence on vocal folds (VFs) leading to vocal fatigue.9,29
According to Sapir et al9 when teachers experience vocal fatigue,
their voice tires easily and they experience difficulty in talking
or singing. It was found true in the present study as signifi-
cantly higher number of teachers in the VP group reported that
they stopped speaking frequently because their voice gets tired.
Prevalence of vocal symptoms experienced by
the teachers
Significant difference was observed in vocal symptoms expe-
rienced by teachers with VP when compared with teachers with
NVP. Out of 14 symptoms listed in the questionnaire, the most
frequently reported vocal symptoms by the teachers with VP were
vocal fatigue (52%), sore/dry throat (34%), vocal strain (29%),
neck muscle tension (19%), and difficulty in projecting the voice
(14%) (Table 3). These are the most common symptoms re-
ported by the teachers in the literature,1,3,5 indicating VP in teachers
may manifest as several symptoms. According to Tavares and
Martins,30 symptoms like vocal fatigue, vocal strain, sore/dry throat
are signs of phonotrauma. Ferreira et al31 and Lime-Silva, et al29
found a positive correlation between reporting of vocal symp-
toms and excessive use of voice, shouting, yelling, inappropriate
hydration, jaw opening limitations, sleep disturbances, and lack
of rest. In teachers, these vocal symptoms may begin slowly and
sporadically, and may contribute to the development of laryn-
geal disorders/occupational voice disorders that prevent their
normal voice production over a period of time. In India, cur-
rently, teachers are not made aware of vocal symptoms associated
with their profession during their training or after they join for
their profession. Hence, there is a great need to educate the teach-
ers to identify early symptoms and prevent symptoms that may
develop into laryngeal disorders.
Personal lifestyle and health-related conditions
No significant relationship was observed between teachers re-
porting VP and lifestyle factors like smoking, consumption of
alcohol and caffeinated drinks, consumption of water, and phys-
ical activities. However, significant relationship was observed
between teachers reporting VP and taking medication. It is re-
ported in the literature that, compared to the general population,
teachers are less likely to drink alcohol or smoke cigarettes.1,32
It was found true in the present study, and there were fewer
numbers of teachers who reported they smoke or consume alcohol
(Table 5). Further, positive relationship was observed between
teachers reporting VP and experiencing respiratory-related
problem. This result was in consonance with findings of other
studies.1,13,33
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016
Functional impairment and missing of work
Overall, about 57.4% of the teachers with VP reported that they
experienced functional impairment due to VP, and 34% of them
reported they missed their work due to their VP during their career.
Among them, majority of the teachers (38%) reported that they
experienced functional impairment and missed work (27%) for
less than a week. This outcome was similar to the findings of
Russell et al3 and Titze et al34 who reported that 39% of the Aus-
tralian and 20% of the American teachers missed work for less
than a week, respectively. Further, the above data show that all
the teachers who reported functional impairment did not miss
their work. According to Roelen et al,35 the relationship between
missing work and illness is not straightforward. The individu-
als with illness may not miss work by the pressure of coming
to work. This finding was supported by the study of Chen et al18
who reported no significant association between the presence
of VP and absence taken by the teachers. This supports the view
that teachers believe VP as a part of their occupation and do not
acknowledge the existing restrictions for carrying out the pro-
fessional and communication activities. Hence, they do not
consider it as an excuse for absence.36 However, Smith et al10
and Titze et al34 reported that significantly higher number of teach-
ers take sick leaves related to VP than the general population.
Because the teachers are a significant portion of the working pop-
ulation, teachers reporting missing work due to VP should be
considered more seriously, and they should be provided appro-
priate voice care strategies to prevent VP-related absenteeism
and related economic consequences.
Awareness/identification of the VP and physician/
SLP consultation
Only 25% (n = 47) of the teachers who experienced VP con-
sulted a physician or SLP in the current study. This is in
accordance to the findings of Roy et al1 and Russell et al3 who
reported that 14.3% and 32.7% of the teachers with VP con-
sulted a physician or SLP. From these findings, it can be
speculated that either the teachers consider VP as associated with
their profession, or do not give much importance to vocal symp-
toms unless it severely affects them, or they are reluctant to take
time off from the work for medical or SLP appointments. Other
possible explanations could be that in a country like India, where
there is very limited awareness about speech and hearing prob-
lems, teachers may not be aware of help available to prevent their
VPs, or teachers may find it difficult to justify their sick leaves
associated with VP as it is not recognized as professional disease.1,3
Further, research aiming to explore these aspects may help SLPs
to arrive at better consensus and develop education programs for
these teachers.
Risk factors associated with the presence of VP
Teaching in the classroom is associated with several risk factors
which affect the voice of teachers. OR showed a significant as-
sociation between self-reported VP and teaching experience,
background noise in the classroom, experiencing psychologi-
cal stress, inappropriate breath management, inappropriate jaw
opening, and health problems such as upper respiratory tract in-
fections, thyroid problem, and experiencing acid reflux.
Work- and environment-related risk factors
Teachers who had more than 20 years of teaching experience
were found to be at 1.7 times greater risk than teachers who had
less than 20 years of experience. It supports the Smith et al10
and Roy et al1 findings that vocal fatigue increases with the
number of years of teaching. According to Titze,37 the accumu-
lated injury during continuous voice use (daily basis) in teachers
can reach a point where day-to-day recovery may not be pos-
sible. This could be the possible reason for the higher prevalence
of vocal symptoms in teachers who had more than 20 years of
teaching experience. However, teaching experience was not found
as risk factor for development of VP in teachers universally, and
contrasting findings are reported by Russell et al3 and Sapir et al.9
These authors found no significant association with number of
years of teaching and vocal symptoms in teachers.
Similarly, teachers who experienced high background noise
in the classroom were found to be at 4.4 times higher risk of
developing VP than teachers who did not report higher back-
ground noise. Speaking in high background noise increases the
vocal loading as the speaker automatically increases the loud-
ness level and spectral contents of voice signal to improve message
transfer.23,38 Increase in loudness may increase the medial com-
pression of the VFs. This may lead to higher mechanical load
on the VF tissue which may increase the risk of vocal fatigue.39
Multiple studies in the literature have shown psychological
stress as being associated consistently with the VP in
teachers.3,7,8,14,15,18,21,22,40 According to Vilkman,23 psychological
stress adds to the subjective perception of the vocal load in teach-
ers. Teachers who experienced psychological stress in the present
study were found to be at 3.1 times higher risk than teachers
who did not experience stress. This finding is in line with the
findings of Sapir et al9 and Gassull, et al41 who reported that psy-
chological stress is common among teachers who report VP. The
current finding supports the views in the literature that if teach-
ers are psychologically stressed while teaching, it may have a
significant negative influence on the voice. Further, it has also
been reported that phonation may change while teachers are
speaking in psychologically stressed situations.15,42
Inappropriate speaking styles (holding breath while talking,
clenching jaw/teeth) exhibited by the teachers were found to have
significant association with VP. Kostyk and Rochet43 reported
the presence of inefficient coordination of respiratory and la-
ryngeal adjustments in teachers who reported VP, and suggested
that this may contribute to the development of symptoms of vocal
fatigue. Supporting this view, the results of the present study
showed that teachers having inappropriate breath management
were at 2.2 times at higher risk of developing VP than teachers
who do not report this. Previous studies have identified altered
speech breathing behavior in teachers who exhibited symp-
toms of vocal fatigue44–46 that resulted in effortful and strained
voice quality.47 These results highlight that there is respiratory
and laryngeal system imbalance in teachers who report VP, and
they begin their utterances 10%–25% above the resting expira-
tory level and terminate at near-resting expiratory level. However,
the physiological respiratory characteristics of teachers who re-
ported holding their breath while speaking and its contribution
to the development of laryngeal pathology is not explored in the
 ARTICLE IN PRESS
Usha Devadas et al Voice Problems Among Primary School Teachers in India
present study. Clenching of jaw or teeth will inhibit the full
opening of vocal tract during production of vowels causing a
tight throat instead of an open one.31 Further, restricted jaw
opening may cause production of words at the back of the mouth
and may tighten the throat and laryngeal muscle tension. Inap-
propriate speaking style by the teachers in the present study by
clenching their jaw and teeth was identified as contributing factors
for the development of VP (OR 2.5). The association between
clenching of jaw and VP may be explained by the above-
mentioned factors.
Health-related risk factors
Upper respiratory tract infection (URTI) (laryngitis, rhinitis/
sinusitis, pharyngitis) was found to be a significant risk factor
(2.2 times higher) in teachers who experienced VP. Other studies
in the literature also showed a significant positive association
between dysphonia and respiratory problem in teachers.8,10,48,49
Exposures to dirt and chalk dust in the classroom were re-
ported to increase the likelihood of developing URTIs in teachers.
URTI can lead to complete loss of voice or hoarseness of the
voice. As URTI leads to laryngitis, the superficial layer of the
VFs becomes stiffer. Persistent use of the voice with laryngitis
may lead to inflammation of the folds and may impair voice pro-
duction. This in turn may increase the need to put extra effort
to convey the message in the classroom teaching, leading to vocal
fatigue.15,50
Studies have reported that thyroid hormones problem causes
voice disturbances.51 In the present study, teachers reporting
thyroid problem were at 3.7 times higher risk than teachers who
did not report thyroid problem. Thyroid hormones secretion modu-
lates the rate of metabolic functions in the body. Thyroid hormone
problem causes increased levels of polysaccharides in the VFs,
leading to increased fluid retention and VF thickening. The VF
thickening results in lower fundamental frequency and a sen-
sation of insufficiency. Hyperthyroidism (high thyroid function)
in severe cases also usually can cause hoarseness.52
Teachers who reported experiencing acid reflux were found
to be 4.8 times at greater risk than teachers who did not expe-
rience acid reflux. It is well documented in the literature that
acid reflux is one of the risk factors for the development of VP.53–56
Reflux can cause laryngitis or tighten the laryngeal muscles due
to irritation of vagus nerve.57 Studies suggesting the associa-
tion between laryngopharyngeal reflux (LPR) disease and
dysphonia have attributed it to the inflammatory process (Reinke
edema) and frequent throat clearing associated with LPR, which
in turn alters the mucosa of the VFs. This could be one of the
possible reasons for the significant association between expe-
riencing symptoms of and vocal symptoms as reported by the
teachers.
In the literature it has been reported that, number of classes
per day (classroom hours), age, gender, and number of stu-
dents per class are related with the development of VP in primary
school teachers. In the present study, these factors did not show
significant OR, which leads to the assumption that contribu-
tion of these factors may be relatively less for the development
of the VP in our primary school teachers compared with other
factors which showed significant OR. On the other hand the non-
9
significant association of these factors with VP in teachers could
be attributed to the study design itself; that is, in cross-sectional
study designs it is difficult to establish the exact cause and effect
relationship.48
Overall, the results of this study confirm that teaching is a high-
risk profession for development of VP, and several factors (work
organization and environment, psycho-emotional, and health) are
significantly associated with development of VP in teachers. If
adequate care is taken, then the effect of majority of these risk
factors can be controlled by the teachers, and they can main-
tain good vocal health. It shows that there is greater need to
educate the teachers about the importance of prevention of VP.
Teachers need to be given adequate education regarding how to
optimize their voice use depending on the room acoustics and
background noise. They should also be made aware of differ-
ent etiological factors and their interplay so that there is a good
interaction between teachers’ working conditions and their general
and vocal health. This action can be brought about by conduct-
ing workshops about knowledge of voice production and factors
influencing it. Further studies are warranted to identify the exact
factors that contribute to the development of VP in teachers by
considering the individual risk factors and their impact on the
vocal mechanism. This will help the SLP to develop effective
preventive voice care programs for teachers.
Acknowledgements
This research was supported by AIISH research fund (SH/CDN/
ARF/4.49/2012-2013). We sincerely thank our director, Dr. S.R.
Savithri, for allowing us to carry out this study. We also thank
all our participants for consenting to be part of this study and
Arya G for helping us with the data collection.
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