Speak Up for Teachers Health: the Importance of Vocal Care in Education Settings

Abstract

This article reviews the elevated prevalence and complex nature of voice complaints among teachers, highlighting their profound impact on students’ academic performance, teachers’ well-being, and overall school productivity. The text discusses the significance of teachers as occupational voice users, provides statistics on the prevalence of voice disorders, summarizes work-related factors and occupational policy contributing to the issue, and presents a comprehensive approach to intervention. This article facilitates recognizing and addressing work-related voice disorders among teachers while enhancing communication between educators and healthcare professionals.

Introduction

Voice disorders among teachers represent a significant and multifaceted challenge that extends beyond individual well-being to impact the entire educational system. While teachers face the direct consequences of these voice disorders, there are many indirect consequences such as those experienced by students whose attention and comprehension are significantly impacted, leading to a decline in academic performance. Thus, a teacher’s voice is not merely a means of communication, but a clear and audible voice is a fundamental tool intricately tied to the success of their pedagogical efforts and a critical factor in maintaining a conducive learning environment. Understanding the causes and consequences of these voice problems is crucial for developing effective strategies to mitigate their impact, which includes students’ performance, and therefore, the school’s productivity.

Teachers navigate unique challenges as occupational voice users due to the nature of their occupation. Recognizing the centrality of the voice in teaching, this article reviews why teachers are particularly vulnerable to voice complaints and voice disorders. To contextualize the scope of this issue, we present statistics on the prevalence of voice disorders among teachers that serve as a quantitative lens through which we can grasp the magnitude of the issue and its far-reaching implications. Beyond numbers, we explain some of the work-related factors contributing to voice complaints and voice disorders, recognizing that teaching involves more than classroom instruction since many other professional interactions further intensify the vocal demands on educators.

Moving beyond the identification of risk factors, the article explores the intricate web of consequences of voice disorders among teachers. Teachers may face unexpected career changes, requiring medical leaves and potential shifts to less demanding roles. Beyond the individual well-being of teachers is the impact on the educational system which results in increased costs for both educators and institutions, affecting budget allocations and workforce planning.

In response to these challenges, we present an analysis of policies and actions to optimize teachers’ vocal health. First, targeted interventions within educational institutions provide educators with the tools and resources necessary to safeguard their vocal well-being. Second, vocal hygiene techniques may be a useful preventive approach to incorporate into teachers’ daily routines. Finally, timely medical attention to vocal health specialists is a key part of proactive healthcare in mitigating the progression of voice disorders.

This article, thus, serves as a resource for educators and administrators, highlighting the significance of occupational voice health and encouraging effective communication between educational professionals and healthcare practitioners.

Part I. The importance of the voice for teachers’ work.

A functional and healthy voice plays a pivotal role in facilitating effective communication and creating an immersive learning atmosphere. It is an indispensable working tool for professionals in various sectors, particularly for those who heavily rely on their voices to fulfill their occupational responsibilities. This category of workers, known as occupational voice users, includes individuals in roles such as teaching, singing, telemarketing, and broadcasting, among others.

In the case of teachers, conventional classroom instruction involves a high vocal demand over long periods of time, resulting in a substantial vocal workload. Educators are consistently engaged in numerous vocal tasks, including delivering lectures, explanations of concepts and instructions, small group discussions, and counseling, along with maintaining order within the classroom. Furthermore, they often must project their voices to ensure audibility in more extensive educational settings (e.g., auditorium, gymnasium, cafeteria), significantly amplifying the vocal demands placed on them. This sustained and often persistent voice use unequivocally distinguishes teachers as occupational voice users (Cantor Cutiva et al., 2013; Cantor Cutiva & Burdorf, 2012).

Moreover, the sphere of occupational voice use for teachers extends beyond the classroom’s boundaries into other activities. It encompasses the essential requirement for effective communication with students, colleagues, and parents where teachers frequently participate in meetings, discussions, and presentations, needing to orally transmit their thoughts and ideas. Other demands may include vocal activities coaching, hall monitoring, and club advising which can take place in the evening or on weekends. The continuous and intensive use of the voice, occurring during both formal and informal interactions, makes teachers one of the groups of occupational voice users with higher risks of developing voice disorders due to the significant vocal load inherently associated with their occupation (Cantor Cutiva, 2018; Vilkman, 2000).

Part II. Prevalence of teacher vocal health complaints.

When professionals depend on their voice as their primary work tool, even minor changes in their voice can significantly affect their job performance. Research has consistently demonstrated that teachers experience a disproportionately high number of voice-related complaints and problems when compared to individuals in other occupations (Cantor Cutiva et al., 2013), making them a significant proportion of patients seeking care at voice clinics (Jardim et al., 2007; Mattiske et al., 1998; Williams, 2003). These worrying statistics include a monthly prevalence of voice symptoms as high as 71% (Cantor Cutiva & Burdorf, 2015a), with 78% of teachers facing recurring voice complaints. Notably, these complaints often follow an episodic pattern, with a recovery rate of 22% and an annual incidence of 44% (Cantor Cutiva & Burdorf, 2016). A recent systematic review of the literature (González-Gamboa et al., 2022) reported a wide range in the prevalence of voice disorders among teachers worldwide, varying from 10.5% in Malaysia to 69.1% in Brazil over the last five years. While this substantial variation may be attributed simply to differences in data collection methodologies, the culmination of reports indicates that the recognition of voice problems among teachers is a top priority for occupational health practitioners.

Voice symptoms commonly experienced by teachers include hoarseness, vocal fatigue, soreness in the neck or throat, singing difficulties, and the need to clear the throat (Pereira et al., 2015). While these symptoms may initially appear mild, they often serve as early indicators of underlying voice problems that can be caused or exacerbated by the vocal demands of the teaching profession (Cantor Cutiva & Burdorf, 2012; de Jong et al., 2006; Pekkarinen et al., 1992; Roy et al., 2004; Sala et al., 2001). Surprisingly, voice symptoms can even manifest during a teacher’s training period (Ohlsson et al., 2012).

While the vocal health community has extensively studied teachers’ voices and has valuable insights that can both mitigate risk factors and assist with recovery, much of this knowledge has not effectively reached the individuals who need it the most: teachers and school administrators. For example, despite acknowledging the prevalence of voice issues in their profession (Byeon, 2019), nearly 70% of teachers experiencing voice symptoms do not seek clinical care from vocal health professionals though many of the symptoms are highly treatable. This hesitancy is often due to a lack of awareness about available treatments and therapies, a lack of knowledge about vocal health expertise among health professionals, and the perception that voice problems are an inevitable part of teaching (Gautam et al., 2022). Additionally, teachers may delay seeking medical advice because of concerns about taking time off work (Giannini et al., 2015).

Part III. Work-related factors that contribute to teachers’ vocal health problems.

Previous studies have identified several factors contributing to the development of voice disorders among teachers. First, students’ classroom behavior can impact a teacher’s vocal health when teachers must frequently speak loudly for extended periods and over the course of days and weeks to maintain the student’s attention. Furthermore, if the teachers’ workload results in long working hours along with vocally active evenings and weekends offering limited recovery time for their voice, the risk of voice complaints increases (Chen et al., 2010; Hunter E.J. & Titze I.R., 2009; J. da S. A. Medeiros et al., 2016). This continuous vocal effort can lead to vocal fatigue, voice strain, and, over time, voice disorders. Additionally, the grade or subject they teach can be a contributing factor to voice issues, with, for instance, physical education teachers being more likely to report voice disorders compared to teachers in other subjects (Cantor Cutiva et al., 2013).

The classroom environment itself may also play a role. Several studies have shown that teachers who reported poor acoustics and noisy conditions in their classrooms had a higher prevalence of voice complaints compared to those teaching in better conditions (Ahlander et al., 2011; Cantor Cutiva & Burdorf, 2015a; Cantor-Cutiva, 2022; Souza et al., 2011). Not surprisingly, classroom capacity also correlates with higher teacher voice problems (Banks et al., 2017). To maintain discipline and ensure effective communication, teachers often need to raise their voices to be heard in larger spaces or over background noise, including students’ chatter or disruptive behavior. Speaking more loudly in noisy conditions, known as the Lombard effect (Bottalico, Passione, et al., 2017) is one of many common responses to communication situations to maintain communication intent, highlighting the adaptability of human communication in challenging acoustic conditions. However, prolonged loud voice use in noisy surroundings or large rooms can lead to teachers continually exerting their voices, making them more vulnerable to vocal disorders. Other environmental components such as inadequate classroom ventilation, temperature conditions, or airborne chemicals and irritants can lead to inadequate hydration as well as irritation of the sensitive skin in the airway, which can affect vocal production and endurance (Cantor Cutiva et al., 2013; Vilkman, 1996).

Another important factor is the lack of formal vocal training and education for teachers. Despite the extensive use of their voices in their profession, many teachers receive minimal instruction on proper vocal care, efficient voice projection, and techniques for preserving vocal health. Insufficient vocal training leaves educators unprepared to effectively manage the demands of their occupation, leading to potentially harmful vocal behaviors, such as speaking loudly or forcefully, often unaware of the potential consequences, thereby contributing to the development of voice disorders.

Part IV. Consequences of Teachers’ Voice Problems.

As mentioned above, voice problems among teachers can have significant consequences that extend beyond their health and well-being but can impact their students, schools, and the healthcare system. For example, a hoarse or weak voice has been implicated in increased listening efforts for students (Sahlen et al., 2018). Voice problems can also lead to increased work absenteeism among teachers (Cantor Cutiva & Burdorf, 2015b; A. M. de Medeiros & Vieira, 2019). When educators develop voice disorders, they may need to take time off work to recover or seek medical attention. Extended periods of absence can disrupt the continuity of learning for students, as substitute teachers often lack the same familiarity with the curriculum and teaching methods which can negatively impact the educational progress of students.

Another significant consequence of teachers’ voice problems is a reduced ability to perform their job functions. In 2013, a study of 438 Colombian teachers found that around 73% of teachers reported productivity loss at work due to voice symptoms in the previous month, with the more severe and prolonged voice symptoms increasing the indirect costs associated with a reduction in productivity (Cantor Cutiva & Burdorf, 2015b). Voice disorders can limit teachers’ ability to deliver lessons effectively, communicate with students, and maintain discipline in the classroom. In turn, this can result in reduced learning outcomes for students, leading to a decline in the overall quality of education. When teachers experience voice problems, they may also find it challenging to participate in non-classroom activities, including school meetings, discussions, and extracurricular activities, all of which are essential components of the school community. (Cantor Cutiva & Burdorf, 2015b).

Teachers’ voice problems can also significantly impact their well-being. Studies have reported that teachers with voice complaints report a lower quality of life and reduced daily participation than both teachers without voice issues and non-teachers in general (Alva et al., 2017; Cantor Cutiva & Burdorf, 2014). Shoeib, Nassar & and Ghandour (2012) found that voice problems increased anxiety regarding employment opportunities, increased teacher frustration, and contributed to social withdrawal. Previous reports have shown correlations between voice problems and participation restrictions, such as difficulty in going out with friends or speaking on the phone, as well as emotional, social, and communication difficulties, and a perception of job pressure (A. M. de Medeiros & Vieira, 2019). These issues often lead to discomfort, frustration, and a reduced sense of well-being, both inside and outside the classroom. This discomfort can lead to increased stress and irritability, affecting their overall emotional and psychological well-being. Furthermore, voice problems may impede teachers’ ability to engage in social and recreational activities, impacting their personal lives and social interactions. This reduction in the quality of life can affect not only the teachers themselves but also their families, friends, and the overall community.

Furthermore, teachers’ absenteeism places an additional burden on school budgets and school administration when teachers require sick days or medical intervention, such as visits to ear, nose, and throat specialists, speech-language pathologists, or other healthcare providers. Previous research has reported that about 25% of teachers with voice problems used healthcare services for their voice symptoms and about 7% of teachers reported sick days due to voice symptoms, with an average duration of 3 days (Cantor Cutiva & Burdorf, 2015b). On average, in a cross-sectional study in 2013, the total costs of voice symptoms per month per teacher were around $US458, with 33% for voice-related absenteeism (Cantor Cutiva & Burdorf, 2015b).

Part V. Preventative and intervention strategies to improve teachers’ vocal health.

While there is still work to do, there are many practical solutions that are available right now that, when implemented, can improve the vocal health of teachers. Where some are just informational, other solutions include both short- and long-term interventions to not only reduce the prevalence of voice issues but also alleviate symptoms once they arise. These can be implemented at the individual level, at the level of school administration, and at higher government policy level. In time, they can happen during university training and in a continuing education situation. School administrators, for example, can work to have balanced teaching schedules, acoustically friendly classrooms, and suitable sick day responses. Government policy can provide long-term goals for physical classroom environments and vocal health educational goals. When considering the literature and policy implementation in several countries, many of these practical solutions are in practice in certain areas across the world; looking to them at what works is the next step. The next three sub-sections summarize when vocal care is commonly recommended, what are some standard responses that can help, as well as some resources for further information.

When Care is needed

The United States’ National Institute of Deafness and Other Communication Disorders (of the National Institutes of Health) has provided a list of warning signs that may indicate the presence of a voice disorder (https://www.nidcd.nih.gov/health/taking-care-your-voice#2). These signs include hoarseness or roughness, difficulty hitting high notes when singing, sudden changes in voice pitch or quality, frequent feelings of throat strain or discomfort, and increased effort required for speaking. While it is common for people to experience these symptoms for a few days after an event (e.g., upper respiratory infection, cheering at a sporting event), experts recommend that individuals experiencing any of these symptoms for more than a week should consult with a health professional to identify the underlying cause. There are several health professionals specifically trained to assist with vocal health. An otolaryngologist, who specializes in disorders of the ears, nose, and throat (ENT), is best equipped to diagnose a voice disorder. Some otolaryngologists have specialty fellowship training in caring for the voice. As health care is often a team approach, speech-language pathologists also may provide additional support and guidance for improving voice use; some speech-language pathologists have additional specialty training in voice rehabilitation. It is important to seek medical attention promptly to address any voice problems to prevent further damage (National Institute on Deafness and Other Communication Disorders, s. f.).

Common responses that can help

Considering the physical teaching environment is important to support teachers’ vocal health. As mentioned above, a noisy classroom can significantly add to the vocal demands of a teacher. Some noise sources, whether internal or external to a classroom, can be dealt with through the scheduling of activities. Others may need professional facilities management to mitigate noise sources or the transmission into a classroom. A recent study demonstrated the effectiveness of a cost-effective workplace intervention in improving voice acoustic parameters among pupils and their teacher. This intervention included training sessions for pupils and teachers on the detrimental effects of noisy environments on the voice, complemented by the implementation of a noise traffic light app during classes. The study’s findings highlight the potential of such interventions to improve vocal health in educational settings (Cantor-Cutiva & Cantor-Cutiva, 2023).

The use of classroom amplification devices is another effective way to reduce the vocal demand of a classroom (Gaskill et al., 2012), but only if they are properly adapted to the classroom environment (Banks et al., 2022). However, not all teachers have access to or use these devices, and many teachers avoid using amplification systems due to the increased noise they generate inside the classrooms and the lack of replacement batteries.

Besides the physical environment, it is also essential for teachers to know their vocal limits including taking time during their teaching activities to allow for periods of vocal rest. These vocal breaks can be longer, such as a vocally easy weekend after a long week of heavy voice use, but also short and intermittent breaks throughout the day which can be particularly beneficial for vocal recovery (Bottalico, Graetzer, et al., 2017; Mattiske et al., 1998; Moreno et al., 2022). Finally, just as an athlete needs to warm up and cool down before exercising as well as watch overall health to perform, there are several ways to have a healthier vocal system by practicing vocal hygiene as well as doing vocal warm-up exercises before class and cool-down exercises after class. Common vocal hygiene suggestions include limiting caffeine and alcohol intake, practicing good posture, avoiding smoking and other airborne irritants, staying hydrated, and mitigating reflux (Pomaville et al., 2019). There are several vocal warm-up and cool-down techniques, many are as simple as humming through a straw (Castillo-Allendes et al., 2021).

Further advice and help

Online, there are many useful sources available for further information and guidance on voice care for teachers, here are some we suggest as starting points:

1. Teach Starter (https://www.teachstarter.com/us/blog/voice-care-for-teachers-us/): This website offers 10 ways for teachers to take care of their voice, providing practical tips and strategies.

2. British Voice Association (https://www.britishvoiceassociation.org.uk/voicecare_take-care-of-your-voice.htm): This website provides comprehensive voice care tips and advice to help individuals take care of their voice effectively.

3. National Education Association (https://www.nea.org/advocating-for-change/new-from-nea/teacher-voice-problems-are-occupational-hazard-heres-how-reduce): This website offers valuable information on how to protect teachers’ voices, highlighting voice problems as an occupational hazard and providing strategies to mitigate risks.

4. The Voice Academy (https://voice-academy.uiowa.edu/), is a no-cost, self-directed virtual school built for the vocal health of teachers.

These resources can serve as valuable references for teachers looking to maintain and improve their vocal health. By following the tips and recommendations provided, teachers can enhance their voice care practices, minimize the risk of voice-related issues, and reduce district costs and learning disruptions for students. However, it is important to note that these resources are not a substitute for professional medical advice. If teachers have persistent voice complaints, it is advisable to consult an ear, nose, and throat (ENT) doctor or a speech-language pathologist (SLP) for further evaluation and treatment.

Part VI. Policy on Occupational Voice in School Settings.

While voice complaints represent significant health concerns among teachers, several countries, including the United States of America, lack clear or coordinated policies guiding school administrators and teachers on preventive strategies and actions to take when teachers voice health issues. Nevertheless, there are several countries with established policies in this regard that could be used as models for use or to gain valuable insights and potential frameworks for implementation. Below are several examples of how such policy has been designed and implemented in various regions of the world.

The Australian state of Victoria has a comprehensive teacher-vocal health policy implemented under the Occupational Health and Safety (OHS) Act 2004 (Stensholt, 2007). The policy outlines the requirements for schools to identify, assess, and implement controls to manage the vocal health risks faced by teachers. This proactive approach aims to prevent voice problems and promote long-term vocal health among teachers, ensuring their ability to sustain quality education delivery. The policy emphasizes the shared responsibility of school administrators and employees to maintain a safe and healthy work environment. Principals, in consultation with Health and Safety Representatives (HSRs) and teachers, are responsible for identifying potential hazards that could impact teachers’ vocal health. This risk assessment process involves evaluating the likelihood and potential consequences of vocal injury or harm associated with various teaching activities. Once risks are identified, the policy requires response plans toward appropriate risk control. Examples of such plans include providing voice training and education to teachers to promote healthy vocal practices, modifying classroom acoustics and sound amplification systems to reduce vocal strain, implementing ergonomic teaching techniques to minimize physical stress on the voice, and establishing rest periods and breaks throughout the workday to allow short-term vocal recovery.

South America also has some general policies in place for voice disorders in school settings, which may vary from country to country. A vanguard of such initiatives, Brazil enacted a decree in 1997 to institute a national program for the prevention and treatment of occupational vocal disorders, which includes elements such as education and training, early diagnosis, and treatment, and then passed a resolution in 2010 formally recognizing occupational vocal disorders in a list of occupational diseases. In 2018, the Brazilian Ministry of Health introduced the Work-Related Voice Disorder (WRVD) protocol, establishing specific criteria for the evaluation and diagnosis of these disorders; notably, in 2020, WRVD was included in the List of Work-Related Diseases (Mello et al., 2021).

Chile has also policies towards occupational vocal health based on 1968 legislation, dysphonia was included in the list of occupational diseases (Law 16.744). Using that as a foundation, a substantial stride occurred in 2013 when Chile enacted legislation establishing a comprehensive national program for the prevention and treatment of occupational vocal disorders. This initiative encompassed key components such as education and training, early diagnosis, and treatment and mandated that employers provide employees with access to vocal health services. In 2018, the Superintendent of Social Security (SUSESO) further refined guidelines through Circular 3331, aiming for more consistent criteria in diagnosing and treating WRVD. While a significant step, some limitations persist, including the restrictive definition which encompasses only laryngitis with voice problems and/or laryngeal nodules, as well as the discretionary application of the law by each insurance company resulting in variances in the treatment of WRVD (Mello et al., 2021).

Colombia’s progress toward occupational vocal health is based on Decree 614 of 1984, Resolution 1016 of 1989, and Resolution 2346 of 2007. Notably, Resolution 2346 of 2007 brings crucial updates to regulations governing occupational examinations. It decrees that medical evaluations must be tailored to the specific risk factors a worker will face. For occupational voice users, these evaluations are required to include, at a minimum, perceptual and acoustic examinations of voice production, combined with the worker’s self-report. However, in practice, routine occupational examinations for occupational voice users may not consistently include a comprehensive assessment of vocal function. In 2014, Decree 1477 of 2014 included voice disorders in the Colombian List of Occupational Diseases. This recognition stresses that working conditions can indeed contribute to the development of these disorders (Mello et al., 2021).

Part VI. Discussion

Teachers, as occupational voice users, face unique challenges due to the substantial vocal demands placed on them during their work. The episodic nature of these complaints is evident, with some studies reporting an annual incidence of up to 44%. Additionally, while in training, prospective teachers can already begin to experience voice problems, underscoring the importance of addressing these issues early in their careers. These findings emphasize the critical need for interventions and strategies to promote the vocal health of teachers.

The consequences of voice disorders among teachers are significant and multifaceted. Beyond the physical discomfort and potential long-term damage, voice problems affect teachers’ quality of life, leading to reduced daily participation and lower overall well-being (Cantor Cutiva & Burdorf, 2014). This can manifest as increased anxiety about employment opportunities, social withdrawal, frustration, and even career change. The correlation between voice problems and participation restrictions, communication difficulties, and feelings of job pressure further compounds these issues. Ultimately, the reduced quality of life not only impacts teachers personally but also their families, friends, and the broader community, highlighting the far-reaching consequences of voice disorders in the teaching profession.

The significance of occupational vocal health policies and prevention initiatives is not exaggerated, given their substantial impact on workers’ health, well-being, and workplace productivity. Occupational voice disorders not only affect individual workers but also incur additional costs for employers. Therefore, implementing well-crafted policies and prevention programs is instrumental in mitigating the risk of these disorders and enhancing overall worker health. Moreover, such measures can lead to cost reductions for employers. To support occupational vocal health policy and prevention, several strategic steps can be taken, including:

1. Raising awareness of the issue: It is crucial to ensure that policymakers, employers, and workers are aware of the challenges presented by occupational vocal disorders and recognize the imperative of addressing them.

2. Developing comprehensive policies and prevention programs: There is a need for a collaborative effort between governments and employers to formulate thorough policies and prevention programs that encompass aspects such as education, training, early diagnosis, and treatment for occupational vocal health.

3. Enforcing existing regulations: Governments must actively enforce regulations designed to safeguard workers from exposure to noise and other hazards contributing to voice disorders, thereby ensuring a safer work environment.

4. Conducting research: To enhance our understanding of the causes and prevention of occupational vocal disorders, increased research efforts are essential. This research serves as a foundation for the development of more effective policies and prevention programs.

Conclusion

Recognizing the occupational voice use of teachers, the prevalence of voice disorders, and their associated repercussions emphasizes the urgency of addressing this often-underestimated work-related health problem and its impact on both the individual as well as society as a whole. Interventions should extend beyond medical treatment to encompass workplace actions, education, and training on vocal health and effective voice use. Comprehensive programs could equip teachers with the knowledge and skills needed to prevent voice problems and minimize their impact. These initiatives would not only benefit teachers’ health but also enhance their effectiveness in the classroom, improving communication and the learning environment.