Abstract
Introduction
Voice problems are common among school-age children. This study evaluates the effectiveness of a voice education program named “Green Voice Scientist” for school-age children.
Methods
Forty primary school students participated in a voice education program to learn about voice care and vocal hygiene concepts. The concepts were presented through the lens of science, technology, engineering and mathematics.
Results
Results suggested that the voice education program was effective in enhancing students’ voice care knowledge and in increasing their interest toward science and technology.
Conclusion
The study provided empirical data to support implementation of “Green Voice Scientist” educational program in school settings.
Keywords: Vocal hygiene; Voice care education; Science, technology, engineering, and mathematics education; Pediatric voice
Introduction
Voice problems are common among school-age children. Epidemiological studies on dysphonia in school-age children reported a wide range of prevalence from 1.4% to 19.3% [1–6], depending on the methodology employed, the criteria used for defining voice disorders, and the characteristics of examiners. Carding et al. [4] conducted a large-scale study to examine the prevalence of voice problems in 7,389 children aged 8 years old in the UK. They identified 6%–11.6% of the children had voice problems, as reported by the speech pathologists and parents, respectively. Another cross-sectional survey conducted in the USA with 1,154 caregivers of children aged between 4 and 12 years old reported 6.7% of children having a current voice problem, with a lifetime prevalence of 12% [7]. Voice problems in children can lead to significant poor voice quality [8–10]. Voices of children with dysphonia are perceived significantly less favorable by listeners in terms of their personality, social characteristics, and physical appearance [11, 12] and are less accepted by their peers [13]. The negative impacts on their quality of life experienced are significant and should not be under-estimated [8, 14–16].
The majority of voice problems in school-age children are caused by phonotrauma [17, 18]. Examples of common phonotraumatic behaviors in children include prolonged loud speaking, crying, excessive throat-clearing and poor vocal techniques. These behaviors exert excessive and repetitive mechanical collision forces on the vocal folds during phonation, leading to the formation of vocal fold lesions such as nodules. Some phonotraumatic factors are more relevant to students in schools. For example, an overloaded curriculum can lead to vocal loading and lack of opportunity for vocal rest, interrupting tissue repair. School-age children are more exposed to background noise in classroom than secondary school children. Younger students in primary schools are not yet skillful in reading and writing and they tend to communicate more vocally. Speaking over background noise in the classroom can also lead to vocal fatigue.
Voice education is a commonly used preventive approach to voice problems in school-age children [19]. Voice education highlights the importance of maintaining good vocal hygiene and promoting vocal well-being. The child will be equipped with what and how to protect his/her voice [20, 21]. In an early study by Cook et al. [22], they developed a six-session vocal hygiene program for school-age children. Thirty-eight grade 3 to grade 6 students exhibiting hoarse voices joined and completed the program. Significant improvements were found in students’ understanding of vocal hygiene concepts, voice terminologies, and discrimination of pitch and voice quality after participation. Nilson and Schneiderman [23] carried out a classroom program to promote healthy voice use and self-monitoring skills in 155 grade 2 to grade 3 students in a primary school. Enhanced vocal hygiene knowledge was maintained in the majority of students (99 students, 64%) 5 months after the completion of the program. Ma and Leung [24] investigated how a school-based vocal hygiene education program can enhance the awareness of healthy voice usage among school-age students. In their study, 39 students from grade 4 and 5 enrolled in a 6-week voice education program called “Green Voice for School.” Students’ knowledge of vocal hygiene increased significantly after attending the program, and a desirable level was maintained 1 year after the completion of the program.
In the recent decade, there has been a growing recognition of the importance of cross-disciplinary approaches to health education, with science, technology, engineering, and mathematics (aka, STEM) education a popular topic of discussion. Educators refer STEM education as a “meta-discipline” [25, 26]. Instead of viewing the four disciplines of science, technology, engineering, and mathematics as discrete disciplines, STEM education integrates them as one large discipline. STEM education approach has shown to be effective in delivering health-related knowledge to children with chronic medical illness. Hardy et al. [27] developed a STEM-based educational program for children with sickle cell disease, with the aim to enrich their health-related knowledge relevant to their medical illness. Hands-on activities were used to connect knowledge around sickle cell disease with concepts around science, technology, engineering, and mathematics. For example, in the “Blood Jar” activity, children built a model of blood using plastic beads, thick corn syrup, and water. Through the activity, children learned about blood composition and also the importance of staying hydrated for better blood flow. One benefit of applying STEM education as a teaching approach is that the content is closely tied with real-life, and hence, STEM education promotes one’s understanding of the world around him/her [25]. STEM education equips students to learn through multiple perspectives and to think more broadly. It has shown to increase student engagement and motivation in learning [28, 29]. Moreover, acquiring health literacy in early years via the STEM approach can significantly influence students’ career preference toward fields related to STEM and health [30].
Voice education, covering vocal hygiene and voicing techniques, touches on concepts and theories around science, technology, engineering, and mathematics. Taking the common vocal hygiene recommendation of “avoid talking against background noise” as an example, why and how talking against background noise is harmful to our voice can be explained using STEM concepts: during phonation, vocal fold vibration induces collision force on the medial surfaces of the vocal folds (science, physics). We involuntary speak louder under noisy environments due to the Lombard effect (science, biology, physics). The louder the voice, the greater the collision force (physics, mathematics), and hence, the higher risk of inducing vocal fold lesions (mathematics). Repetitive and excessive collision force exerted on the vocal folds can lead to outgrowth of vocal fold lesions such as nodules, which appear as two lumps on either side of the vocal folds under endoscopy examination (technology). Another example of effective voice use recommendation, “speaking with open mouth”, can be explained by physics concept of resonance. Integrating STEM education into voice care education enables students understand the consequences of vocal misuse from a scientific perspective. By linking science concepts with their own vocal health, the learning process becomes more engaging. When adopting STEM education for children, one should exercise strategies that map the content to learners’ language and cognitive level. Interactive hand-on activities, demonstration, and age-appropriate terminologies should be used to facilitate younger children (e.g., preschool and school-age children) understanding the link between science and vocal health.
Given the close proximity between vocal hygiene, voice use concepts and STEM concepts, this study expands the scope of the school-based voice education program “Green Voice for Schools” [24] by incorporating science, technology, engineering, and mathematics concepts around voice and its disorders. A program “Green Voice Scientist” was developed. The present study aimed to address two research questions: First, is the “Green Voice Scientist” program effective in increasing students’ knowledge of voice care? Second, is the “Green Voice Scientist” program effective in motivating students’ interests toward STEM and health-related fields? It was hypothesized that the “Green Voice Scientist” program would be effective in increasing students’ knowledge of voice care, as shown by the higher accuracy of voice care knowledge questionnaire. It was also hypothesized that students would demonstrate an increase in the level of interests toward science, technology, engineering, and mathematics after completing the program.
Methods
Participants
A total of 40 students, consisting of 23 boys and 17 girls from grade 2 to grade 5, were recruited from four local primary schools in Hong Kong. Their ages ranged from 7 to 11 years. All participants were native Cantonese speakers. None of them had received any formal training in voice use and voice education prior to their participation in the study.
Procedures
Pretraining Questionnaire on Voice Care Knowledge
Students completed a questionnaire to assess their voice care knowledge before the training. The questionnaire consisted of 17 statements, with 6 of them described behaviors that can contribute to good vocal health (that is, positive factors). Examples of the positive factors are “drink more water”, “do more stretching exercise,” and “avoid chatting in noisy environments.” The remaining 11 statements described behaviors that can be harmful to vocal health (that is, negative factors). For example, “laugh/cry loudly”, “throat clearing,” and “breathe through the mouth.” Students had to categorize whether the statement refers to a positive or negative factor. An option of “not certain” was also provided for each statement in order to avoid random guessing. Students were encouraged to choose the “not certain” option for statements that they were in doubt of the correct answer.
The “Green Voice Scientist” Program
Participants took part in the voice education program “Green Voice Scientist” that consisted of six consecutive weekly sessions. Each session lasted for 1 h. The training sessions were conducted in the participants’ schools. The voice education training protocol was developed based on the “Green Voice for School” program reported in Ma and Leung [24]. Students learned about laryngeal anatomy and physiology, vocal pathologies, vocal hygiene, and effective voicing techniques of sighing and resonant voice. All sessions were facilitated by a speech-language pathologist. Components of science, technology, engineering, and mathematics were added to different parts of the protocol, wherever applicable. Games and experiments were used to introduce concepts around STEM. For example, to introduce the relationship between Bernoulli’s effect and vocal fold vibration, students were asked to observe how the two papers move when blowing air between two pieces of paper held in parallel. Moreover, a series of short videos, written in simple and children-friendly language, were developed to explain STEM concepts related to voice (see Fig. 1). Examples of videos include “how hydration protects our vocal folds” and “how yelling and screaming hurts our vocal folds.” The details of the session plan are listed in Table 1.
Fig. 1.
Examples of the short STEM-based educational videos with theme of “How is voice produced?” (a) and “Why hydration is good for our voice?” (b).
Table 1.
Details of the session plan
| Session | Content on voice and its disorders | Content on STEM components |
|---|---|---|
| 1 | Laryngeal anatomy and phonatory physiology (part one) | Bernoulli effect and vocal fold vibration |
| Relationships between vocal fold vibration frequency and pitch level | ||
| 2 | Revision of materials presented in previous session | Transmission of sound wave |
| Laryngeal anatomy and phonatory physiology (part two) | Resonance demonstrated by tuning forks | |
| | Mechanism of pitch and loudness control | |
| | Voice attenuation with facemasks | |
| 3 | Revision of materials presented in previous sessions | Hydration and protection of vocal folds |
| Common types of vocal pathologies and concepts on vocal hygiene | ||
| 4 | Revision of materials presented in previous sessions | |
| Impacts of voice problems on the individual | ||
| 5 | Relaxation exercises and its relevance to voice production | Mechanism of straw phonation |
| Diaphragmatic breathing and its relevance to voice production | Demonstration of resonance using tuning forks | |
| Vocal facilitative technique: sighing and resonant voice | Building a lung model | |
| 6 | Revisions of materials presented in previous sessions | |
| Conclusion |
Post-Training Questionnaires on Voice Care Knowledge and Satisfaction
At the end of the program, students completed the voice care knowledge questionnaire again to evaluate any change in their knowledge resulting from attending the training. They were asked to complete the questionnaire again 1 year after the completion of training to evaluate their knowledge maintenance. In addition, students and their parents completed a satisfactory questionnaire.
Data Analysis and Statistical Analysis
For the voice care knowledge questionnaire, a correct answer received a score of “1”, while an incorrect answer or a missing answer received a score of “0.” The voice care knowledge scores were converted to a scale of 100, with higher scores indicating better knowledge of voice care. Out of the 40 students who took part, one student had already left school by the post-training evaluation with another three students had left school by the maintenance, making them uncontactable for follow-up. The analysis excluded the incomplete dataset of these participants. Therefore, data and statistical analysis included information at the pre, post, and maintenance evaluations from the remaining 36 students.
The training program’s effectiveness was assessed using repeated measures analysis of variance. Students’ voice care knowledge accuracy served as the dependent variable. The independent variable consisted of three time points: pretraining, post-training, and 1-year maintenance. Mauchly’s test of sphericity was used to evaluate whether the assumption of compound symmetry was violated.
Results
Voice Care Knowledge before and after Training
Table 2 lists the distribution of responses (in percentage) for voice care questionnaire item at pretraining, immediate post-training, and 1-year post-training. The mean percentage of accuracy at pretraining was 71.2% (SD = 22.0; range = 33.3%–97.2%) and the mean percentage accuracy at post-training was 94.0% (SD = 7.6; range = 72.2%–100%). The mean percentage accuracy obtained at 1 year after completion of training was 83.2% (SD = 14.1; range = 58.3%–100%). Mauchly’s test of sphericity for the within-subject factor time point was not significant (Mauchly’s W = 0.92, df = 2, p = 0.26), indicating that the data did not violate the assumption of compound symmetry. The results of the analysis of variance revealed a significant difference in voice care knowledge between the three time points (F[1.86, 65.02] = 6.81, p = 0.003, partial η2 = 0.16). Post hoc tests with Bonferroni correction revealed a significant increase in voice care knowledge score immediately after training comparing to that before training (p = 0.001). The voice care knowledge scores obtained 1 year after training remained similar and were not significantly different from those obtained immediately after training (p = 0.052).
Table 2.
Distribution of responses (in percentage) for voice care questionnaire item for knowledge checking at pretraining and post-training
| Questionnaire item | Pretraining | Post-training | Maintenance | ||||||
|---|---|---|---|---|---|---|---|---|---|
| positive factor | negative factor | not certain | positive factor | negative factor | not certain | positive factor | negative factor | not certain | |
| Positive factors | |||||||||
| Sleep sufficiently | 80.6 | 2.8 | 16.7 | 97.2 a | 0.0 | 2.8 | 91.7 a | 0.0 | 8.3 |
| Drink more water | 94.4 | 2.8 | 2.8 | 100.0 a | 0.0 | 0.0 | 100.0 a,b | 0.0 | 0.0 |
| Maintain good posture | 50.0 | 5.6 | 44.4 | 88.9 a | 0.0 | 11.1 | 66.7 a | 0.0 | 33.3 |
| Do more stretching exercises | 69.4 | 0.0 | 30.6 | 100.0 a | 0.0 | 0.0 | 75.0 a | 2.8 | 22.2 |
| Maintain a good mood | 75.0 | 5.6 | 19.4 | 91.7 a | 0.0 | 8.3 | 83.3 a | 0.0 | 16.7 |
| Avoid chatting in noisy environments | 61.1 | 16.7 | 22.2 | 72.2 a | 25.0 | 2.8 | 58.3 | 30.6 | 11.1 |
| Overall accuracy (positive factors) | 71.8 | 5.6 | 22.7 | 91.7 a | 4.2 | 4.2 | 79.2 a | 5.6 | 15.3 |
| Negative factors | |||||||||
| Chronic coughing | 2.8 | 91.7 | 5.6 | 2.8 | 97.2 a | 0.0 | 2.8 | 97.2 a,b | 0.0 |
| Laugh/cry loudly | 2.8 | 88.9 | 8.3 | 0.0 | 100.0 a | 0.0 | 2.8 | 94.4 a | 2.8 |
| Consumption of Coca Cola, coffee, or tea | 5.6 | 63.9 | 30.6 | 2.8 | 97.2 a | 2.8 | 2.8 | 88.9 a | 8.3 |
| Speak with a fast rate | 0.0 | 83.3 | 16.7 | 0.0 | 97.2 a | 2.8 | 2.8 | 83.3 a | 13.9 |
| Chat in polluted environment | 13.9 | 63.9 | 22.2 | 5.6 | 94.4 a | 0.0 | 2.8 | 91.7 a | 5.6 |
| Throat clearing | 55.6 | 33.3 | 11.1 | 8.3 | 91.7 a | 0.0 | 30.6 | 61.1 a | 8.3 |
| Mimic sounds of car engine/monster | 2.8 | 91.7 | 5.6 | 2.8 | 97.2 a | 0.0 | 2.8 | 94.4 a | 2.8 |
| Screaming | 0.0 | 97.2 | 2.8 | 0.0 | 100.0 a | 0.0 | 2.8 | 94.4 | 2.8 |
| Smoking | 0.0 | 94.4 | 5.6 | 0.0 | 100.0 a | 0.0 | 2.8 | 97.2 a | 0.0 |
| Whispering | 36.1 | 36.1 | 27.8 | 11.1 | 80.6 a | 8.3 | 13.9 | 63.9 a | 22.2 |
| Breathe through the mouth | 22.2 | 36.1 | 41.7 | 2.8 | 91.7 a | 5.6 | 11.1 | 72.2 a | 16.7 |
| Overall accuracy (negative factors) | 13.9 | 68.9 | 17.2 | 3.3 | 95.0 a | 2.0 | 7.5 | 83.3 a | 8.3 |
Items are reorganized in this table and are presented according to positive and negative factors. Bold values indicate correct responses.
aScore either the same or higher than that obtained at pretraining.
bScore either the same or higher than that obtained in post-training.
A closer evaluation of individual student’s test performance across the three time points revealed that immediately post-training, 32 out of 36 students (88.9%) demonstrated an increase in voice care knowledge score, two students (5.6%) maintained the same score as pretraining, and two students (5.6%) showed a decrease in their voice care knowledge score. Comparing students’ performance 1 year after completion of the program to pretraining, 24 out of the 36 students (66.7%) demonstrated an increase in voice care knowledge score, seven students (19.4%) maintained the same score, and five students (13.9%) showed a decrease in the voice care knowledge score. For students who demonstrated an increase in knowledge score at post-training, 11 of them (30.6%) demonstrated either a further increase in score or maintained the same score at 1 year post-training.
Students’ and Parents’ Perception of the Program
Table 3 lists the perception of the Green Voice Scientist program by the students and parents. In general, students and parents commented positively about their learning experience. A total of 72.2% of the students who participated in the program strongly agreed with the statement “The program helps me understand skills of voice care” and 80.6% strongly agreed that they liked the program. Meanwhile, 95.8% of parents agreed with the statements “The program helps my child understand skills of voice care” and “The program helps my child understand voice care knowledge through STEM concepts”, and 100% of parents felt that the program has broadened their child’s horizons. From Table 4, 75% students reported that there are interested in STEM- or medical-related subjects; 78% students considered that they can use the vocal hygiene knowledge through the program in their daily life.
Table 3.
Distribution of responses (in percentage) for the satisfactory survey
| Questionnaire item | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| Completed by students | |||||
| 1. The program helps me understand skills of voice care | 72.2 | 25.0 | 2.8 | 0.0 | 0.0 |
| 2. The program helps me understand knowledge of voice care through the aspect of STEM | 55.6 | 30.6 | 13.9 | 0.0 | 0.0 |
| 3. The program makes me interested in voice care | 66.7 | 19.4 | 13.9 | 0.0 | 0.0 |
| 4. The program makes me interested in science, health care and related topics | 61.1 | 25.0 | 8.3 | 5.6 | 0.0 |
| 5. I can generalize the learned knowledge into daily life | 69.4 | 22.2 | 8.3 | 0.0 | 0.0 |
| 6. I enjoy the activities of the program | 72.2 | 27.8 | 0.0 | 0.0 | 0.0 |
| 7. The program widens my horizon | 52.8 | 47.2 | 0.0 | 0.0 | 0.0 |
| 8. Overall, I like the program | 80.6 | 11.1 | 8.3 | 0.0 | 0.0 |
| Completed by parents | |||||
| 1. The program helps my child understand skills of voice care | 45.8 | 50.0 | 4.2 | 0.0 | 0.0 |
| 2. The program helps my child understand voice care knowledge through STEM concepts | 45.8 | 50.0 | 4.2 | 0.0 | 0.0 |
| 3. The program makes my child interested in voice care | 45.8 | 50.0 | 4.2 | 0.0 | 0.0 |
| 4. The program makes my child interested in science, health care and related topics | 45.8 | 41.7 | 8.3 | 4.2 | 0.0 |
| 5. My child can generalize the learned knowledge into daily life | 45.8 | 41.7 | 8.3 | 4.2 | 0.0 |
| 6. My child enjoys the activities of the program | 62.5 | 33.3 | 4.2 | 0.0 | 0.0 |
| 7. The program widens my child’s horizon | 54.2 | 45.8 | 0.0 | 0.0 | 0.0 |
| 8. Overall, my child like the program | 58.3 | 41.7 | 0.0 | 0.0 | 0.0 |
Percentages = >50.0% are highlighted in bold typeface.
Table 4.
Distribution of responses in percentage for each questionnaire item for evaluation during maintenance stage
| Questionnaire item | Strongly agree, n (%) | Agree, n (%) | Neither agree nor disagree, n (%) | Disagree, n (%) | Strongly disagree, n (%) |
|---|---|---|---|---|---|
| After joining the program… | |||||
| 1. I am interested in STEM- or medical-related subjects | 12 (33) | 15 (42) | 6 (17) | 1 (3) | 2 (6) |
| 2. I am participating in STEM activities | 10 (28) | 7 (19) | 11 (31) | 5 (14) | 3 (8) |
| 3. I can use the voice care knowledge learned from the program in daily life | 20 (56) | 8 (22) | 5 (14) | 1 (3) | 2 (6) |
Discussion
The purpose of this study was to investigate whether the voice education program “Green Voice Scientist” is effective in enhancing school-age students’ voice care knowledge and arousing their interest toward scientific studies. Results obtained from immediate post-training test and 1-year follow-up suggest that students benefited from the program. Students generally lacked sufficient knowledge about vocal hygiene. Before undergoing training, less than half of the students were able to correctly identify factors of “throat clearing” (33.3% accuracy), “whispering” (36.1% accuracy), and “breathing through the mouth” (36.1% accuracy) that can potentially harm the voice. After training, the accuracy of the factors above increased to 91.7%, 80.6%, and 91.7%, respectively. The significant increase in scores after training indicated substantial improvements in all of these aspects.
However, students’ performance in 1-year maintenance evaluation was not as good as that obtained in the study by Ma and Leung [24]. In that study, the accuracy level in almost half of the items (8 out of 17) obtained in the 1-year follow-up was the same or higher than that obtained at the immediate post-training evaluation. However, in the present study, despite all the 17 items in the voice care questionnaire showed improvements immediately after training completed, maintenance of knowledge level was seen in only two items of “drink more water” and “chronic coughing” 1-year post-training. Regression was noted in the other 15 items. The “Green Voice Scientist” program was conducted during the COVID-19 pandemic times. Over that 1-year maintenance period, the participating schools experienced multiple waves of school suspension, mandated by the Hong Kong Government, as a preventative measure against waves of the COVID-19 pandemic. Such recurring school suspensions might have interrupted and affected students’ voice care knowledge retention.
To highlight is that in the voice care knowledge questionnaire, the option of “not certain” was provided in order to avoid students from random guessing for items that they did not know the answer. Students choosing the option “not certain” decreased for all factors in the subsequent post-training and maintenance phases.
This study has several limitations that should be acknowledged. First, the small number of subjects (N = 36) is too small to make robust statistical analysis. As such, the results reported in this study should only be considered as a pilot study. Future study with more samples, preferably with a no-training control group included for comparison, is warranted. Second, apart from using quantitative survey to obtain participants’ perception and satisfaction of the learning experience, qualitative interviews with thematic analysis can be conducted to provide larger themes that can be tied to the STEM concepts. Third, previous research suggested that learning about voice care and vocal hygiene can influence how individuals take care of their voices [19]. In their study, the preschool children showed decrease in the undesirable voice use behaviors of yelling after attending the vocal hygiene training. Subsequent research should evaluate whether the gain in vocal hygiene knowledge in the Green Voice Scientists affect their voice use behaviors. Further studies should also assess the improvement in students’ understanding around voice disorders and STEM concepts.
Conclusions
The findings of this study showed that a voice education program for school-age children with STEM concepts had immediate treatment effect and was effective 1 year after the training completes. The results support the implementation of this program in primary schools to promote the awareness of voice care and knowledge of vocal hygiene.
Acknowledgments
The authors gratefully acknowledge the support from the Strategic Research Partnership on Translational Research in Voice and Speech Sciences between Sik Sik Yuen and Faculty of Education, The University of Hong Kong, for supporting participant recruitment.
Statement of Ethics
This study was performed in accordance with the Declaration of Helsinki. This human study was approved by Human Research Ethics Committee at The University of Hong Kong – approval: EA200283. All parents, guardians, or next of kin provided written informed consent for the minors to participate in this study. All adult participants provided written informed consent to participate in this study. Written informed consent has been obtained for the publication of photos and any accompanying images shown in Figure 1.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This study was supported by University Grants Council Knowledge Exchange Impact Fund (KE-IP-2020/21-33) in Hong Kong.
Author Contributions
Estella P.-M. Ma: conceptualization, data curation, funding acquisition, methodology, supervision, and writing – review and editing; Irene Y.-L. Li: data curation, formal analysis, and writing – original draft; Crystal W.-N. Yuen: methodology, project administration, and formal analysis; William M.-Y. Cheung: conceptualization, funding acquisition, methodology, and writing – review and editing.
Funding Statement
This study was supported by University Grants Council Knowledge Exchange Impact Fund (KE-IP-2020/21-33) in Hong Kong.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquires can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquires can be directed to the corresponding author.
