More and more people use their voice at work whether in a call centre or a
classroom. This presents a challenge the
OH team which needs to help workers develop strategies to look after their
vocal health. By Carey Gardner
In modern societies about one third of the labour force works in professions
in which the voice is the primary tool. And this number is in- creasing with
the development of new employment arenas such as telephone banking and call
Recent research has suggested that teachers, trainers and instructors
comprise a large proportion of the population who seek help and therapy for
voice disorders. Although voice problems are common, they are most common in
professions where there is a heavy vocal loading, for example, prolonged voice
use, long speaking distances and in the presence of background noise1.
Smith et al2 found that schoolteachers report voice problems at a rate of
nearly three times that of a randomly selected group of individuals who worked
in a variety of other occupations2.
The voice is the primary instrument of communication for humans both
socially and in the workplace. Although rarely life-threatening, voice problems
can have a tremendous impact on daily life3.
According to Perkins, because the human voice is a powerful indicator of an
individual’s physical and emotional health, personality, identity and aesthetic
orientation as well as an acoustic signal for speech, singing, drama and
emotional expression, voice disorders may exert a profound effect on affected
Voice disorders can result from many causes including disease processes, congenital
abnormalities, faulty use of the vocal mechanism, and psychogenic causes. The
majority of voice disorders are due to the latter two factors, that is
functional rather than organic causes5.
Koufman6 suggests that the voice in actuality is the entire person, since
any abnormality of the psyche or soma can give rise to an abnormality of the
voice. Therefore, the voice is a measure of a person’s overall sense of
well-being. He also claims that traditional medicine has created a dichotomous
model of disease – organic versus functional – but many voice disorders can be
both organic and functional simultaneously. However, this dichotomy has little
relevance to understanding the management of voice disorders.
The causes of voice change
Voice changes appear to be associated with vocalisations that occur over
long periods of time, at a high volume, at an unusual pitch, with excessive or
inappropriate tension, in the presence of unhealthy vocal fold tissue or due to
a combination of these factors7.
Over the past 10 years there have been several studies that have sought to
identify the nature, frequency and risk factors that contribute to voice
symptoms experienced by teachers. However, research is important in identifying
risk factors for any profession where there is a heavy vocal loading and
environmental risk factors.
A survey by Sapir et al8, which was designed to assess the prevalence and
impact of voice loss, suggested that it was prevalent among teachers. More than
half of teachers suffered more than three voice symptoms, and these symptoms
adversely affected their ability to teach effectively. Teachers also felt that
their voice was a chronic source of frustration or stress to them8.
In research by Smith et al2 teachers complained that teaching had an adverse
impact on their voices, and 39 per cent had cut down on their teaching
activities as a result.
Further research on teachers in comparison to individuals working in other
occupations, suggested that teachers are at a high risk for disability from
voice disorders and that this health problem may have significant work-related
and economic effects: 20 per cent of teachers but only 4 per cent of
non-teachers had missed work due to voice problems2.
A group of aerobics instructors were studied by Long et al9. Results showed
that a significant number of instructors experienced partial or complete voice
loss during and after instruction, as well as increased episodes of hoarseness
and sore throats unrelated to illness.
Several studies indicate teaching produces a high risk of voice symptoms,
and that the problem is related to vocally abusive behaviours associated with
the occupation. This health problem may have significant work-related and
economic effects on the affected individual.
The working environment
Individuals who use their speaking voice as the main instrument of their
profession are often required to speak for prolonged periods where optimal
voice quality and projection is demanded, in environments which are not
conducive, and where they are required to place exceptional and continual
demands on their voices in stressful circumstances.
Background noise can be significant in the development of vocal symptoms.
Individuals will increase the volume of their voice in noisy situations in
order to be heard. Therefore, vocal intensity and the consequential strain
increase proportionately in order to communicate effectively in noisy
Humidity and temperature
A hot dry environment can be detrimental to the voice and humidification may
be required, especially during the winter. Dehydration should be avoided since
this can affect the vocal process and it is important to have access to
drinking water to lubricate the vocal system.
Pace of work and job content
Prolonged periods of using the voice can contribute to vocal fatigue. Not
all vocal demands are of equal importance. Therefore a schedule of work that
leaves room for voice rest and recovery should be developed.
If workers are suffering vocal problems and throat symptoms due to the
nature of their work this has important implications from an occupational
health point of view since employers have responsibilities under legislation
such as the Health and Safety at Work Act 1974 and the Management of Health and
Safety at Work Regulations 1992. This legislation requires employers to carry
out systematic health and safety inspections of their premises and practices
and to identify any risks or hazards to their workers arising from those
premises or practices. Employers are then required to take action to eliminate
the risks and hazards to health identified, or reduce them as far as is reasonably
Remedial action could apply to environmental considerations such as room
acoustics, speaking duration, distance, humidity and noise levels.
Combined with remedial environmental changes, where required, and a
reduction in risk factors associated with vocal abuse and overuse, the
development of health education programmes focusing on the voice may help to prevent
the development of voice symptoms.
Education would increase awareness of the factors that affect voice health,
and encourage workers to become more attentive to the risk factors that lead to
vocal fatigue and discomfort.
Chan has detailed a programme of vocal hygiene education. This programme
– Education on the anatomy and physiology of the vocal system
– Explanation of vocal abuses, talking loudly, forced whispering, for
– Lifestyle behaviours that can affect voice health – smoking, caffeine, and
alcohol, for instance
– Education on healthy vocal use including strategies to maintain order, by
non-vocal signals such as clapping, which aims to conserve the voice
– Moving closer to the target audience to alleviate the need for strenuous
The impact of a voice disorder on an individual is considered immeasurable,
and the resulting symptoms such as vocal fatigue, hoarseness, voice loss and
discomfort of the throat, can affect a worker’s ability to function and
therefore may have significant work-related and economic effects.
Voice dysfunction can lead to increased sickness absence, reduced effectiveness
and may in severe circum- stances, lead to the individual leaving employment.
Clear evidence is emerging from a number of recent studies for development
of strategies and educational programmes for the maintenance of voice health.
The voice is the primary instrument of one-third of the labour force and as
such every effort should be made to protect it.
1. Vilkman E (2000) Voice problems at work: a challenge for occupational
safety and health arrangement. Folia Phoniatr Logop 52(1-3):120.
2. Smith E, Lemke J, Taylor M, Kirchner HL, Hoffman H (1998) Frequency of
voice problems among teachers and other occupations. Journal Voice, 2(4):480-8.
3. Garrett.CG, Ossoff RH (1999) Hoarseness. Medical Clinics of North
America, 83 (1):115-123.
4. Perkins WH (1971) Vocal function: a behavioural analysis. In:Travis LE,
ed. Handbook of speech, pathology and audiology. New York: Appleton-Century
5. Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone M (1988)
Description of laryngeal pathologies by age, sex and occupation in a treatment
seeking sample. .Journal of Speech & Hearing Disorders, 53:57-64.
6.Koufman, James A. Medicine in the vocal arts. Center for Voice Disorders
of Wake Forest University. http://www.bgsm.edu/voice/medicine_vocal_arts.html
7. Gotaas C, Starr CD (1993) Vocal fatigue among teachers. Folia Phoniatr
8. Sapir S, Keidar A, Mathers-Schmidt B (1993) Vocal attrition in teachers: survey
findings.European Journal of Disorders of Communication, 28 (2): 177.
9. Long J, Williford HN, Olson MS, Wolfe. (1998) Voice problems and risk
factors among aerobics instructors. Journal Voice, 12(2):197-207.
10. Rontal E, Rontal M, Jacob HJ, Rolnick MI (1979) Vocal cord dysfunction –
an industrial health hazard. Ann Otol Rhinol Laryngol,88(pt 1):818-21.
11. Chan RW (1994) Does the voice improve with vocal hygiene education? A
study of some instrumental voice measures in a group of kindergarten teachers.
Journal Voice, 8(3):279-91.
Carey Gardner RGN, BA(hons), BSc OHN (Bristol) Specialist Nurse
Practitioner is a health adviser for Bupa Wellness (Cardiff)
The manifestation of voice disorders
Vocal fatigue a problem that begins to occur as the speaking day
progresses and which worsens during the day
Laryngeal fatigue affects the physical sensations and effort and
perceptual quality of voice production
Hoarseness a term used to describe a change in a person’s normal
voice quality or change in normal pitch, vocal abuse is one of the most common
causes of hoarseness and can lead to other vocal pathologies such as vocal
Aphonia loss of voice
Odynophonia pain and soreness in the throat with prolonged vocal use
Voice break or voce "crack"
A loss of pitch range