Voice Related Coping in Professional Voice Users-A Systematic Review

Summary: Objectives. This systematic review explored coping with voice problems in professional voice users. The objectives were to: 1) evaluate how voice-related coping is assessed in professional voice users 2) investigate how they cope with voice problems, and 3) identify factors associated with voice-related coping. Design. Systematic review. Methods. A systematic literature search of ten electronic databases using both EBSCOhost and OVID online platforms was conducted following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Only peer-reviewed articles which assessed coping in the context of voice problems in professional voice users were included. Methodological quality was assessed using Johanna-Briggs Institute Critical Appraisal checklists. Data analysis was conducted using narrative synthesis. Results. Following deduplication, abstract and full-text screening, seven articles were included in the review. All participants (n=2484) were teachers; no other professional voice users were covered. 98% of the cases studied were females. The tools used to assess voice-related coping were Utrecht Coping List (UCL) and Voice Disability Coping Questionnaire (VDCQ). Studies which used UCL reported a passive coping pattern in teachers with high vocal handicap whereas VDCQ showed increased use of social support. Factors associated with coping were not examined by any of the studies. Conclusion. Seeking social support was highlighted as a frequently used coping strategy across studies and measures. Teachers with high vocal handicap used a passive coping pattern and active coping styles were not signi ﬁ cantly used. Current evidence does not suf ﬁ ciently specify factors affecting coping in professional voice users. More research on voice-related coping involving all professional voice users is warranted to identify associated factors and further ascertain its in ﬂ uence on vocal health. distribution, demographic characteristics, work experience of participants, response rate, objectives (of the study), inclusion/exclusion criteria, measures used to assess coping, coping related factors in ﬂ coping key


INTRODUCTION AND OBJECTIVES
Professional voice users are individuals whose ability to earn a living is impacted negatively by loss of vocal quality and endurance. 1 This includes singers, teachers, actors, lawyers etc. The reported lifetime prevalence of voice problems is estimated to be between 50%-80% in teachers 2,3 in contrast to 29.9% 4 in the general population. Other professional voice groups such as singers 5 and telemarketers 6 have also shown higher prevalence rates (46.09% and 68% respectively) which makes professional voice users a vocally vulnerable group.
Given higher prevalence rates and increased impact of voice problems, it becomes essential to explore how professional voice users manage these voice problems. This is often referred to as coping, which is defined as an adaptational response to a situation or 'stressor' using cognitive or behavioral processes to manage the stress of illness. 7 Many classifications of coping have been proposed, of which problem-focused vs emotion-focused 7 and active vs passive coping 8 are most common. Research indicates that problem-focused and active coping can be positively linked to increased well-being whereas emotion-focused and passive coping is associated with negative health outcomes. 9 However, such classifications only provide a general description of how an individual copes with an illness and do not take into account the context or the variability across the trajectory of an illness. Recent scales such as the Voice Disability Coping Questionnaire (VDCQ) 10 provide a multi-dimensional and context-specific description of coping using subscales.
Studies on coping in the context of voice problems are scarce; however, type of voice disorder and severity have been reported to influence how individuals cope with voice problems. Epstein et al (2009) studied coping in two clinical groups namely Muscle Tension dysphonia (MTD) and Adductor Spasmodic Dysphonia (ASD) and reported that avoidance and passive coping were used by the latter group significantly more than the former. This demonstrates the relevance of coping in differentiating between clinical groups and targeting adaptive coping during intervention. De Freitas Valadares, Occhi-Alexandre and Teixeira (2020) 11 also reported that reliance on emotional coping strategies increased with increased severity of dysphonia.
Coping forms an important mediating link between the way individuals view their illness and how health outcomes are appraised 12 (Figure 1). Therefore, coping is directly related to the physical and functional outcomes of a voice problem. 13 Consequently, coping can be associated with onset and development of a voice problem, 14 particularly in professional voice users who require a high level of vocal skills such as teachers and singers.
The objective of this paper was to identify and analyze the available research evidence pertaining to voice-related coping in professional voice users. The review will summarize relevant data and provide implications for vocal health and identify gaps that need to be addressed in future research. More specifically, the review aimed to address the following questions: 1. How is voice-related coping assessed in professional voice users? 2. How do professional voice users cope with voice problems? 3. What factors are associated with different coping strategies addressing voice problems in professional voice users?

METHODS
The methods and reporting of this review complied with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. 15 PROSPERO and Cochrane databases were searched to establish the absence of a current or recent review in the area.

Eligibility criteria
To be eligible studies had to address coping in the context of voice problems in professional voice users. All study designs were eligible. To be included, studies had to measure coping in a valid and reliable manner, using standardized measurement procedures; i.e. voice and coping outcomes had to be measured with psychometrically sound measures (for studies presenting quantitative data), or established ways of analyzing data (for qualitative studies). Studies that measured multiple outcomes, of which coping was one, were included if coping measures were discussed separately.
Studies were excluded if they explored coping related to performance anxiety, or any other 'non-vocal' parameter; as were reviews, editorials or unpublished theses/dissertations or articles published in non-peer reviewed journals or magazines.

Information sources
A systematic search using 10 electronic databases (Medline Complete, Academic Search Complete, CINAHL, EMBASE, Music Periodicals, Communication Source, Psy-cINFO, SCOPUS, Web of Science and NICE) was carried out in February 2020 and regular search alerts were set up to ensure no recent publications were excluded from the review. Searches were last re-run in March/April 2022. Grey literature was also searched using OpenGrey and BASE databases. Citation and reference tracking were carried out for all the studies which were included at the end of the selection process to check for articles which may not have been picked up during database searching.

Search strategy
A subject librarian was consulted to develop the search strategy. Each database was searched separately using a customized search strategy which included keywords and subject terms using EBSCO Host and Ovid platforms. The basic search strategy is provided in Appendix 1.

Selection process
The studies retrieved were first imported into Rayyan 16 for duplicate removal and study selection; following which, the selected articles were transferred into EPPI-Reviewer, 17 for data extraction and data synthesis. The entire screening process was carried out by AR. The title and abstract of the articles were screened against the eligibility criteria to identify studies to include in the review and reasons for exclusion were clearly documented. The full text of all the articles which fulfilled the eligibility criteria was retrieved and reviewed. 25% of articles were screened at both title and abstract and full text level by a second reviewer (ND) who worked independently and was blinded to decisions made by the first reviewer. Disagreements on study selection were discussed by the reviewers for resolution. For papers where a consensus could not be reached between the reviewers, a senior member of the research team (SPH) was consulted for a final decision.

Data collection process
Data was extracted by AR following which 25% of studies were independently double screened to check for consistency of extracted data (ND). A data extraction table was created to collect information pertaining to study and participant characteristics, assessment methods, coping related outcomes and factors influencing coping. Disagreements in decisions surrounding extracted data were discussed by the reviewers for resolution. When a consensus could not be reached, a senior member of the research team (SPH) was consulted for advice regarding reconciliation. distribution, demographic characteristics, work experience of participants, response rate, objectives (of the study), inclusion/exclusion criteria, measures used to assess coping, coping related outcomes, factors influencing coping and key conclusions. Authors were contacted (n=3) if more information was required to aid in data synthesis. After the initial email, one more reminder was sent to the authors.

Risk of bias assessment
The Joanna-Briggs Institute (JBI) Critical Appraisal checklists were used for assessing methodological quality and risk of bias. Since not all the selected studies had the same design, different JBI critical appraisal tools suitable for specific study designs were adopted. The JBI does not provide clear guidelines on including or excluding articles based on quality; therefore, a review specific scoring system was developed to aid in quantifying the decision-making process. The responses outlined in JBI were assigned values as follows:-All responses marked yes were given a value of 2, responses marked no were given a value of 0 and those marked unclear were assigned a value of 1. For each study, the total percentage score was calculated, and this value was compared across studies. A cut-off paradigm was then developed by the authors and the scores were interpreted as follows: Scores > 80%= Good methodological quality Scores between 60-80%= Fair methodological quality Scores < 60%= Poor methodological quality If any studies were of poor methodological quality, they were not included in the synthesis of the results.
A second reviewer (ND) carried out an independent quality appraisal assessment, the results of which were discussed with the first reviewer (AR). Any discrepancies that arose were discussed by the reviewers. When a consensus could not be reached, a senior member of the research team was consulted for advice regarding reconciliation (SPH).

Data synthesis
Heterogeneity assessment was done using the I 2 measure to ascertain if a meta-analysis could be performed with a fixed or random measure and calculate a pooled estimate. As a meta-analysis could not be performed, a narrative synthesis was performed. The first step was familiarizing with the included studies. This was done by systematically and comprehensively reading each study and highlighting important characteristics. Each study was described in detail and all key features were summarized for each study. The studies were then tabulated to identify patterns across the included studies. Between and within study differences were explored and this data was used to highlight assessment methods, describe voice related coping in professional voice users, identify factors affecting coping and ascertain the relationship between voice problems and coping in the study population.

Study selection
The searches identified 2474 articles. Following deduplication, title and abstract screening, and full text screening, seven studies were included in the review. Figure 2 provides the PRISMA flow diagram and further details regarding the study selection process and reasons for study exclusions.
The percentages of agreement between the raters involved in double coding were 88.2% and 100% for title and abstract and full text screening respectively. All discrepancies were resolved by the reviewers following discussion.

Study characteristics
Study characteristics are detailed in Table 1. The publication dates of the studies ranged from 2003-2017 spanning a period of 15 years. Of the seven included studies, three took place in the Netherlands, 18−20 two in Brazil, 21,22 one in Sweden 23 and one in Belgium. 14 Five studies employed a cross sectional study design with a control group, while the other two used a case control 23 and a longitudinal 20 study design.

Participant characteristics
All studies included in the review involved teachers and/or student teachers; no studies involving other professional voice users were identified. The sample sizes ranged from 43 20 to 911. 18 The mean age of participants ranged from 18.6 years 20 to 48.7 years 23 and the age range, in the studies that reported it, was 16-62. Five studies recruited only women. 14,19−22 There was a total of 1322 female cases, 26 male cases (total n=1348) and 1136 control subjects. Since information regarding sex was not provided in the largest study 18 for the control group, the number of males and females in the control groups across the review could not be generated. The participants ranged from student teachers to primary and secondary school teachers.

Methodological quality
The cross-sectional studies (n=5), and the case-control study (n=1) were assessed using the JBI tool designed specifically for these study designs. Since a critical appraisal tool specifically designed for longitudinal studies could not be found, the JBI cohort design tool was used for assessing the quality of the longitudinal study (n=1). The initial agreement between the reviewers was 61%. The items with disagreements were discussed between the raters and consensus was reached (100% agreement) for all items. Only one study was rated as of good methodological quality 23 and the other studies (n=6) were of fair quality. Table 2 describes the results of the quality assessment with individual item scores.
Since the studies were of acceptable methodological quality, all seven studies were taken forward for data synthesis.

Assessment of coping
The Utrecht Coping List (UCL) 24 was used in four studies 14,19,20,23 all of which were undertaken in Europe.

Aparna Ramachandran, et al
Voice related coping in professional voice users UCL is a questionnaire which assesses the general coping style of individuals using 47 questions across seven subscales (Table 3). One study used only some sections of the UCL (22 out of 47 questions). The two Brazilian studies used the Voice Disability Coping Questionnaire (VDCQ). 10 VDCQ is has 15 items across four subscales which helps to generate a coping profile to evaluate how individuals cope with voice problems. However, they used an earlier version of VDCQ with 27 items, which was culturally adapted and translated to Brazilian Portuguese, where items are classified as 'problem focused' or 'emotion focused' strategies instead of the four subscales described in the original VDCQ. The various coping subscales measured by UCL and VDCQ and their definitions are provided in Table 3. One study 18 used a different approach where coping was conceptualized and assessed based on the principles of the psychological cascade model. 25 The psychological cascade model describes three phases from dysfunction to recoveryphase 1, where the patient considers the disorder a threat which is characterized by anxiety, fear and terror of loss, struggle against the loss, searching for help, exhaustion and isolation, and depression; phase 2 (called the pit), characterized by surrendering to the loss without giving up; phase 3 which is characterized by hope and renewal which may lead to recovery. The model also describes some maintaining factors and coping strategies (described in terms of externalization, dependence and awareness) which is believed to influence transition between the phases. According to the model, a patient proceeds from phase 1 to phase 2 if the maintaining factors are absent and coping strategies are adequate. Alternatively, if coping is inadequate and the maintaining factors are too strong, the patient may be in a deadlocked situation of phase 1 thereby promoting chronicity.
Coping strategies used by professional voice users to manage voice problems The findings have been organized based on the assessment tool since the constructs used to measure coping are different in the UCL (seven subscales) and VDCQ (problemfocused vs emotion-focused).
Of the four studies that used UCL to assess coping, two studies 14,19 reported the median values of the UCL subscales for teachers with low and high vocal handicap measured using the Voice Handicap Index. The combined median scores of the two groups (high and low vocal handicap) across both studies are presented in Figure 3.  A comparison of the UCL scores of the two teacher groups in the two studies with the normative scores of the UCL subscales 24 revealed the following patterns: Teachers with low vocal handicap tended to mirror the normative curve closely, barring the social support subscale, which was higher in both groups of teachers than the controls. Teachers with high vocal handicap used more passive coping than teachers with low vocal handicap and the controls, indicated by higher scores in the subscale 'passive reaction pattern'. Teachers with high vocal handicap used lesser active coping than teachers with low vocal handicap and the controls, indicated by lower scores in the subscale 'active confrontation or dealing with the problem'.
To summarize, teachers in general used social support more than the control groups (based on the published normative scores), while teachers with high vocal handicap employed more passive coping and less active coping.
A summary of coping patterns based on UCL subscale scores is presented in Table 4 for three studies where subscale scores were available. 14,19,20 In comparison to teachers with low vocal handicap, three studies reported higher scores on the 'passive reaction pattern' subscale, in teachers with higher vocal handicap. Results also showed that teachers with high vocal handicap were less likely to use "active confrontation or dealing with the problem" and "reassuring thoughts" strategies to cope with vocal handicap.
One study did not report the UCL subscale scores; however, they indicated that there was no significant difference in UCL scores between teachers with and without selfreported voice problems. 23 All further details pertaining to results are described in Table 5.
Ticks indicate strategies used more and crosses indicate strategies which are unlikely to be used in teachers with voice problems. Table 6 presents the synthesis of 10 most reported items by groups with voice disorders from the two studies 21,22 that used the VDCQ. Overall, results of 99 patients were analyzed. Five problem-focused and four-emotion focused strategies were reported across the two studies. Additionally, we attempted to classify these items based on the original four subscales of the VDCQ namely information seeking, seeking social support, passive coping and avoidance. This was done by cross referencing these items with the original published article of the standardization of the VDCQ. 10 The frequency of occurrence of each subscale is provided in Table 6. The results of the VDCQ suggested that seeking social support was the most commonly used mode of coping whereas avoidance was used the least.
De Jong (2003) 18 did not use a standardized coping assessment tool since the parameters considered for assessment in the study were directly linked to the psychological cascade model. 24 The results revealed that coping contributed to patients remaining in phase 1 of the psychological  Information seeking "Problem solving coping through seeking information about the condition" 2 Passive coping "Individuals who do not embrace or reject any proactive coping strategy" 4 Avoidance "Use of denial, withdrawal, and reorganization of routine activities in the face of dysphonia" 3 Social support "Range of interpersonal exchanges that provide the individual with information, emotional reassurance, material assistance and self-esteem"   Meulenbroek (2010a) @ @ @ @ Meulenbroek (2010b) @ X @ Van-Wijck Warnaar (2010) X @ @

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Aparna Ramachandran, et al Voice related coping in professional voice users differences in methodology, particularly the definition and measurement of coping, the outcomes of this study could not be synthesized with the other studies of this review and are presented separately.

Factors associated with coping in professional voice users
None of the studies aimed to investigate factors affecting coping; however, results from three studies 14,19,20 which used the Voice Handicap Index and the UCL suggested that perception of vocal handicap influenced coping styles, leading to significant differences in UCL subscale scores between groups with high and low vocal impairment. Details pertaining to these differences can be found in Table 5.
Meulenbroek et al (2010b) 20 reported that student teachers in training showed a more passive style of coping at the end of their training period suggesting that trainee experience could potentially influence coping.

DISCUSSION
The purpose of this review was to investigate how professional voice users cope with voice problems. It also aimed to evaluate how coping was assessed and identify factors associated with coping in professional voice users.
Coping with voice problems in professional voice users was explored in this review. Seven studies fulfilled the inclusion criteria and were included in the review. We found that teachers used both active/problem focused and passive/emotion focused coping styles with a slight inclination towards the former. While studies using the UCL reported a more passive coping style and lesser active coping in teachers with higher vocal handicap, studies using the VDCQ reported that social support was used the most in teachers with voice problems and avoidance, the least. Seeking social support was highlighted as a frequently used coping strategy across studies and measures. In terms of factors affecting coping, vocal handicap was an influencing factor; and in student teachers, trainee periods seemed to affect coping. An issue in this review was that though all professional voice users were included in the search strategy, all studies found were undertaken with teachers. This could be because teachers are a common profession with high voice use and at a higher risk for developing a voice disorder and has therefore received more research attention. Additionally, teachers may also be easier to recruit since considerable numbers of participants can be recruited from a single source (e.g., schools, universities).
The evidence base was highly focused on female voice users with five of the seven studies recruiting only females. The justifications provided for recruiting only females were higher incidence of voice problems in women 20 and that the majority of the teaching population were women. 21 However, it can be argued that focusing on only one gender does not allow the testing or verification of whether males and females use different coping strategies. It is, therefore, imperative to study both genders to verify if females and males use different coping strategies in future studies.
In terms of the quality of the included studies, limited information was provided regarding the participants and setting in six out of seven studies. This posed difficulties in making comparisons across studies particularly to identify factors which may be associated with coping. Only one study was of good methodological quality. 23 The two Brazilian studies 21,22 scored the lowest among all the studies included in the review. This was due to methodological flaws in the use of VDCQ and reporting of results where both studies described the frequency of use of coping strategies using a presence/absence paradigm rather than using the 6-point Likert scale of the VDCQ, thereby reducing specificity and variance of the collected information.
The review summarized the measures used to assess coping in teachers. The tools used for self-assessment of coping were UCL and VDCQ. Though there is overlap between subscales of the two measures (e.g; social support, passive coping), subscales of UCL are constructed on the premise that individuals tend to use fairly similar coping strategies across a wide variety of situations. Therefore, UCL conceptualizes coping as a trait or disposition and essentially measures coping styles and describes the consistent ways in which individuals cope with stress providing validity across different situations. 26 This was reflected in the present review where the measure was used consistently and reliably across all studies (n=4) and yielded similar results. This stability also enables the use of one set of normative data developed by the authors 24 for comparison with different populations across studies. However, measurement of coping as a dispositional style does not account for the inevitable variability in coping behavior induced by the context, thereby oversimplifying the coping process. 26 Moreover, UCL is a generic coping questionnaire which is not disease specific and is therefore not specifically designed to measure voice-related coping. It could be argued that the lack of context-specificity of UCL could potentially overlook the dynamism of a voice problem across situations and across time. Secondly, the full version of UCL is long with 47 questions and could be wearisome and tiring for patients, thereby leading to information loss if not completed in full or properly due to response fatigue.
In comparison to UCL, VDCQ is a disease specific-measure which allows clinicians to evaluate voice-related coping, in a relatively shorter format. The VDCQ measures coping as a state rather than a trait, which means it assumes coping to be a process which is linked to the situation (such as vocal problems, and the specific stage or time within the course of the illness trajectory) rather than a personality characteristic which is relatively stable across situations.
Only two studies 21,22 in the review used VDCQ to assess coping in teachers and there were issues with scoring. The original 15-item VDCQ compares the individual mean item scores of the four subscales to generate coping profiles. However, both studies in the review used an earlier 27-item version of VDCQ and adopted a binary subclassification namely problem focused and emotion focused strategies. Additionally, both studies reported results based on the total VDCQ scores which only shows the levels of overall coping rather than identifying patterns across subscales and does not provide a meaningful measure e.g., a higher total VDCQ score does not indicate effective coping. Therefore, these results were not included in the review and only the absolute values of individual items provided by both studies were considered for analysis. This, however, poses an inherent lack of clarity in the interpretation of VDCQ which is supported by the results of a systematic review conducted by Francis et al (2017) 27 on patient-reported outcome measures for voice. They reported that the VDCQ does not describe the proposed scoring approach or algorithm which would assist in interpretation.
Results of UCL and VDCQ revealed that teachers in general have an inclination to seek support from their peers, friends and family. Evidence 28 suggests that women are more likely to seek social support to deal with problems which may explain this finding since most of the participants in the present review were women. Van-Wijck Warnaar (2010) 14 suggests that a passive coping response indicates a defensive approach, where teachers demonstrate an inclination to use situation oriented or emotion focused strategies. They indicated that the combination of social support and passive coping strategies is maladaptive and can be detrimental to effective problem solving and lead to reduced selfesteem and self-confidence. Passive coping is also linked to the development of psychological and physical symptoms and active-problem solving coping to increased well-being and overall health outcomes. 9 To illustrate this point further, let us consider a singer who has developed hoarseness of voice. They may take control and seek medical help to know more about the problem which is likely to culminate in a positive outcome. Alternatively, they may undertake a passive approach and continue performing, hoping that the voice problem would resolve on its own, thereby creating a situation where a more serious and permanent vocal damage is possible. Even though the pattern of results from research suggests that passive coping correlate with better  29 refuted this view after performing a systematic review which examined this relationship. They concluded that it was unfeasible to collectively report findings on the association between active and passive coping styles and physical and psychological symptoms due to the vast differences in coping strategies included in the assessment tools and how these strategies were operationally defined. Therefore, implications regarding coping purely based on the active/passive paradigm should be interpreted with caution and clinicians should provide guidance on adaptive coping based on a multifaceted approach, considering specific coping styles or strategies and context requirements, including the stage of illness. Epstein et al (2009) 10 suggested that individuals with 'chronic' conditions, which require coping with the voice problem over a lengthy period of time, such as Spasmodic Dysphonia, are likely to use avoidance and passive coping because they feel there is little they can do about their voice problem. While this may be beneficial for the individual in the short term, especially in the early stages of the illness, long term use of these mechanisms could impact their quality of life. Therefore, the frequency of use of such strategies should be closely monitored throughout the illness, to avoid maladaptive behavior. De Jong (2003) 18 explored coping strategies in teachers with persisting voice problems by drawing parallels with the psychological cascade model described by Anderson (cited in De Jong et al, 2003). The study suggested that the majority of the teachers were stuck in phase 1 of the psychological cascade model due to a combination of externalization and unawareness, along with the severity of the voice problem. These factors hindered progressing to phase 2 and 3 which is characterized by acceptance of the disorder and hope finally leading to recovery. Therefore, this study highlights the temporal nature of the process of coping and its evolving trajectory across situations and reiterates the need to take context of the condition into account while taking clinical decisions.

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Rong et al (2017) 30 explored the factors affecting adoption of coping strategies while dealing with illness and reported that ethnicity, religion, disease duration, symptom management and various sociodemographic factors influenced coping. Current research in professional voice users does not sufficiently specify these parameters to allow comparisons and synthesis.
Limitations and strength of evidence A vast amount of heterogeneity was noticed in the results and methodologies adopted to measure outcomes related to coping. The primary reason is the diversity of definitions used to describe coping and lack of a consistent conceptual framework to study coping. More specifically, coping in the context of voice disorders has not received much attention, particularly pertaining to professional voice users.
As indicated above, only studies involving teachers were identified and included in the review. This limits the generalizability of the findings to other professional voice users. Moreover, the quality of included studies was fair.
Despite these limitations, an extensive search was carried out to identify articles for this review. The search was implemented across 10 databases using both EBSCO and Ovid platforms. Additionally, grey literature was also searched, and reference tracing undertaken. These improve the strength of the present review in terms of comprehensiveness of the search results. This review is the first of its kind to examine voice related coping in professional voice users and provides a comprehensive analysis of research evidence in the area.

CONCLUSION AND FUTURE DIRECTIONS
Results of the systematic review identified significant gaps in the evidence base, pertaining to methodological strength and population groups. Firstly, only one study was found to be of good methodological quality which recognizes the need for well-developed studies with clear and reliable reporting of results. Secondly, this review identified that only teachers have been studied in the context of coping. More research is warranted involving other professional voice users such as singers to determine if similar mechanisms and resolutions apply. Similarly, a greater balance in examination of genders to identify if they use different strategies is recommended.
Models and frameworks that research coping (transactional model etc.) can account for context and changes over time. Using models, frameworks and qualitative methodologies will provide in-depth understanding of coping processes. Current research does not sufficiently specify factors affecting coping to allow comparisons and synthesis. Examining the influence of constructs such as impact of voice problems, measured using standardized tools such as the Voice Handicap Index, 31 Voice Activity Participation Profile 32 etc. on coping would widen the understanding of factors affecting coping and is a potential area for further research.

DECLARATION OF INTERESTS
None.

SUPPLEMENTARY DATA
Supplementary data related to this article can be found online at doi:10.1016/j.jvoice.2022.08.024.