Advertisement

Voice Related Coping in Professional Voice Users-A Systematic Review

Open AccessPublished:October 12, 2022DOI:https://doi.org/10.1016/j.jvoice.2022.08.024

      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 significantly used. Current evidence does not sufficiently 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 influence on vocal health.

      Key Words

      INTRODUCTION AND OBJECTIVES

      Professional voice users are individuals whose ability to earn a living is impacted negatively by loss of vocal quality and endurance.
      • Sataloff RT.
      Professional Voice: The Science and Art of Clinical Care.
      This includes singers, teachers, actors, lawyers etc. The reported lifetime prevalence of voice problems is estimated to be between 50%-80% in teachers
      • Cantor Cutiva LC
      • Vogel I
      • Burdorf A
      Voice disorders in teachers and their associations with work-related factors: a systematic review.
      ,
      • Martins RHG
      • do Amaral HA
      • Tavares ELM
      • Martins MG
      • Gonçalves TM
      • Dias NH
      Voice disorders: etiology and diagnosis.
      in contrast to 29.9%
      • Roy N
      • Merrill RM
      • Gray SD
      • et al.
      Voice disorders in the general population: prevalence, risk factors, and occupational impact.
      in the general population. Other professional voice groups such as singers
      • Pestana PM
      • Vaz-Freitas S
      • Manso MC.
      Prevalence of voice disorders in singers: systematic review and meta-analysis.
      and telemarketers
      • Jones K
      • Sigmon J
      • Hock L
      • et al.
      Prevalence and risk factors for voice problems among telemarketers.
      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.

      Lazarus RS, Folkman S. Stress, Appraisal, and Coping. 11. [print.]. Springer; 20.

      Many classifications of coping have been proposed, of which problem-focused vs emotion-focused

      Lazarus RS, Folkman S. Stress, Appraisal, and Coping. 11. [print.]. Springer; 20.

      and active vs passive coping
      • Billings AG
      • Moos RH.
      The role of coping responses and social resources in attenuating the stress of life events.
      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.
      • Penley JA
      • Tomaka J
      • Wiebe JS.
      The association of coping to physical and psychological health outcomes: a meta-analytic review.
      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)
      • Epstein R
      • Hirani SP
      • Stygall J
      • et al.
      How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
      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)
      • de Freitas Valadares G
      • Occhi-Alexandre IGP
      • Teixeira LC
      Sense of coherence and coping strategies in patients with dysphonia.
      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
      • Rachman S.
      Medical Psychology.
      (Figure 1). Therefore, coping is directly related to the physical and functional outcomes of a voice problem.
      • Hagger MS
      • Orbell S.
      A meta-analytic review of the common-sense model of illness representations.
      Consequently, coping can be associated with onset and development of a voice problem,
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      particularly in professional voice users who require a high level of vocal skills such as teachers and singers.
      FIGURE 1:
      FIGURE 1Figure explaining the mediating role of coping.
      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.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      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, PsycINFO, 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
      • Ouzzani M
      • Hammady H
      • Fedorowicz Z
      • et al.
      Rayyan—a web and mobile app for systematic reviews.
      for duplicate removal and study selection; following which, the selected articles were transferred into EPPI-Reviewer,
      • Thomas J
      • Brunton J
      • Graziosi S.
      EPPI-Reviewer 4.0: Software for Research Synthesis. EPPI-Centre Software.
      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.

      Data items

      Data extracted included title, authors, year of publication, study design, country, participants, population size and 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 I2 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.

      RESULTS

      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.
      FIGURE 2
      FIGURE 2PRISMA Flow Diagram illustrating the study selection process.
      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,
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      two in Brazil,
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      ,
      • Zambon F
      • Moreti F
      • Behlau M.
      Coping strategies in teachers with vocal complaint.
      one in Sweden
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      and one in Belgium.
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      Five studies employed a cross sectional study design with a control group, while the other two used a case control
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      and a longitudinal
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      study design.
      TABLE 1Description of Study Characteristics
      Study NameCountryParticipantsAge Mean, (SD), RangeSexStudy DesignResponse
      MalesFemalesRate
      Ahlander (2012)SwedenTotal N=62

      N=31: Teachers with self-reported voice problems having 15 years of teaching experience (Cases)

      N=31: Age, gender and school matched teachers without self-reported voice problems having 15 years of teaching experience (Controls)
      Mean ages: Cases=48.7 (10.7); Controls=44.6 (9.9)Group 1=5 (16.12%) Group 2=5 (16.12%)Group 1=26 (83.87%) Group 2=26 (83.87%)Case control47.10%
      De Jong (2003)NLTotal N=911

      N=76: Primary and secondary teachers with self-reported voice problems (Cases)

      N=835: Primary and secondary teachers without self-reported voice problems (Controls/comparison group)
      Mean age: cases=45 (NR); Controls: NR Age range: cases=23-59 (NR); Controls: NRCases=21 (27.63%)Cases=55 (72.36%) Controls-No infoCross-sectional with comparison groupNR
      Ferracciu (2015)BrazilTotal N=110

      N=39: Elementary school teachers with voice disorder (based on 100mm VAS: >35mm) (Cases)

      N=71: Elementary school teachers without voice disorder (based on 100mm VAS: <35mm) (Controls/comparison group)
      Mean age=45.81 (7.41) Age range=29-62-Females only=110Cross sectional with comparison groupNR
      Meulenbroek (2010a)NLTotal N=755

      N=186: Student teachers with high vocal handicap (75th percentile of VHI) (Cases)

      N=167: Student teachers with low vocal handicap (25th percentile of VHI) (Controls/comparison group)

      N=402 moderate handicap (not analyzed)
      Mean age=18.8 (NR) Age range=16-29

      -Females only=755Cross sectional with comparison group100%
      Meulenbroek (2010b)NLTotal N=43

      Student teachers having 2 training periods (2 days a week for 25 days)
      Mean age=18.6 (NR) Age range=17-23-Females only=43Longitudinal survey42%
      Van Wijck-Warnaar (2010)BelgiumTotal N=470

      N=230: Primary school teachers with voice problems of which N=56 have high vocal handicap (75% percentile of VHI scores) and N=54 have low vocal handicap (Cases)

      N=240: Females from general population (Controls/comparison group)
      Mean ages: Teachers=36.3 (NR) Controls=40.4 (NR) Age Range Teachers=21-60; controls=21-59-Females only Cases=230 Controls= 240Cross sectional with comparison groupTeachers= 51%

      Controls=60%
      Zambon (2014)BrazilTotal N=90

      N=30: Primary, middle and high school teachers with self-reported voice problems who sought voice therapy (Cases-Group 1)

      N=30: Primary, middle and high school teachers with self-reported voice problems who did not seek voice therapy (Cases-Group 2)

      N=30: Primary, middle and high school teachers without self-reported voice problems (Controls/comparison group-Group 3)
      Mean ages: Group 1=26.2 (7.5); Group 2=35.1 (7.9); Group 3-37.2 (9.8) Age range: Group 1=23-49; Group 2=21-51; Group 3=23-66-Females only=90Cross sectional with comparison groupNR
      Abbreviations: NL, Netherlands; SD, Standard Deviation; NR, Not Reported; VAS, Visual Analogue Scale; VHI, Voice Handicap Index.

      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
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      to 911.
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      The mean age of participants ranged from 18.6 years
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      to 48.7 years
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      and the age range, in the studies that reported it, was 16-62. Five studies recruited only women.
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      ,
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      • Zambon F
      • Moreti F
      • Behlau M.
      Coping strategies in teachers with vocal complaint.
      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
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      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
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      and the other studies (n=6) were of fair quality. Table 2 describes the results of the quality assessment with individual item scores.
      TABLE 2Quality Assessment of the Selected Articles Using the Joanna Briggs Institute Critical Appraisal Tools
      Ahlander (2011)De Jong (2003)Ferracciu (2015)Meulenbroek (2010a)Meulenbroek (2010b)Van Wijck-Warnaar (2010)Zambon (2014)
      Comparability Of Groups (For Case Control studies)2NANANANANANA
      Matching of Cases and Controls (For Case Control Studies)1NANANANANANA
      Same Criteria for Identification of Cases and Controls (For Case Control Studies)2NANANANANANA
      Clearly Defined Inclusion CriteriaNA212NA12
      Description of Sample And SettingNA111NA11
      Valid and Reliable Measurement of Exposure2211121
      Same Measurement of Exposure for Cases and Controls (For Case Control Studies)/ Free of exposure at start of study (For longitudinal study)2NANANA1NANA
      Measurement of Condition Using Objective Standard CriteriaNA221NA11
      Identification Of Confounding Variables1122212
      Strategies Adopted to Deal with Confounding Variables1122211
      Valid and Reliable Measurement of Outcomes2101220
      Adequate Duration of Exposure (Only Applicable for Case Control and longitudinal Studies)1NANANA2NANA
      Appropriate Statistical Analysis2222222
      Completion of follow up (For longitudinal studies)NANANANA0NANA
      Utilization of strategies to address incomplete follow-up (For longitudinal studies)NANANANA0NANA
      Total Score16/2012/1611/1612/1612/1811/1610/16
      Total Score (%)80%75%69%75%67%69%63%
      Quality LevelGoodFairFairFairFairFairFair
      Include/ExcludeIncludeIncludeIncludeIncludeIncludeIncludeInclude
      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)
      • Scheurs PJG
      • van de Willege G
      • Brosschot JF
      • et al.
      De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
      was used in four studies
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      ,
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      ,
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      ,
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      all of which were undertaken in Europe. 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).
      • Epstein R
      • Hirani SP
      • Stygall J
      • et al.
      How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
      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.
      TABLE 3Details of Coping Subscales Measured by UCL
      • Scheurs PJG
      • van de Willege G
      • Brosschot JF
      • et al.
      De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
      and VDCQ
      • Epstein R
      • Hirani SP
      • Stygall J
      • et al.
      How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
      Voice Disability Coping Questionnaire
      SubscaleDefinitionNo: of items in each subscale
      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”6
      Utrecht Coping List
      SubscaleDefinitionNumber of items in each subscale
      Active handlingActive approach to solve a problem where the problem is thought about and approached directly7
      Palliative ReactionsEfforts directed at changing the feelings elicited by a problem.8
      Avoidance/waitingNo effort to change the problem itself, but avoiding the problem or situation8
      Seek social supportWorries are shared with someone6
      Passive reactionsFeelings of helplessness or being pessimistic and overwhelmed by the problem7
      Expression of emotionsExpressing feelings about the problem to others3
      Reassuring thoughtsEngaging in self-encouragement and comforting thoughts5
      One study
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      used a different approach where coping was conceptualized and assessed based on the principles of the psychological cascade model.
      • Anderson DJ
      The psychologic cascade; in White AH, Schofferman JA, eds. Spine Care. One ed. Mosby; 1995; in 18. de Jong FICRS, Cornelis BE, Wuyts FL, et al. A Psychological Cascade Model for Persisting Voice Problems in Teachers.
      The psychological cascade model describes three phases from dysfunction to recovery-phase 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 (problem-focused vs emotion-focused).
      Of the four studies that used UCL to assess coping, two studies
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      ,
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      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.
      FIGURE 3:
      FIGURE 3Comparison of UCL scores of teachers with low and high vocal handicap and normative scores.
      A comparison of the UCL scores of the two teacher groups in the two studies with the normative scores of the UCL subscales
      • Scheurs PJG
      • van de Willege G
      • Brosschot JF
      • et al.
      De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
      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.
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      ,
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      ,
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      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.
      TABLE 4Coping Patterns Seen in Teachers With High Vocal Handicap Based on UCL Subscales
      StudyActive Confrontation or Dealing With the ProblemAvoidance-WaitingPassive Reaction PatternReassuring ThoughtsPalliative ReactionsEmotional ExpressionSeeking for Social Support
      Meulenbroek (2010a)
      Meulenbroek (2010b)X
      Van-Wijck Warnaar (2010)X
      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 self-reported voice problems.
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      All further details pertaining to results are described in Table 5.
      TABLE 5Synthesis of Outcomes Reported in the Included Studies
      Study NameObjectivesEligibility CriteriaCoping Related OutcomesKey Study Conclusions
      Ahlander (2011)1. Compare teachers with and without self-reported voice problems and relate the self-assessed voice function to laryngeal findings, voice quality, personality and psychosocial circumstances such as burnout and coping.

      Inclusion:

      1. Cases and controls belong to the same school

      2. Subjectively free from upper airway infections and allergies
      No significant differences between teachers with and without self-reported voice problems1. No significant differences were found within the pairs with respect to coping strategies.
      De Jong (2003)1. Describe the factors that maintain the voice problem and the way in which teachers with chronic voice complaints cope with their voice problem

      2. Address the question whether a parallel can be drawn to the psychological cascade model
      1. A history of persisting voice problems

      2. A previous or present period of absence from work due to voice problems.
      Number of patients in:

      Phase 1: 54 (71%)

      Phase 2: 12 (16%),

      Phase 3: 11 (14%)

      1. Unawareness: present in 30 patients (39%)

      2. Externalization: present in 57 patients (75%).

      3. Dependence: present in 51 patients (67%)

      Significant difference between patients in phase 1 and not in phase 1 with respect to prevalence of:

      a. unawareness: p=0.001

      b. externalization: p value=0.001

      c. dependence: p=0.015

      d. VAS: p=0.039

      Factors significant to classify patients into phase 1 or not in phase 1 a. unawareness: p=0.033 b. Externalization: p=0.009
      1. Organic lesions may not be responsible for maintaining a voice problem.

      2. The positive correlation between the maintaining and coping factors and the severity of voice complaints suggest that these factors play a role in keeping up the voice problem.

      3. Patients found in phase 1 are in a deadlocked situation due to the 3 ways of coping-externalization, unawareness and dependency.
      Ferracciu (2015)Assess the association between voice disorders with sociodemographic characteristics, vocal aspects, types of coping strategies and vocal impact on daily activities.Exclusion:

      Males
      VDCQ results-frequency of 5 most reported items for groups with and without (in brackets) voice disorder Item 1: “It helps me to cope with my voice problem if other people are sympathetic”- 94.9%, (87.3%)

      Item 8:” I find it easier to cope with my voice problem by finding out as much about it as I can” 87.2%, (84.5%)

      Item 13: “I find it easier to cope with my voice problem if I ask the doctor questions about it”-87.2%, (83.1%)

      Item 24: “Resting my voice at times, helps me cope with my voice problem” 87.2%, (78.9%)

      Item15: "I find it easier to cope with my voice problem by wishing that it would go away or somehow be over with”- 84.6% (only group with voice disorder)

      Item 2: “I try to avoid situations where my voice problem would become evident” (77.5%) (only group without voice disorder)

      1. No significant differences in coping reported between the groups

      2. Slightly inclined to use more problem focused strategies although not statistically significant
      Meulenbroek (2010a)Investigate coping behavior in relation to the biopsychosocial impact of the voice in female student teachers.Exclusion:

      Male students
      PAL VHI>75-17 (10-25), VHI<25-16 (8-24); p<0.001 AV-W VHI>75-16 (11-26) VHI<25-15 (8-24); p<0.001 PAS VHI>75-11 (7-21) VHI<25-9 (7-20); p<0.001 EXP VHI>75-6 (3-11) VHI<25-6 (3-11); p<0.003

      1. Student teachers with relatively high VHI scores showed higher scores on all subscales related to a passive coping style such as PAS, AV-W and PAL

      Meulenbroek (2010b)Investigate the relation between trainee periods and voice handicap, the general coping style and psychosomatic well-being in starting student teachersExclusion:

      Male students
      Difference in VHI total scores in relation to UCL subscale scores

      PAS Higher VHI- PAS LOW=3 (30) PAS HIGH=7 (70) Lower VHI PAS LOW=22 (66.7) PAS HIGH=11 (33.3); p=0.039 SOC Higher VHI- SOC LOW=5 (50) SOC HIGH=5 (50) Lower VHI SOC LOW=20 (76.9) SOC HIGH=13 (23.1); p=0.551 REAS Higher VHI- REAS LOW=8 (80) REAS HIGH=2 (20) Lower VHI REAS LOW=21 (63.6) REAS HIGH=12 (36.4); p=0.333

      1. At the end of training period, 40% students showed more passive coping modes.

      2. Students with high VHI at the end of training showed higher scores in PAS and higher risk for higher score in SOC and lower risk of higher score in REAS.

      3. Overall coping style is more passive than active.

      Van Wijck-Warnaar (2010)Explore the general coping style of female teachers who report a relatively low voice handicap compared with teacher who report a relatively high voice handicap.Exclusion:

      Males
      Median and (IQR values) and significance value:

      Teachers:

      ACT

      low VHI-19.0 (3.00), high VHI-16.0 (4.25); p =0.001

      PAS

      low VHI-10.0 (3.00), high VHI-12.0 (5.00); p =0.001

      General population and teachers irrespective of vocal handicap

      SOC

      p =0.001 (mean and IQR values not provided)

      General population and teachers-high voice handicap

      SOC

      Teachers-15.0 (6.00), Controls-13.0 (5.25); p =0.022

      AV-W

      Teachers-15.0 (4.00), Controls-16.0 (3.00); p=0.027

      1. Teachers with high VHI cope overall with a passive reaction pattern and less with an active coping style.

      2. Teachers in general tend to seek for social support.

      Zambon (2014)1. Understand coping strategies used by teachers with vocal complaint

      2. Compare the differences between those who seek and do not seek treatment

      3. Check relationship between coping and perceptual analysis, vocal signs and symptoms and VAPP
      Exclusion:

      1. Use of medications for psychiatric disorders during time of research

      2. Being off work/unemployed

      3. History of previous voice therapy

      4. Males
      Strategies which were reported more by group 1-Frequency and significance Item 2:” I try to avoid situations where my voice problem would become evident”- G1-26 (86.7%), G2-17 (56.7%), G3-10 (33.3%), p=0.010 Item 4: “I try to find as much information as possible about my voice problem”-G1-28 (93.3%), G2-20 (66.7%), G3-6 (20%), p=0.010 Item 5: “I find it easier to cope with my voice problem by expressing my feelings outwardly”- G1-26 (86.7%), G2-18 (60%), G3-8 (26.7%), p=0.020 Item 13: “I find it easier to cope with my voice problem if I ask the doctor questions about it”- G1-28 (93.3%), G2-19 (63.3%), G3-4 (13.3%), p=0.005 Reported more by G2 Item 22: “I ignore my voice problem by only looking at the good things in life”- G1-9 (30%), G2-18 (60%), G3-5 (16.7%), p=0.0201. Strategies used by teachers with vocal complaints are more problem focused.

      2. No correlation observed between VDCQ scores and treatment seeking behavior

      VAS, Visual Analog Scale; VHI, Voice Handicap Index; PAL, Palliative Reactions; AV-W, Avoidance and Waiting; PAS, Passive Reaction; EXP, Expression of emotion; ACT, Active tackling; SOC, Seeking social support; REAS, Reassuring thoughts; VAPP, Voice Activity and Participation Profile.
      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
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      ,
      • Zambon F
      • Moreti F
      • Behlau M.
      Coping strategies in teachers with vocal complaint.
      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.
      • Epstein R
      • Hirani SP
      • Stygall J
      • et al.
      How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
      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.
      TABLE 6Combined Frequencies of 10 VDCQ Items With Highest Scores Reported by Zambon et al (2014) and Ferracciu et al (2015) and Classification of Items into Relevant Subscales of the Original Validated Version of the VDCQ (Epstein et al, 2007)
      Q no:QuestionYes (n%)CategoryInfo SeekingSocial SupportPassive CopingAvoidance
      8I find it easier to cope with my voice problem by finding out as much about it as I can

      87%Problem
      13I find it easier to cope with

      my voice problem if I ask the doctor questions about it

      82%Problem
      24
      Question 24 is not a part of the original VDCQ items; therefore, the subscale could not be determined.
      Resting my voice at times, helps me cope with my voice problem

      82%Problem
      3I find myself wishing that I never had a voice problem

      80%Emotion
      1It helps me to cope with my voice problem if other people are sympathetic

      79%Emotion
      4I try to find as much information as possible about my voice problem

      79%Problem
      15I find it easier to cope with my voice problem by wishing that it would go away or somehow be over with

      77%Emotion
      2I try to avoid situations where my voice problem would become evident

      75%Problem
      5I find it easier to cope with my voice problem by expressing my feelings outwardly

      75%Emotion
      7I find talking with friends and family about my voice problem helpful72%Problem
      low asterisk Question 24 is not a part of the original VDCQ items; therefore, the subscale could not be determined.
      De Jong (2003)
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      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.
      • Scheurs PJG
      • van de Willege G
      • Brosschot JF
      • et al.
      De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
      The results revealed that coping contributed to patients remaining in phase 1 of the psychological cascade model where the patient continues to view the problem as a threat and is anxious, struggling, exhausted and potentially depressed as a result of remaining in phase 1. Of these factors, externalization (whether the patient experienced the causes and solutions of problems as being beyond his control) and unawareness (awareness of whether one was actually in phase 1 of the psychological cascade model) were most correlated with phase 1. Due to 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
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      ,
      • Meulenbroek LFP
      • Thomas G
      • Kooijman PGC
      • et al.
      Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
      ,
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      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)
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      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
      • Meulenbroek LFP
      • de Jong FICRS.
      Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
      and that the majority of the teaching population were women.
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      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.
      • Åhlander VL
      • Rydell R
      • Löfqvist A.
      How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
      The two Brazilian studies
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      ,
      • Zambon F
      • Moreti F
      • Behlau M.
      Coping strategies in teachers with vocal complaint.
      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.
      • Greenaway KH
      • Louis WR
      • Parker SL
      • et al.
      Measures of coping for psychological well-being.
      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
      • Scheurs PJG
      • van de Willege G
      • Brosschot JF
      • et al.
      De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
      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.
      • Greenaway KH
      • Louis WR
      • Parker SL
      • et al.
      Measures of coping for psychological well-being.
      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
      • Ferracciu CCS
      • Santos LV de A
      • Teixeira LR
      • et al.
      Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
      ,
      • Zambon F
      • Moreti F
      • Behlau M.
      Coping strategies in teachers with vocal complaint.
      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)
      • Francis DO
      • Daniero JJ
      • Hovis KL
      • et al.
      Voice-related patient-reported outcome measures: a systematic review of instrument development and validation.
      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
      • Tamres LK
      • Janicki D
      • Helgeson VS.
      Sex differences in coping behavior: a meta-analytic review and an examination of relative coping.
      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)
      • Van Wijck-Warnaar A
      • Van Opstal MJMC
      • Exelmans K
      • et al.
      Biopsychosocial impact of voicing and general coping style in teachers.
      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 self-esteem 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.
      • Penley JA
      • Tomaka J
      • Wiebe JS.
      The association of coping to physical and psychological health outcomes: a meta-analytic review.
      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 outcomes, Austenfield and Stanton (2004)
      • Austenfeld JL
      • Stanton AL.
      Coping through emotional approach: a new look at emotion, coping, and health-related outcomes.
      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)
      • Epstein R
      • Hirani SP
      • Stygall J
      • et al.
      How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
      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)
      • de Jong FICRS
      • Cornelis BE
      • Wuyts FL
      • et al.
      A psychological cascade model for persisting voice problems in teachers.
      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.
      Rong et al (2017)
      • Rong X
      • Peng Y
      • Yu H
      • et al.
      Factors associated with adoption of coping strategies among Chinese patients with heart failure in ethnic minority regions.
      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,
      • Jacobson B
      • Johnson A
      • Grywalski C
      • et al.
      The Voice Handicap Index (VHI) Development and Validation.
      Voice Activity Participation Profile
      • Ma EPM
      • Yiu EML.
      Voice activity and participation profile: assessing the impact of voice disorders on daily activities.
      etc. on coping would widen the understanding of factors affecting coping and is a potential area for further research.

      Declaration of interests

      None.

      REFERENCES

        • Sataloff RT.
        Professional Voice: The Science and Art of Clinical Care.
        2nd ed. Singular Pub. Group, 1997
        • Cantor Cutiva LC
        • Vogel I
        • Burdorf A
        Voice disorders in teachers and their associations with work-related factors: a systematic review.
        J Commun Disord. 2013; 46: 143-155https://doi.org/10.1016/j.jcomdis.2013.01.001
        • Martins RHG
        • do Amaral HA
        • Tavares ELM
        • Martins MG
        • Gonçalves TM
        • Dias NH
        Voice disorders: etiology and diagnosis.
        J Voice. 2016; 30: 761.e1-761.e9https://doi.org/10.1016/j.jvoice.2015.09.017
        • Roy N
        • Merrill RM
        • Gray SD
        • et al.
        Voice disorders in the general population: prevalence, risk factors, and occupational impact.
        The Laryngoscope. 2005; 115: 1988-1995https://doi.org/10.1097/01.mlg.0000179174.32345.41
        • Pestana PM
        • Vaz-Freitas S
        • Manso MC.
        Prevalence of voice disorders in singers: systematic review and meta-analysis.
        J Voice. 2017; 31: 722-727https://doi.org/10.1016/j.jvoice.2017.02.010
        • Jones K
        • Sigmon J
        • Hock L
        • et al.
        Prevalence and risk factors for voice problems among telemarketers.
        Arch Otolaryngol Neck Surg. 2002; 128: 571https://doi.org/10.1001/archotol.128.5.571
      1. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. 11. [print.]. Springer; 20.

        • Billings AG
        • Moos RH.
        The role of coping responses and social resources in attenuating the stress of life events.
        J Behav Med. 1981; 4: 139-157https://doi.org/10.1007/BF00844267
        • Penley JA
        • Tomaka J
        • Wiebe JS.
        The association of coping to physical and psychological health outcomes: a meta-analytic review.
        J Behav Med. 2002; 25: 551-603https://doi.org/10.1023/A:1020641400589
        • Epstein R
        • Hirani SP
        • Stygall J
        • et al.
        How do individuals cope with voice disorders? Introducing the voice disability coping questionnaire.
        J Voice. 2009; 23: 209-217https://doi.org/10.1016/j.jvoice.2007.09.001
        • de Freitas Valadares G
        • Occhi-Alexandre IGP
        • Teixeira LC
        Sense of coherence and coping strategies in patients with dysphonia.
        J Voice. 2020; (Published online October)S0892199720303556https://doi.org/10.1016/j.jvoice.2020.09.012
        • Rachman S.
        Medical Psychology.
        Pergamon press, 1980 (Accessed May 19, 2021)
        • Hagger MS
        • Orbell S.
        A meta-analytic review of the common-sense model of illness representations.
        Psychol Health. 2003; 18: 141-184https://doi.org/10.1080/088704403100081321
        • Van Wijck-Warnaar A
        • Van Opstal MJMC
        • Exelmans K
        • et al.
        Biopsychosocial impact of voicing and general coping style in teachers.
        Folia Phoniatr Logop. 2010; 62: 40-46https://doi.org/10.1159/000239062
        • Moher D
        • Liberati A
        • Tetzlaff J
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339 (b2535-b2535)https://doi.org/10.1136/bmj.b2535
        • Ouzzani M
        • Hammady H
        • Fedorowicz Z
        • et al.
        Rayyan—a web and mobile app for systematic reviews.
        Syst Rev. 2016; 5: 210https://doi.org/10.1186/s13643-016-0384-4
        • Thomas J
        • Brunton J
        • Graziosi S.
        EPPI-Reviewer 4.0: Software for Research Synthesis. EPPI-Centre Software.
        Social Science Research Unit. Institute of Education, University of London., 2010
        • de Jong FICRS
        • Cornelis BE
        • Wuyts FL
        • et al.
        A psychological cascade model for persisting voice problems in teachers.
        Folia Phoniatr Logop. 2003; 55: 91-101https://doi.org/10.1159/000070091
        • Meulenbroek LFP
        • Thomas G
        • Kooijman PGC
        • et al.
        Biopsychosocial impact of the voice in relation to the psychological features in female student teachers.
        J Psychosom Res. 2010; 68: 379-384https://doi.org/10.1016/j.jpsychores.2009.10.002
        • Meulenbroek LFP
        • de Jong FICRS.
        Trainee experience in relation to voice handicap, general coping and psychosomatic well-being in female student teachers: a descriptive study.
        Folia Phoniatr Logop. 2010; 62: 47-54https://doi.org/10.1159/000239063
        • Ferracciu CCS
        • Santos LV de A
        • Teixeira LR
        • et al.
        Estratégias de enfrentamento e perfil de participação e atividades vocais em professoras da rede pública de ensino com e sem distúrbios de voz.
        Rev CEFAC. 2015; 17: 1184-1194https://doi.org/10.1590/1982-0216201517415714
        • Zambon F
        • Moreti F
        • Behlau M.
        Coping strategies in teachers with vocal complaint.
        J Voice. 2014; 28: 341-348https://doi.org/10.1016/j.jvoice.2013.11.008
        • Åhlander VL
        • Rydell R
        • Löfqvist A.
        How do teachers with self-reported voice problems differ from their peers with self-reported voice health?.
        J Voice. 2012; 26: e149-e161https://doi.org/10.1016/j.jvoice.2011.06.005
        • Scheurs PJG
        • van de Willege G
        • Brosschot JF
        • et al.
        De Utrechtse coping Lijst: UCL Omgaan met problemen engebeurtenissen. Swets & Zeitlinger; 1988.
        Eur Eat Disord Rev. 2012; 20 (A Psychometric Evaluation of an English Version of the Utrecht Coping List: An English Version of the UCL): 339-342https://doi.org/10.1002/erv.2173
        • Anderson DJ
        The psychologic cascade; in White AH, Schofferman JA, eds. Spine Care. One ed. Mosby; 1995; in 18. de Jong FICRS, Cornelis BE, Wuyts FL, et al. A Psychological Cascade Model for Persisting Voice Problems in Teachers.
        Folia Phoniatr Logop. 2003; 55: 91-101https://doi.org/10.1159/000070091
        • Greenaway KH
        • Louis WR
        • Parker SL
        • et al.
        Measures of coping for psychological well-being.
        Measures of Personality and Social Psychological Constructs. Elsevier, 2015: 322-351https://doi.org/10.1016/B978-0-12-386915-9.00012-7
        • Francis DO
        • Daniero JJ
        • Hovis KL
        • et al.
        Voice-related patient-reported outcome measures: a systematic review of instrument development and validation.
        J Speech Lang Hear Res. 2017; 60: 62-88https://doi.org/10.1044/2016_JSLHR-S-16-0022
        • Tamres LK
        • Janicki D
        • Helgeson VS.
        Sex differences in coping behavior: a meta-analytic review and an examination of relative coping.
        Personal Soc Psychol Rev. 2002; 6: 2-30https://doi.org/10.1207/S15327957PSPR0601_1
        • Austenfeld JL
        • Stanton AL.
        Coping through emotional approach: a new look at emotion, coping, and health-related outcomes.
        J Pers. 2004; 72: 1335-1364https://doi.org/10.1111/j.1467-6494.2004.00299.x
        • Rong X
        • Peng Y
        • Yu H
        • et al.
        Factors associated with adoption of coping strategies among Chinese patients with heart failure in ethnic minority regions.
        J Clin Nurs. 2018; 27: 3324-3334https://doi.org/10.1111/jocn.14199
        • Jacobson B
        • Johnson A
        • Grywalski C
        • et al.
        The Voice Handicap Index (VHI) Development and Validation.
        J Voice. 1997; 6: 66-70
        • Ma EPM
        • Yiu EML.
        Voice activity and participation profile: assessing the impact of voice disorders on daily activities.
        J Speech Lang Hear Res. 2001; 44: 511-524https://doi.org/10.1044/1092-4388(2001/040