Are Occupational Voice Disorders Accurately Measured? A Systematic Review of Prevalence and Methodologies in Schoolteachers to Report Voice Disorders

Published:December 08, 2022DOI:



      Different measuring instruments have been described to determine the prevalence of voice disorders in schoolteachers. However, the heterogeneity of prevalence figures has made it difficult in determining the impact of voice disorders in this group. This investigation aims to review and identify scientific evidence of methodological analysis of voice disorders in teachers, the relevance of measuring instruments, the prevalence of dysphonia, and the impact on the development of vocal health prevention programs.


      A systematic review was conducted by searching six important scientific databases. Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were carried out. Articles were included whether they presented data related to the prevalence of dysphonia and the impact of therapy programs on teachers.


      Twenty articles out of 8,998 were selected. The cross-sectional design type was predominant throughout the investigations. Differences were observed in the number of participants across studies, leading to heterogeneous prevalence figures – which ranged from 10.5% to 69.1%. The assessment instruments are not standardly used to effectively determine the disease burden. Despite the fact of the extensive evidence of the effectiveness of programs that address dysphonia in teachers, the scarcity of literature is yet evident on systematic programs promoted by either the government or educational institutions.


      Findings suggest that future investigations should consider the consensus of a global definition for occupational dysphonia in teachers in order to develop accurately measuring instruments and to assist with voice care programs and treatment approaches in this population. This might be crucial since it could also assist with the implementation of Delphi-type studies that could support the development of further evidence-based agreements around these programs (voice care and treatment approaches) in schoolteachers.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Giannini SP
        • Latorre M
        • Fischer FM
        • et al.
        Teachers' voice disorders and loss of work ability: a case-control study.
        J Voice. 2015; 29: 209-217
        • Pemberton C.
        Speech pathology has an important role in efficiently and cost-effectively managing teachers' voice problems.
        Submission to Australian Senate Inq. 2014; 86 (2019(31/07)): 1-14
        • Rinsky-Halivni L
        • Klebanov M
        • Lerman Y
        • et al.
        adherence to voice therapy recommendations is associated with preserved employment fitness among teachers with work-related dysphonia.
        J Voice. 2017; 31 (e19-386.e26): 386
        • Naunheim MR
        • Goldberg L
        • Dai JB
        • et al.
        Measuring the impact of dysphonia on quality of life using health state preferences.
        Laryngoscope. 2020; 130: E177-E182
        • Stachler RJ
        • Francis DO
        • Schwartz SR
        Clinical practice guideline: hoarseness (dysphonia) (Update).
        Otolaryngol Head Neck Surg. 2018; 158: S1-S42
        • Bovo R
        • Galceran M
        • Petruccelli J
        • et al.
        Vocal problems among teachers: evaluation of a preventive voice program.
        J Voice. 2007; 21: 705-722
        • Williams N.R.
        (2003). Occupational groups at risk of voice disorders: a review of the literature.
        Occup Med. 2003; 53: 456-460
        • 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: 143-155
        • Carrillo-Gonzalez A
        • Camargo-Mendoza M
        • Cantor-Cutiva LC
        Relationship between sleep quality and stress with voice functioning among college professors: a systematic review and meta-analysis.
        J Voice. 2021; 35: 499
        • Silva BG
        • Chammas TV
        • Zenari MS
        • et al.
        Analysis of possible factors of vocal interference during the teaching activity.
        Rev Saude Publica. 2017; 11: 124
        • Roy N
        • Merrill RM
        • Thibeault S
        • et al.
        Prevalence of voice disorders in teachers and the general population.
        J Speech Lang Hear Res. 2004; 47: 281-293
        • De Jong FI
        • Kooijman PG
        • Thomas G
        • et al.
        Epidemiology of voice problems in Dutch teachers.
        Folia Phoniatr Logop. 2006; 58: 186-198
        • Lu D
        • Wen B
        • Yang H
        • et al.
        A comparative study of the VHI-10 and the V-RQOL for quality of life among chinese teachers with and without voice disorders.
        J Voice. 2017; 31 (e1-509.e6): 509
        • Medeiros AM
        • Vieira MT.
        Work absenteeism due to voice disorders in Brazilian schoolteachers. Ausência ao trabalho por distúrbio vocal de professores da Educação Básica no Brasil.
        Cad Saude Publica. 2019; 15e00171717×00171717
        • Abo-Hasseba A
        • Waaramaa T
        • Alku P
        • et al.
        Difference in voice problems and noise reports between teachers of public and private schools in upper Egypt.
        J Voice. 2017; 31: 508
        • Seifpanahi S
        • Izadi F
        • Jamshidi AA
        • et al.
        Prevalence of voice disorders and associated risk factors in teachers and nonteachers in Iran.
        J Voice. 2016; 30: 506
        • Devadas U
        • Bellur R
        • Maruthy S.
        Prevalence and risk factors of voice problems among primary school teachers in India.
        J Voice. 2017; 31: 117
        • Byeon H.
        The risk factors related to voice disorder in teachers: a systematic review and meta-analysis.
        Int J Environ Res Public Health. 2019; 16: 3675
        • Horácek J
        • Laukkanen AM
        • Sidlof P.
        Estimation of impact stress using an aeroelastic model of voice production.
        Logoped Phoniatr Vocol. 2007; 32: 185-192
        • Horácek J
        • Laukkanen AM
        • Sidlof P
        • et al.
        Comparison of acceleration and impact stress as possible loading factors in phonation: a computer modeling study.
        Folia Phoniatr Logop. 2009; 61: 137-145
        • Sliwinska-Kowalska M
        • Niebudek-Bogusz E
        • Fiszer M
        • et al.
        The prevalence and risk factors for occupational voice disorders in teachers.
        Folia Phoniatr Logop. 2006; 58: 85-101
        • Angelillo M
        • Di Maio G
        • Costa G
        • et al.
        Prevalence of occupational voice disorders in teachers.
        J Prev Med Hyg. 2009; 50: 26-32
        • Branco A
        • Rodrigues SA
        • Fabro AT
        • et al.
        Hyaluronic acid behavior in the lamina propria of the larynx with advancing age.
        Otolaryngol Head Neck Surg. 2014; 151: 652-656
        • Menon UK
        • Raj M
        • Antony L
        • et al.
        Prevalence of voice disorders in school teachers in a district in South India.
        J Voice. 2021; 35: 1-8
        • Tao Y
        • Lee CT
        • Hu YJ
        • et al.
        Relevant work factors associated with voice disorders in early childhood teachers: a comparison between kindergarten and elementary school teachers in Yancheng, China.
        Int J Environ Res Public Health. 2020; 17: 3081
        • Ramig LO
        • Verdolini K.
        Treatment efficacy: voice disorders.
        J Speech Lang Hear Res. 1998; 41: S101-SS16
        • Martins RH
        • Pereira ER
        • Hidalgo CB
        • et al.
        Voice disorders in teachers. a review.
        J Voice. 2014; 28: 716-724
        • Trinite B.
        Epidemiology of voice disorders in Latvian school teachers.
        J Voice. 2017; 31: 508
        • Barbosa IK
        • Behlau M
        • Lima-Silva MF
        • et al.
        Voice symptoms, perceived voice control, and common mental disorders in elementary school teachers.
        J Voice. 2021; 35: 158
        • Verdolini K
        • Ramig LO.
        Review: occupational risks for voice problems.
        Logoped Phoniatr Vocol. 2001; 26: 37-46
        • Pereira ER
        • Tavares EL
        • Martins RH.
        Voice disorders in teachers: clinical, videolaryngoscopical, and vocal aspects.
        J Voice. 2015; 29: 564-571
        • Van Houtte E
        • Claeys S
        • Wuyts F
        • Van Lierde K.
        The impact of voice disorders among teachers: vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-related absenteeism.
        J Voice. 2011; 25: 570-575
        • Hazlett DE
        • Duffy OM
        • Moorhead SA.
        Review of the impact of voice training on the vocal quality of professional voice users: implications for vocal health and recommendations for further research.
        J Voice. 2011; 25: 181-191
        • Timmermans B
        • De Bodt MS
        • Wuyts FL
        • et al.
        Training outcome in future professional voice users after 18 months of voice training.
        Folia Phoniatr Logop. 2004; 56: 120-129
        • Yiu EM.
        Impact and prevention of voice problems in the teaching profession: embracing the consumers' view.
        J Voice. 2002; 16: 215-228
        • Ruotsalainen J
        • Sellman J
        • Lehto L
        • et al.
        Systematic review of the treatment of functional dysphonia and prevention of voice disorders.
        Otolaryngol Head Neck Surg. 2008; 138: 557-565
      1. Nusseck M, Immerz A, Spahn C, et al. Long-term effects of a voice training program for teachers on vocal and mental health. J Voice. 2019;S0892-1997(19)30338-8.

        • Porcaro CK
        • Howery S
        • Suhandron A
        • et al.
        Impact of vocal hygiene training on teachers' willingness to change vocal behaviors.
        J Voice. 2019;
        • Richter B
        • Nusseck M
        • Spahn C
        • et al.
        Effectiveness of a voice training program for student teachers on vocal health.
        J Voice. 2016; 30: 452-459
        • Yu L
        • Lu D
        • Yang H
        • et al.
        A comparative and correlative study of the Voice-Related Quality of Life (V-RQOL) and the Voice Activity and Participation Profile (VAPP) for voice-related quality of life among teachers with and without voice disorders.
        Medicine (Baltimore). 2019; 98: e14491
        • Munn Z
        • Moola S
        • Lisy K
        • et al.
        Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data.
        Int J Evid Based Healthc. 2015; 13: 147-153
        • Gadepalli C
        • Fullwood C
        • Ascott F
        • et al.
        Voice burden in teachers and non-teachers in a UK population: a questionnaire-based survey.
        Clin Otolaryngol. 2019; 44: 1045-1058
        • Moher D
        • Liberati A
        • Tetzlaff J
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; : 339
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 21: b2700
        • Straus SE
        • Sackett DL.
        Using research findings in clinical practice.
        BMJ. 1998; 317: 339-342
      2. O'Connor D, Green S, Higgins JP. Defining the review question and developing criteria for including studies. Cochrane handbook for systematic reviews of interventions: cochrane book series, 2008;81-94.

        • Cooper H.
        Research Synthesis and Meta-analysis: A Step-by-Step Approach.
        2 Ed. Sage publications, 2017
        • Dollaghan CA
        The Handbook for Evidence-based Practice in Communication Disorders.
        Paul H Brookes Publishing, Baltimore2007
        • Whiting PF
        • Weswood ME
        • Rutjes AW
        • et al.
        Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies.
        BMC Med Res Methodol. 2006; 6: 9
        • Da Rocha LM
        • de Lima Bach S
        • do Amaral PL
        • et al.
        Risk factors for the incidence of perceived voice disorders in elementary and middle school teachers.
        J Voice. 2017; 31: 258
        • Da Rocha LM
        • Behlau M
        • Souza L.
        Risk factors for recurrent perceived voice disorders in elementary school teachers-a longitudinal study.
        J Voice. 2021; 35: 325
        • Rossi-Barbosa LA
        • Barbosa MR
        • Morais RM
        • et al.
        Self-reported acute and chronic voice disorders in teachers.
        J Voice. 2016; 30: 755
        • Leão SH
        • Oates JM
        • Purdy SC
        • et al.
        Voice problems in New Zealand teachers: a national survey.
        J Voice. 2015; 29: 645
        • Moy FM
        • Hoe VC
        • Hairi NN
        • et al.
        Determinants and effects of voice disorders among secondary school teachers in Peninsular Malaysia Using a Validated Malay Version of VHI-10.
        PloS One. 2015; 10e0141963
        • Vertanen-Greis H
        • Löyttyniemi E
        • Uitti J.
        Voice disorders are associated with stress among teachers: a cross-sectional study in Finland.
        J Voice. 2020; 34: 488
        • Marques da Rocha L
        • Behlau M
        • Dias de Mattos Souza L
        Behavioral dysphonia and depression in elementary school teachers.
        J Voice. 2015; 29: 712-717
        • Korn GP
        • Augusto de Lima Pontes A
        • Abranches D
        • et al.
        Hoarseness and risk factors in university teachers.
        J Voice. 2015; 29: 518
        • Rossi-Barbosa LAR
        • Guimarães DHF
        • Arantes EDS
        • et al.
        Teachers’ self-referred chronic dysphonia associated factors.
        Rev Fund Care Online. 2019; 11: 411-416
        • Gomes A
        • Martins F
        • Mariade T
        • et al.
        Diagnostic validity of Voice Handicap Index-10 (VHI-10) compared with perceptive-auditory and acoustic speech pathology evaluations of the voice.
        J Voice. 2010; 24: 715-718
        • Fillis MM
        • Andrade SM
        • González AD
        • et al.
        Frequency of self-reported vocal problems and associated occupational factors in primary schoolteachers in Londrina, Paraná State, Brazil.
        Cad Saude Publica. 2016; 32×00026015
        • Nusseck M
        • Spahn C
        • Echternach M
        • et al.
        Vocal health, voice self-concept and quality of life in German school teachers.
        J Voice. 2020; 34: 488
        • Pestana PM
        • Vaz-Freitas S
        • Manso MC.
        Prevalence of voice disorders in singers: systematic review and meta-analysis.
        J Voice. 2017; 31: 722-727
        • Hoffmann F
        • Eggers D
        • Pieper D
        • et al.
        An observational study found large methodological heterogeneity in systematic reviews addressing prevalence and cumulative incidence.
        J Clin Epidemiol. 2020; 119: 92-99
        • Simões-Zenari M
        • Latorre Mdo R.
        Mudanças em comportamentos relacionados com o uso da voz após intervenção fonoaudiológica junto a educadoras de creche [Changes in behavior associated to the use of voice after a speech therapy intervention with professionals of child day care centers].
        Pro Fono. 2008; 20: 61-66
        • Lin FC
        • Chen SH
        • Chen SC
        • et al.
        Correlation between acoustic measurements and self-reported voice disorders among female teachers.
        J Voice. 2016; 30: 460-465
        • Chan RW.
        Does the voice improve with vocal hygiene education? A study of some instrumental voice measures in a group of kindergarten teachers.
        J Voice. 1994; 8: 279-291
        • Duffy OM
        • Hazlett DE.
        The impact of preventive voice care programs for training teachers: a longitudinal study.
        J Voice. 2004; 18: 63-70
        • Godall P
        • Gassull C
        • Godoy A
        • et al.
        Epidemiological voice health map of the teaching population of Granollers (Barcelona) developed from the EVES questionnaire and the VHI.
        Logoped Phoniatr Vocol. 2015; 40: 171-178
        • Gauer RL.
        Otolaryngeal and oropharyngeal conditions: dysphonia.
        FP Essent. 2021; 501: 11-16
        • Cohen SM
        • Kim J
        • Roy N
        • et al.
        Prevalence and causes of dysphonia in a large treatment-seeking population.
        Laryngoscope. 2012; 122 (PMID: 22271658): 343-348
        • Van Houtte E
        • Van Lierde K
        • D'Haeseleer E
        • et al.
        The prevalence of laryngeal pathology in a treatment-seeking population with dysphonia.
        Laryngoscope. 2010; 120: 306-312
        • Butler JE
        • Hammond TH
        • Gray SD.
        Gender-related differences of hyaluronic acid distribution in the human vocal fold.
        Laryngoscope. 2001; 111: 907-911
        • Viswanathan M
        • Ansari MT
        • Berkman ND
        • et al.
        Assessing the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions. Agency for Healthcare Research and Quality Methods Guide for Comparative Effectiveness Reviews.
        AHRQ Publication No, 2012 (12-EHC047-EF. Available in)
        • Cuschieri S
        The STROBE guidelines.
        Saudi J Anaesth. 2019; 13: S31-S34
        • Mattiske JA
        • Oates JM
        • Greenwood KM.
        Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment.
        J Voice. 1998; 12: 489-499
        • Patel RR
        • Awan SN
        • Barkmeier-Kraemer J
        • et al.
        Recommended protocols for instrumental assessment of voice: american speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
        Am J Speech Lang Pathol. 2018; 27: 887-905
        • Roy N
        • Barkmeier-Kraemer J
        • Eadie T
        • et al.
        Evidence-based clinical voice assessment: a systematic review.
        Am J Speech Lang Pathol. 2013; 22: 212
        • Wolf J
        • Prüss-Ustün A
        • Ivanov I
        • et al.
        Preventing Disease Through a Healthier and Safer Workplace.
        World Health Organization, Geneva, SwitzerlandLicense: CC2018 (BY-NC-SA 3.0 IGO)
        • Faham M
        • Ahmadi A
        • Drinnan M
        • et al.
        The effects of a voice education program on VHI scores of elementary school teachers.
        J Voice. 2016; 30: 755
        • Karjalainen S
        • Sahlén B
        • Falck A
        • et al.
        Implementation and evaluation of a teacher intervention program on classroom communication.
        Logoped Phoniatr Vocol. 2020; 45: 110-122
        • López JM
        • Catena A
        • Montes A
        • et al.
        Effectiveness of a short voice training program for teachers: a preliminary study.
        J Voice. 2017; 31: 697-706
        • Pizolato RA
        • Beltrati Cornacchioni Rehder MI
        • dos Santos Dias CT
        • et al.
        Evaluation of the effectiveness of a voice training program for teachers.
        J Voice. 2013; 27: 603-610
        • Meier B
        • Beushausen U.
        Long-Term effects of a voice training program to prevent voice disorders in teachers.
        J Voice. 2021; 35: 324
        • Pasa G
        • Oates J
        • Dacakis G.
        The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers.
        Logoped Phoniatr Vocol. 2007; 32: 128-140
        • Munier C
        • Brockmann-Bauser M
        • Laukkanen AM
        • et al.
        Relationship between laryngeal signs and symptoms, acoustic measures, and quality of life in finnish primary and kindergarten school teachers.
        J Voice. 2020; 34: 259-271
        • Bottalico P
        • Graetze S
        • Hunter EJ.
        Effects of speech style, room acoustics, and vocal fatigue on vocal effort.
        J Acoust Soc Am. 2016; 139: 2870
        • Abou-Rafée M
        • Zambon F
        • Badaró F
        • et al.
        Vocal fatigue in dysphonic teachers who seek treatment.
        Codas. 2019; 31e20180120
        • Phyland D
        • Miles A.
        Occupational voice is a work in progress: active risk management, habilitation and rehabilitation.
        Curr Opin Otolaryngol Head Neck Surg. 2019; 27: 439-447
        • Nusseck M
        • Immerz A
        • Spahn C
        • et al.
        Long-term effects of a voice training program for teachers on vocal and mental health.
        J Voice. 2021; 35: 438-446
        • Sundram ER
        • Norsa'adah B
        • Mohamad H
        • et al.
        The effectiveness of a voice care program among primary school teachers in Northeastern Malaysia.
        Oman Med J. 2019; 34: 49-55
        • Niebudek-Bogusz E
        • Śliwińska-Kowalska M.
        An overview of occupational voice disorders in Poland.
        Int J Occup Med Environ Health. 2013; 26: 659-669
        • Mailänder E
        • Mühre L
        • Barsties B.
        Lax Vox as a voice training program for teachers: a pilot study.
        J Voice. 2017; 31: 262
        • Cantor Cutiva LC
        • Puglisi GE
        • Astolfi A
        Four-day follow-up study on the self-reported voice condition and noise condition of teachers: relationship between vocal parameters and classroom acoustics.
        J Voice. 2017; 31: 120
        • Masson MLV
        • de Araújo TM.
        Protective strategies against dysphonia in teachers: preliminary results comparing voice amplification and 0.9% NaCl Nebulization.
        J Voice. 2018; 32 (e1-257.e10): 257
        • Sinkiewicz A
        • Garstecka A
        • Mackiewicz-Nartowicz H
        • et al.
        Sanatoryjna rehabilitacja głosu u nauczycieli [Teachers' voice rehabilitation in sanatorium conditions].
        Med Pr. 2021; 72 (Polish): 399-405
      3. Nallamuthu A, Boominathan P, Arunachalam R, et al. Outcomes of vocal hygiene program in facilitating vocal health in female school teachers with voice problems. J Voice. 2021;19:S0892-1997(21)00018-7.

        • de Oliveira Bastos PRH
        • Hermes EC
        Effectiveness of the teacher's vocal health program (TVHP) in the municipal education network of campo grande, MS.
        J Voice. 2018; 32: 681-688
        • Dragone ML.
        Voice activity and participation profile presenting coordinates for readjustment of preventive action of educators.
        Folia Phoniatr Logop. 2011; 63: 49-54
        • Alves IAV
        • Paulino VCP
        • Souza ALR
        • et al.
        Voice care from the student teachers' perspective.
        J Voice. 2021; 35: 664
        • Pizolato RA
        • Rehder MI
        • Meneghim Mde C
        • et al.
        Impact on quality of life in teachers after educational actions for prevention of voice disorders: a longitudinal study.
        Health Qual Life Outcomes. 2013; 27: 28
        • Schiavetti N
        • Metz D
        • Orlikoff R.
        Evaluating Research in Communicative Disorders.
        6th ed. Pearson, Hoboken, NJ2011
        • Gall M
        • Gall J
        • Borg W.
        Educational Research.
        8th Edición. Pearson, Boston2007
      4. American Speech-Language-Hearing Association. Voice Disorders. (Practice Portal). N.D. Available in Retrieved October, 15, 2021

        • Behlau M
        • Zambon F
        • Madazio G.
        Managing dysphonia in occupational voice users.
        Curr Opin Otolaryngol Head Neck Surg. 2014; 22: 188-194
        • Szeszenia-Dąbrowska N
        • Wilczyńska U.
        Occupational diseases in Poland–an overview of current trends.
        Int J Occup Med Environ Health. 2013; 26: 457-470
        • Masson M
        • Ferrite S
        • Pereira L
        • et al.
        Seeking the recognition of voice disorder as work-related disease: historical-political movement.
        Cien Saude Colet. 2019; 24: 805-816
        • Superintendencia de Seguridad Social
        Compendio de Normas del Seguro Social de Accidentes del Trabajo y Enfermedades Profesionales.
        Santiago, Chile2018 (Available from:)