Protective and Risk Factors Associated With Voice

Strain Among Teachers in Castile and Leon, Spain:

Recommendations for Voice Training

n de los Tratamientos
Factores de Riesgo y Proteccio

tricos en Docentes de Castilla y Leo

n: Pautas
Fonia

n Vocal
para la Formacio
~ ez, and Ioseba Iraurgi, *Burgos and yBilbao, Spain
*Silvia Ubillos, *Javier Centeno, *Jaime Iban
Summary: Objectives. The aim of this research was to know the protective and risk factors associated with voice
strain in teachers.
Method and Study Design. A total of 675 teachers from Castille and Le
on, Spain took part in the research within an
age range between 23 and 66 years (from nursery school to university). A cross-sectional, descriptive, and analytic
design was applied to data from a self-administered questionnaire.
Results. The research showed that 16.4% had suffered some voice disorder and a remarkable percentage had never
received any kind of voice training. The bivariate and multivariate analyses show that the size of the classroom, being
a primary school teacher, teaching physical education, the noise caused by the students in the classroom, the struggle to
keep the order within the class, raising the voice, and bad sleep are risk factors in the voice disorders. Each learning stage
features a different risk factor, namely in nursery school, the noise caused by the pupils; in primary education, raising the
voice; and in secondary education, the struggle to keep the order within the class. All these risk factors are linked with
each other.
Conclusions. The preventive measures must provide adequate answers to the voice requirements for every subject
and stage, and these preventive measures must be based on the educational psychology principles to help the teachers
deal with the problems originated by the lack of authority or the noise made by the students, using the proper voice
techniques.
Key Words: Phoniatric pathologyTeachersProtective and risk factorsVoice training.
INTRODUCTION
Several researchers confirmed years ago that there is an
intrinsic relationship between voice-related problems and
teaching.15 Nevertheless, despite the scientific evidence, the
voice-related disorders in the teaching profession appear, in
Spain, in a recent list of occupational illnesses, although they
did not enter into force until January 1, 2007.6
Different studies2,714 have noted the high prevalence of voice
disorders among professional teachers, fluctuating between 17%
and 63%, reaching an high of 80%. The review performed by
Garcia et al14 confirmed the high prevalence of voice disorders
in teachers, for whom it is two- to three-fold more frequent
than for the general population. As other authors15,16 have
indicated, the prevalence of voice disorders among teachers
varies significantly owing to the different sampling procedures,
the different operationality of the voice problem variable, the
methodological strategies used to detect the presence of a
phoniatric disorder, the different ways of recording these
disorders, and the increase in voice disorders over recent years.

Accepted for publication August 11, 2014.

From the *University of Burgos, c/ Villadiego s/n, Burgos, Spain; and the yUniversity of
Deusto, Avenida de las Universidades, Bilbao, Spain.
Address correspondence and reprint requests to Silvia Ubillos, University of Burgos, c/
Villadiego s/n, 09001 Burgos, Spain. E-mail: subillos@ubu.es
Journal of Voice, Vol. 29, No. 2, pp. 261.e1-261.e12
0892-1997/$36.00
2015 Published by Elsevier Inc. on behalf of The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.08.005

In response to this situation, it was necessary to know what

the protective and the risk factors were in the face of possible
voice problems. All of these were with a view to developing
programs with the objective of endowing students and professional teachers with a larger amount of positive and healthy
resources and practices, both in the field of work and in their
personal life.
Aspects related to voice pathologies were divided into
different factors to give the investigation clear boundaries,
namely sociodemographic characteristics, working conditions,
class management techniques, voice training, and certain
healthy habits.
Among various sociodemographic characteristics, most
studies2,10,1723 have shown that the prevalence of phoniatric
disorders is higher in women than in men. Some authors18,24
explain that women have a smaller larynx and the vibration
frequencies of their vocal folds are higher than men, which
itself is a cause of more voice disorders.
With regard to working conditions, the educational level at
which teachers exercise their profession, their years as a
teacher, the subject matter they teach, the number of weekly
teaching hours, and the number of students in the class have
all been studied.
Studies have found that, in general, nursery, primary, and secondary school teachers are those presenting the highest rate of
voice pathologies, whereas the prevalence of this type of disorder among university teachers is less frequent.15,22,25,26 Among

261.e2
the possible causes, Ga~
net et al10 argue that voice strain in the
university setting is less prevalent owing to the reduced number
of classroom hours and the age of the students.
It is generally accepted that vocal performance decreases
with age, especially among voice strained professions, which
may lead to occupational dysphonia throughout the teaching
years. However, two studies27 pointed out that there is no unanimity over the years of teaching experience. Some researchers4,10,28 found that the longer the length of service, the
greater the prevalence of teachers with the symptoms of
voice-related disorders, although length of service might also
be a protective factor, as classroom practice could always
improve with experience. Accordingly, Kooijman et al29
confirmed a decrease of voice complaints during the career of
the teachers. On the other hand, authors such as Chen et al,30
Preciado et al,11 or Tavares and Martins31 stated that the age
and years spent teaching had no cumulative effect on voice disorders among teaching staff.
If we look at teaching load, a great number of researchers26,31
33
noted that dysphonic patients had more classroom hours a
week than nondysphonic patients. Nevertheless, there is no
agreement on this variable. In other studies,10,28,34 teaching
load was not associated with phoniatric pathologies.
The referenced literature underlines that the appearance of
dysphonias is strongly associated with the teaching of certain
subjects, such as foreign languages, language and literature,
mathematics, music, and physical education.4,16,22 According
to Preciado,26 the increase of voice disorders among teachers
of language and literature and foreign languages is owing to
the predominance of oral over written work in the classroom.
Mathematics teachers put a lot of information on the blackboard
and (in the absence of interactive whiteboards) inhale a lot of
chalk dust, which deposits itself on the laryngeal mucous
complicating the lubrication of the larynx and exacerbating
symptoms of irritation, coughing, and rasping, thereby
increasing phonatory voice disorders. With regard to music
teachers, they are more likely to suffer frequent voice disorders
because of inappropriate changes from song to the spoken
word. Cantor Cutiva et al27 noted that several publications
consistently observed that physical education teachers reported
voice disorders more often than teachers of other subjects. A
possible explanation is that those teachers are forced to work
in open or very roomy places with poor acoustics as well as talking, while demonstrating the exercises, being both damaging
factors for the voice.
The number of students in the classroom has been marked by
several authors as a risk factor for voice problems.14,23,26,29,31
The study performed by Preciado26 stated that at the level of nursery education and the first years of primary education, dysphonic
teachers had a higher number of students than nondysphonic
teachers. Urrutikoetxea et al13 considered that having a lower
number of students in class might suppose less voice exertion.
The way teachers perceive noise generated by students in the
classroom and their capability to maintain order in the classroom, as well as the phonatory techniques they used to capture
the attention of students also appear to play an important role in
voice problems.

Journal of Voice, Vol. 29, No. 2, 2015

It is understood that one among other factors that contributes

to the development of dysphonia among teachers is a noisy
environment.1,14,22,23,27,33,3540 Adverse acoustic conditions in
school rooms (inappropriate materials of walls, ceilings and
floors that propagate noise and reverberations, not using voice
amplification to decrease phonotory overload, and so on.)
and the students themselves, either because of their age or
because of their behavior, may all be the sources of noise. On
numerous occasions, the noisy environment is so strong that
teachers raise their voices above the recommended level of
decibels (from 58 to 90.5 dB), which involves an important
risk of suffering vocal cord injuries.14,41
Likewise, many authors16,28,42 have recognized that a lack of
classroom behavioral management is linked to the development
of voice disorders. In the study by Hern
andez,43 when discipline
is poor, the teacher will be four times more likely to suffer from
dysphonia, probably because teachers resorted to ineffective
techniques to maintain order, such as forcing the voice or shouting. It has been seen that this type of phonatory practice is very
common among teachers, as they do not know how to use natural
resonances in an effective way, all too often injuring their vocal
ligaments.44 Diverse studies2,26,27,30,36,45,46 confirmed that
voice strain and being loud among teachers is one of the main
causes of voice-related pathologies.
Hence, numerous researchers7,28,4749 recommend training
in phonoaudiological techniques to teach the necessary skills
to manage the voice in an acceptable way and, thus, to
prevent possible problems with the vocal cords. However,
Gassull et al50 indicate that voice training for students and professional teachers in Universities is scarce. Various authors
have noted that teachers possess few corporal and voicerelated resources, such as training on speech disorders,20
postural alignment for voice production,51 or vocal function exercises, resonant voice exercises, relaxation, and yoga techniques,52,53 which leaves them with insufficient techniques to
attend to and to satisfy such exhausting and rigorous voicerelated needs that the teaching profession requires.54
With regard to healthy habits, numerous investigations38,43,46,55 have identified excessive smoking and alcohol
consumption as important risk factors for dysphonia because
these two habits, either together or separately, produce less
hydration of the respiratory tract, slight edema in the vocal
cords, and reddening and irritation of the respiratory mucous.
Neither does a definitive agreement exist between experts on
the efficacy of the principal protective measures to counter
voice disorders among professional voice users such as the
example of healthy life styles (food, physical exercise, and so
on).56 However, sleep disorders are further health-related habits
associated with the emergence of morbid phoniatric symptoms.46 It appears that sleep facilitates recovery.10
For all these reasons, the objectives of this study are, on the
one hand, to analyze the relation that exists between these aspects and phoniatric disorders among teachers. On the other
hand, it establishes both the protective and the risk factors that
best predict the emergence of voice pathologies among teaching
professionals. Finally, it suggests a series of lines of action to
contribute to the prevention of voice disorders among teachers.

Silvia Ubillos, et al

Protective and Risk Factors in Voice Strain

METHOD
This study applied an analytical cross-sectional design in which
the variable result (phoniatric treatment) and the variables of
exposure (sociodemographic, working conditions, training
behavioral, and so on) were simultaneously measured.
Sample
A total of 675 teachers from the Autonomous Region of Castile
and Leon, Spain participated in this study. The average age of
the sample was approximately 46.96 years (standard
deviation 9.43) and the range fluctuated between 23 and 66
years. The sample comprised both women (59.2%) and men
(40.8%). According to the statistics supplied by the Ministry
of Science and Innovation and the Ministry of Education, the
percentages of male and female teachers in Castile and Leon,
Spain (from higher and further education and obligatory
schooling) over the period of data collection were 35.96%
men and 64.05% women, which reflect the same ratios as in
this study.
Instrument of measurement
An ad hoc questionnaire was designed for this study that was
self-administered. Its questions were prepared on the basis of
the questionnaire that Jackson-Menaldi57 proposed for voice
evaluation, divided into a series of thematic blocks, namely
sociodemographic characteristics (sex and age), working conditions (educational level, working experience, material,
weekly classroom hours, and class size), voice training (questions on voice training), perception of noisy environments,
and vocal cord abuse (perceptions that teachers hold of the
noise generated in the classroom, the capability to maintain order, and the use of some negative techniques for the development of voice disorders such as raising the voice), voice
health (consulting a general practitioner [GP], otorhinolaryngologist, and/or phoniatrician, for voice problems, sick leave,
and phoniatric treatments) and health-related habits (smoking,
drinking, food, sleep quality, and sporting activity).
The response scales were either nominal (eg, men/women,
nursery/secondary/university, yes/no, a lot/a little/not at all,
and always/a little/never) or ordinal (eg; between 0 and 5
years/between 6 and 10 years/between 11 and 15 years/more
than 15 years).
Procedures
The questionnaires were delivered through two different channels either by post to each educational center or they were
personally delivered. The information was collected at various
educational centers in the Autonomous Community of Castile.
These centers were chosen at random from among secondary
schools, institutes, and universities, both private and public,
which ranged from nursery education up to university studies.
Participation was voluntary, and participants could withdraw
from the study at any time. No social security number or other
identification data were asked, and no invasive examinations
were made. The project was conducted with the approval of
each municipalitys school and colleges authorities.

261.e3

Statistical analysis
The data obtained were processed with the statistical software
program SPSS 18.0 (IBM SPSS statistics 18.0). Contingency tables were applied to analyze the associations between different
variables and the phoniatric treatment, together with the statistical index c2 and the analysis of the standardized (adjusted) residuals. These analyses were also used to ascertain the existing
relations between sociodemographic characteristics and working conditions with perception of noisy environments and vocal
cord abuse. However, the logistical regression models were
applied to investigate the causal factors of phoniatric treatments
in teachers and to study what factors modify the probability of a
particular outcome. We selected the odds ratio as the parameter
to study the strength of the statistical association, as the study
sample is not statistically representative of the population.
This index tells us how many times the illness is more likely
to be contracted in the presence of a particular factor rather
than in its absence. The determined estimated significance level
was P  0.05.
RESULTS
Our objective was to identify both risk and protective factors
associated with phoniatric pathologies and consequently with
their treatment. To do so, people who requested phoniatric treatment were contrasted with those who did not request this type of
treatment. We selected phoniatric treatment as the dependent
variable because it is the best proxy we have for the true incidence of vocal pathologies, as it reflects the greatest seriousness
from among all of the variables under examination. Variables
such as visits to the GP because of voice-related ailments and
to the otorhinolaryngologist and the phoniatrician were ruled
out as less-sensitive indicators of voice-related pathologies.
Sick leave was also ruled out as a possible dependent variable
because it was less restrictive than medical treatment. Moreover, we have confirmed that phoniatric treatment presents significant and positive correlations with the other indicators of
phoniatric disorders.
We found that 16.4% of the sample of teaching staff from
Castile and Leon, Spain were once administered a treatment
to cure voice disorders. With regard to the other indicators,
57% of the sample went to the family doctor because of voice
ailments, 71% visited the laryngologist and/or phoniatrician,
and 36.2% went on sick leave once because of voice-related ailments. In addition, the percentage of teachers who had not
received any type of voice training is really high, at more
than half of the sample (52.2%).
Variables associated with phoniatric treatment
With regard to the sociodemographic characteristics and working conditions, the comparative analysis indicated that phoniatric treatment was not associated in a significant way with either
the sex or the educational level or the length of service or the
number of teaching hours of the teachers. However, the analysis
of adjusted residuals indicated that the number of nursery education teachers who have received some type of phoniatric
treatment was higher than predicted, whereas the number of

261.e4
teachers with 610 years of teaching experience, who have followed phoniatric treatment, was statistically lower than the predicted frequency.
The two variables related in a statistically significant way
with phoniatric treatment are the subject that is taught and the
size of the class. Analysis of the standardized (adjusted) residuals indicated that the number of teachers of physical education
and sciences as well as the number of teachers with more than
20 students who have received phoniatric treatment is greater
than the number that was statistically predicted, whereas the
number of teachers of music and the arts who have received
this type of treatment was statistically less than predicted.
Voice training also has a very statistically significant relation
with phoniatric treatment. Surprisingly, the number of teachers
who have received voice training in speaking and who have
received phoniatric treatment is greater than the predicted
value, if both variables were independent.
The perception of noise generated by students, the difficulties
of maintaining order in the classroom, and the technique of
relying forcing or raising their voice to maintain discipline in
class are associated in a significant way with phoniatric treatment. In particular, the number of teachers who have followed
voice therapy and who consider that their students speak a lot in
class, who find it difficult to maintain order, and who force or
raise their voice in class was higher than the predicted
frequency.
Among the healthy habits, the variables that are associated in
a significant way with phoniatric treatment are: smoking,
sleeping, and alimentary habits. In a surprising way, the number
of teachers who have received phoniatric treatment and who say
that they do not usually smoke or that they are careful about
their diet was greater than the predicted value. On the contrary,
the number of teachers who received phoniatric treatment and
who slept well was lower than predicted (Table 1).
Variables associated with the perception of noise
and teaching techniques to manage behavior in the
classroom
In the earlier section, we have shown that voice disorders are
associated with a series of perceptions among teachers such
as the noise generated in the classroom by their students, lack
of discipline, and a series of behavioral patterns that are harmful
to the voice (forcing the voice).
On the other hand, the data show that these perceptions and
poor behaviors present a very significant and positive association (P < 0.001), structuring a constellation of perceptions and
behaviors that are in turn associated with phoniatric treatment.
Preciado26 noted the relation that exists between these aspects,
in such a way that classroom noise that bothers most teachers
obliges them to raise their voice to make themselves heard
and to impose their authority.
We analyzed the profiles of the teachers from our sample that
presented these perceptions and risk behaviors, as when
coupled with vocal abuse behaviors, they were all associated
with voice disorders.
The perception of noise generated by the students was associated in a statistically significant way with sex, educational

Journal of Voice, Vol. 29, No. 2, 2015

level, length of service, the weekly number of teaching hours,

and the subject that is taught. The analysis of adjusted residuals
indicated that the number of teachers who believed that their
students spoke too much during the classes was statistically
greater than that predicted among men, nursery education
teachers, teachers with little work experience (from 0 to 5
years), teachers of physical education and geography, and those
who gave more than 16 hours of class weekly (Table 2).
The difficulties of maintaining order in the classroom are
related in a tendential way with sex and in a significant way
with the educational stage, length of service, number of weekly
teaching hours, and the subject matter. The data on the analysis
of adjusted residuals showed that the number of teachers who
confessed to having discipline problems in the classroom was
statistically greater than that predicted among men, secondary
school teachers, those with less than 10 years teaching experience, those who had a high weekly teaching load (between 16
and 20 hours), and teachers of plastic arts and geography
(Table 3).
Vocal cord abuse such as forcing or raising the voice was also
found to be related in a statistically significant way with sex,
educational level, length of service, teaching load, and the subject that is taught. The results from the analysis of the adjusted
residuals made it clear that the number of teachers who use this
unsatisfactory resource to maintain discipline in the classroom
was greater than that statistically predicted among men; teachers of primary education; those with more than 15 years of
teaching experience; those who impart more than 16 hours of
class every week; and teachers of plastic arts, sciences, geography, and generalists (Table 4).
Protective and risk factors in phoniatric treatments
As our objective is to identify both the protective and the risk
factors associated with phoniatric pathologies and by doing
so their treatment, the people who received phoniatric treatment
(a condition assigned a value of one) were contrasted with those
who did not receive this type of treatment (assigned a value of
0). The relation between the factors and dependent variable
(phoniatric treatment) was analyzed through logistic regression
techniques where the magnitude of the association between the
variables is determined by the odds ratio (OR). In the case of
there being no relation between the dependent variable and
the factor, the value of OR is 1, values more than 1 will define
a risk factor, whereas values lower than 1 will be indicative of
a protection factor. Likewise, the confidence intervals of 95%
for the estimations of the ORs were calculated by using the
standard errors of the regression parameters.
In the first place, the raw ORs were calculated for each
explanatory variable using simple logistic regression models
and the number of contemplated predictors. A multiple logistic
regression model was used to estimate the joint effect, taking
the variable elimination method step by step, beginning with
the model that includes all the variables without interactions
(complete or principal effects model). The meaning of the eliminated variables was evaluated with the likelihood-ratio test between the nested models. In general, we should consider this to
be an exploratory analysis of the data.

Silvia Ubillos, et al

261.e5

Protective and Risk Factors in Voice Strain

TABLE 1.
Teaching Staff Variables Associated With Phoniatric Treatments
Variables
Sex
Men
Women
Educational level
Nursery
Primary
Secondary
University
Work experience (y)
05
610
1115
+15
Weekly classroom (h)
05
610
1115
1620
+20
Subject taught
Physical education
Music
Plastic arts
Sciences
Arts
Geography
Support
All
Number of students in class
Between 0 and 20
More than 20
Voice training
Yes
No
Perception of student noise levels
A lot
A little/nothing
Difficulties maintaining order
Yes
No
Raising or forcing the voice
Yes
Not
Consume alcohol
Yes
No
Practice a sport
Yes
No
Smoke
Yes
No
Dietary habits
Yes
No
Rest
Yes
No

Treatment (%)

c2/P Value

No Treatment (%)
c

17.3
16.9

82.7
83.1

25
13.2
18.9
13.8

75
86.8
81.1
86.2

(1,645) 0.02;

P 0.888

c2 (3,600) 7.22; P 0.065

c2 (3,630) 5.29; P 0.152

20
7.1
16.7
17.9

80
92.9
83.3
82.1
c2 (4,620) 3.82; P 0.431

0
13.6
20
20
15.7

100
86.4
80
80
84.3

37.5
6.7
0
21.7
9.4
0
0
16.7

62.5
93.3
100
78.3
90.6
100
100
83.3

c2 (7,545) 35.05; P  0.0001

c2 (1,625) 4.78; P 0.029

9.5
18.3

90.5
81.7
c2 (1,665) 44.87; P  0.0001

26.6
7.2

73.4
92.8

25
10.3

75
89.7

c2 (1,650) 25.04; P  0.0001

c2 (1,650) 60.58; P  0.0001
36.7
10

63.3
90
c2 (1,655) 4.00; P 0.045

19.3
13.5

80.7
86.5
c2 (1,635) 1.27; P 0.259

20.8
16.5

79.2
83.5
c2 (1,670) 0.78; P 0.376

17.2
14.3

82.8
85.7

9.5
18.2

90.5
81.8

c2 (1,655) 4.73; P 0.030

c2 (1,665) 4.45; P 0.035
17.9
9.5

82.1
90.5
c2 (1,660) 12.74; P  0.0001

14.4
28.6

85.6
71.4

261.e6

Journal of Voice, Vol. 29, No. 2, 2015

TABLE 2.
Variables Associated With the Perception of Student Noise Levels
Perception of Student Noise Levels
Variables
Sex
Men
Women
Educational level
Nursery
Primary
Secondary
University
Work experience (y)
05
610
1115
+15
Weekly classroom (h)
05
610
1115
1620
+20
Subject taught
Physical education
Music
Plastic arts
Sciences
Arts
Geography
Support
All
Number of students in class
Between 0 and 20
More than 20

A Lot

Little/Nothing

c2/P Value
c2 (1,630) 4.39; P 0.036

45.3
37

54.7
63
c2 (3,590) 90.08; P  0.0001

81.3
43.2
36.1
17.2

18.7
56.8
63.9
82.8
c2 (3,620) 19.19; P  0.0001

60
46.7
16.7
40.2

40
53.3
83.3
59.8

0
9.1
0
46.2
56

100
90.9
100
53.8
44

c2 (4,610) 110.71; P  0.0001

c2 (7,535) 65.24; P  0.0001

77.8
42.9
50
21.7
29
100
0
39.1

22.2
57.1
50
78.3
71
0
100
60.9

42.1
39.4

57.9
60.6

c2 (1,615) 0.24; P 0.623

In Table 5, the results of 23 simple logistic regression analyses are presented; one for each factor that is contemplated.
It may be seen that in 13 cases, the association between the factor and the variable result is statistically significant. Among
these same factors, six are risk related and the other seven are
protective factors.
The risk factors to determine the position of the teachers who
received phoniatric treatment, as opposed to those who did not
receive this type of treatment, are listed in accordance with the
magnitude of their effect: the perception that order is only
maintained in the classroom with difficulty, having received
voice training, the perception that students speak more in class,
a class size of more than 20 students, and telling students to be
quiet by raising or forcing the voice. Paradoxically, the people
who said that they had healthy eating habits also presented a
greater risk of following therapeutic treatment. This unexpected
result may be because responsibility for personal dietary habits
is related to other health-related practices, such as visiting the
doctor for check-ups and undergoing therapy, as against other
teachers that might also need treatment, but do not visit
specialist doctors.58

In contrast, the protection factors associated with phoniatric

treatment are: being a teacher of music, arts teacher or a generalist as opposed to teachers of physical education, having sufficient rest and sleeping well, and being a primary or university
teacher as opposed to nursery school teachers. Surprisingly,
teachers who confess to smoking presented a lower risk of
phoniatric treatment. The explanation behind these data may
reside in the unwillingness of many smokers to stop their addiction to nicotine and the fact of having to visit the doctor. The
58


study by Alvarez
concluded that people with harmful life
styles, such as smokers, visit the doctor less than smokers
who lead more healthy life styles, and that might be because
they are less sensitive to health problems.
A multiple regression model was applied with a total of 13
variables to obtain the most parsimonious model to arrive at
an acceptable explanation of the results, by only introducing
those that gave statistically significant differences in the bivariate analysis (except in the case of secondary school teachers
and science teachers). With this aim, voice training was not
included in the questionnaire as, even if there was a specific
question about the received courses in their formation stage

Silvia Ubillos, et al

261.e7

Protective and Risk Factors in Voice Strain

TABLE 3.
Variables Associated With Difficulties Over Maintaining Order in the Classroom
Difficulties over maintaining
order in the classroom
Variables
Sex
Men
Women
Educational level
Nursery
Primary
Secondary
University
Work experience (y)
05
610
1115
+15
Weekly classroom (h)
05
610
1115
1620
+ 20
Subject taught
Physical education
Music
Plastic arts
Sciences
Arts
Geography
Support
All
Number of students in class
Between 0 and 20
More than 20

Yes

No

26.9
20.5

73.1
79.5

c2/P Value
c2 (1,625) 3.46; P 0.063
c2 (3,585) 40.05; P  0.0001

20
21.6
36.1
6.9

80
78.4
63.9
93.1

60
35.7
25
18.5

40
64.3
75
81.5

c2 (3,615) 31.37; P  0.0001

c2 (4,605) 65.17; P  0.0001

0
4.5
0
38.5
22.4

100
95.5
100
61.5
77.6
c2 (7,530) 34.12; P  0.0001

28.6
21.4
50
26.1
15.6
100
0
26.1

71.4
78.6
50
73.9
84.4
0
100
73.9
c2 (1,610) 1.09; P 0.296

19
23.8

as teachers, and despite the fact that the bivariate data proved
this variable as a risk factor, this result is possibly originated
because most teachers have received voice training as a type
of phoniatric therapy, maybe creating an overlap between
both variables. Apart from erasing the confusion in the results
and in the interpretation, erasing this variable did not modify
the results substantially.
The logistic regression model, using a joint input analysis
procedure, offered a significant adjustment index (2LL:
279.02: c2 (14) 91.07; P 0.0001) and produced an acceptable level of correct classifications of the typology (85.4%).
The value R2 of Nagelkerke shows that 33% of the variation
in the dependent variable is explained by the variables included
in the model. From among the 13 factors included in the analysis, three were significant, one corresponded to risk factors,
and one to protection (Table 6).
The only risk factor related to phoniatric treatment was
raising or forcing the voice. On the other hand, the following
may be found among the protective factors: the fact of being
a teacher of arts involves a protection factor for phoniatric

81
76.2

treatments, as opposed to being a teacher of physical education,

and certain healthy habits such as sleeping well.

DISCUSSION
A total of 16.4% of the teachers in Castile and Leon, Spain
have been shown to present some sort of vocal pathology.
This percentage was obtained with a restrictive indicator of
voice disorders, which is having followed some type of
phoniatric treatment, in a similar way to other studies. The
prevalence indices of voice pathologies found by other researchers using this criterion fluctuate between a 5.9% and
a 33%.59,60 Although the phoniatric therapy has been
frequently used as an indicator of the presence of voice
pathology, not all teachers with symptoms related to vocal
use have sought treatment or professional help. Therefore,
this study may underestimate their true prevalence in the
teaching population compared with other indicators. Despite
the subjective measures being valid and reliable methods of
data collection, the use of more objective instrumental

261.e8

Journal of Voice, Vol. 29, No. 2, 2015

TABLE 4.
Variables Associated With Inappropriate Voice Techniques: Forcing or Raising the Voice
Forcing or Raising the Voice
Variables
Sex
Men
Women
Educational level
Nursery
Primary
Secondary
University
Work experience (y)
05
610
1115
+15
Weekly classroom (h)
05
610
1115
1620
+20
Subject taught
Physical education
Music
Plastic arts
Sciences
Arts
Geography
Support
All
Number of students in class
Between 0 and 20
More than 20

Yes

No

c2/P Value
c2 (1,635) 6.12; P 0.013

49.1
39.2

50.9
60.8
c2 (3,595) 34.21; P  0.0001

50
55.6
44.7
24.1

50
44.4
55.3
75.9
c2 (3,625) 15.70; P 0.001

60
33.3
25
46.2

40
66.7
75
53.8

0
9.1
30
56.1
53.1

100
90.9
70
43.9
46.9

c2 (4,615) 82.69; P  0.0001

c2 (7,540) 96.51; P  0.0001

55.6
33.3
100
56.5
18.8
100
50
59.1

44.4
66.7
0
43.5
81.3
0
50
40.9

40
44.2

60
55.8

c2 (1,620) 0.61; P 0.435

methods for a more accurate calculation of the prevalence of

voice problems in teachers is recommended. Nevertheless,
apart from the used criteria or the instrument applied for
measuring, the prevalence of vocal difficulties among
teachers indicates that vocal dysfunction is a significant
problem in this professional group.
Despite the high presence of voice problems, we have noted
that a very high percentage of these teachers have received no
type of training for the voice, as it is not a subject that is found
in any of the current study plans for the specialist teacher
training courses. Evident from this study is the exclusive attention that should be given to all aspects of the field of educational
psychology that help the teacher to manage problems of lack of
authority and noise generated by students, in a satisfactory way.
Especially, using resources such as raising or forcing their voice
to maintain the order within the class appears as the main risk
factor in voice problems. As in the study from Angelillo
et al,7 those teachers who have detected that lack of authority
and who perceive that their students speak during the classes
are those who resort most to harmful strategies for the speech
apparatus, seeking to impose themselves through raising and

forcing the voice, in such a way that they present a greater likelihood of suffering from voice disorders.
Also special attention does have to be given to the classroom
size and to the educational cohort with which the teacher works,
as the teachers with large-sized classes and that specialized in
nursery education were those who received phoniatric treatment
more frequently. The educational level should not be a reason to
forget that primary and secondary school teachers also present
phoniatric symptoms and that they should therefore receive specific types of training and care with regard to preventive measures and voice care. This training should cover the specific
problems of each teaching group; although the main problem
in nursery education that teachers face is the noise generated
by their pupils, teachers in primary resorted to raising and forcing their voice, and teachers in secondary education face problems of discipline that are not confronted in an acceptable way.
We should not lose sight of the teaching staff with timetables
that have a heavy teaching load. The number of weekly classroom hours is linked to the perception of noise and the unsuitable educational techniques to keep discipline in the classroom
being precisely the nursery, primary, and secondary education

Silvia Ubillos, et al

261.e9

Protective and Risk Factors in Voice Strain

TABLE 5.
Factors Related to Phoniatric Treatment. Complete Model. Simple Bivariate Logistic Regression Analysis
Factors
Sex (women vs men)
Study level (nursery vs)
Primary
Secondary
University
Subject (physical education vs)
Music
Plastic arts
Sciences
Arts
Geography
Support
All
Work experience SE from  to +
Number of hours/weeks teaching (from  to +)
Average number of students (from  to +)
Students speaking in class (no vs yes)
Difficult to maintain order (no vs yes)
Raise or force the voice (no vs yes)
Voice training (no vs yes)
Smoking (no vs yes)
Drink (no vs yes)
Eat well (no vs yes)
Sleep well (no vs yes)
Sport (yes vs no)

ET

Wald

P-Value

Odds Ratio

95% Confidence Interval

0.030

0.21

0.020

0.888

0.97

0.641.47

0.79
0.36
0.73

0.34
0.32
0.35

5.51
1.25
4.32

0.019
0.264
0.038

0.45
0.70
0.48

0.230.88
0.371.31
0.240.96

2.13
20.69
0.77
1.76
20.69
20.69
1.10
0.19
0.05
0.75
1.07
1.65
0.43
1.53
0.75
0.29
0.72
0.86
0.22

0.57

0.40
0.43

0.41
0.14
0.10
0.35
0.22
0.23
0.21
0.24
0.35
0.25
0.35
0.25
0.25

14.11
0.00
3.76
17.14
0.00
0.00
7.24
1.88
0.23
4.60
23.69
53.50
3.97
39.71
4.55
1.27
4.29
12.21
0.78

0.0001
0.998
0.053
0.0001
0.999
0.999
0.007
0.171
0.630
0.032
0.0001
0.0001
0.046
0.0001
0.033
0.260
0.038
0.0001
0.376

0.12
0.00
0.46
0.17
0.00
0.00
0.33
1.21
1.05
2.12
2.92
5.21
1.53
4.63
0.47
1.33
2.06
0.42
1.24

0.040.36
0.00
0.211.01
0.070.40
0.00
0.00
0.150.74
0.921.60
0.871.26
1.074.23
1.894.49
3.358.11
1.012.33
2.877.46
0.240.94
0.812.19
1.044.10
0.260.68
0.772.02

teachers with an onerous teaching load who have most problems with the noise that their students cause and that resort
more frequently to harmful behavior for the voice.
Prevention programs should also take into consideration that
the working experience affects differently the risk factors associated to the presence of voice problems. On the one hand, we
have confirmed how teachers, as they gain further experience,

use more frequently a form of vocal cord abuse (raising or forcing the voice) increasing the risk of suffering phoniatric disorders of some sort or another at that age, although it would
appear a priori that experience could be a protective factor
against this type of problem. According to Scivetti,54 variable
and prolonged exertion of the voice in speaking professions,
added to inappropriate voice techniques, all too often mean

TABLE 6.
Factors Associated With Phoniatric Treatment. Reduced Model. Multivariate Analysis of Logistic Regression
Factors
Study level (nursery vs)
Primary
Secondary
University
Subject (physical education vs)
Music
Sciences
Arts
All
Average class size (from  to +)
Students speak in class (no vs yes)
Hard to maintain order (no vs yes)
Raising/forcing the voice (no vs yes)
Smoking (no vs yes)
Eat well (no vs yes)
Sleep well (no vs yes)

ET

Wald

P-Value

Odds Ratio

95% Confidence Interval

0.35
0.88
1.02

0.78
0.99
0.99

0.20
0.78
1.08

0.656
0.376
0.299

0.71
2.42
2.79

0.153.26
0.3416.99
0.4019.29

0.70
0.62
1.25
0.72
0.34
0.60
0.24
1.36
20.34
0.84
1.74

0.71
0.57
0.59
0.79
0.66
0.45
0.43
0.45

0.49
0.44

0.99
1.17
4.41
0.82
0.27
1.80
0.31
9.22
0.00
3.02
15.55

0.319
0.280
0.036
0.364
0.603
0.179
0.579
0.002
0.996
0.082
0.0001

0.49
0.54
0.29
0.49
0.71
1.82
1.27
3.89

0.43
0.17

0.121.97
0.181.65
0.090.92
0.102.30
0.202.58
0.764.36
0.552.95
1.629.35

0.171.11
0.070.42

261.e10
that teachers will strain their voices, as a way of compensating
their incapability to manage the voice with an appropriate technique. On the other hand, lacking experience also negatively affects teachers, who do not have effective resources to face the
excessive noise made by the students or to keep discipline
within the classroom. Hence, P
erez and Preciado1 concluded
that teachers with fewer years in the profession presented a
higher predisposition toward the development of nodular pathologies, perhaps arising from less experience, stress, and
the lack of voice techniques.
Given that other protection factor associated with phoniatric
treatment outside of the workplace is sufficient sleep, the
awareness among teachers of caring for their voice should
also be cultivated outside of working hours.
This research presents two main limitations common to the
cross-sectional studies.38 First, temporal relationships could not
be assessed because of the cross-sectional design. Second,
because of a lack of sufficient resources, we could not obtain
comprehensive information about potential confounds and
modifiers.
A specific area where these limitations are evident is the effect of vocal training on the development of voice disorders.
Contrary to what was found in prior studies, it has also been
observed that in the case of having received voice training,
most, probably, do so because of therapeutic referral. At present, therefore, we could assume that the voice dysfunctions
that teachers present are in most cases treated once the ailment
has presented itself. In a recent study carried out by Ohlsson
et al,61 vocal training also appears as a risk factor for voice
problems. Even when voice training should bring on a positive
training effect on the voice with increased vocal skill and
awareness, our questionnaire does not bring sufficient information about what kind and the amount of voice training that they
had received. On the issue of the relation between voice training
and the presence of voice problems, more research is necessary
to reach meaningful conclusions.
CONCLUSIONS
In conclusion, our study demonstrated that voice disorders are
common among teachers in Spain. Teachers who use a loud
speaking voice, work in noisy classrooms, with large-sized
classes, specialized in nursery education, teach physical education, and bad sleep are at greater risk of associated voice disorders. A remarkable percentage has never received any kind of
voice training.
Longitudinal studies and prospective cohort are urgently
required to get more insight into the development of voice disorders, their work-related determinants, and the consequences
of these voice disorders for functioning and work performance
among teachers.
Ultimately, the aim is to draw up a formative proposal adequate
to the real needs and demands on the voices within the teaching
profession for each of the educational contexts and stages. In doing so, the aim is to inform, raise awareness, and stimulate teaching staff to learn about their voice as an educational tool and as a
motivating element of self-knowledge and professional and
personal development.

Journal of Voice, Vol. 29, No. 2, 2015

This reaffirms the idea that for so long as spoken voice

training is not integrated, in a coherent and disciplinary way,
in previous and ongoing teacher training programs run by the
Public Administrations and the relevant educational bodies,
voice disorders and voice-related problems will continue to
emerge and will persist among teachers, contributing to a large
number of days off work, as well as health-related social costs
in nonpriority phoniatric treatments, rehabilitations, surgical
interventions, and so on that would be avoidable if the pertinent
training and preventive measures were taken.
Biographical Information
S.U. is a contracted doctoral professor at the Department of
Educational Sciences, University of Burgos and holds a
doctorate in Psychology from the University of the Basque
Country. Prominent among her lines of research is the study of
predictive factors of risk behavior applied to various fields,
among which, voice problems in teachers. She has also published
and given conference presentations on this research question.
J.C. is a titular university professor in the Area of Musical
Expression at the University of Burgos. His doctoral thesis
centered on investigating risk factors and the protection of
phoniatric problems among teachers. In addition, he is the
author of publications on voice technique and teaching and music pedagogy. He shares his teaching and research duties with
his performances as a tenor.
J.I. is a contracted professor with a doctorate in the Teaching
of Spanish Language and Literature from the University of Burgos. His research and publications are centered on the scope of
detection and solutions to phoniatric ailments among teaching
staff, as well as in the fields of the teaching of literature to infants and young children, the encouragement of their reading
skills, and the teaching of Spanish as a foreign language.
I.I. is a lecturer of the Department of Personality, Psychological Assessment and Treatment at the Faculty of Psychology
and Education in the University of Deusto (Spain). He is
main researcher in the research team on Clinical and Health
Evaluation, and he manages the clinical area in DeustoPsych
(R + I + D in health and psychology). His main areas of interest
are the assessment of health outcomes and the development of
assessment tools.
REFERENCES
1. P
erez Fern
andez CA, Preciado L
opez J. N
odulos de Cuerdas Vocales. Factores de Riesgo en los Docentes. Estudio de Casos y Controles. Acta Otorrinolaringol Esp. 2003;54:253260.
2. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech
Lang Hear Res. 2004;47:281293.
3. Smith EM, Gray SD, Dove H, Kirchner HL, Heras H. Voice disorders in
teachers. J Voice. 1997;11:8187.
4. Thibeault SL, Merrill RM, Roy N, Gray SD, Smith EM. Occupational risk
factors associated with voice disorders among teachers. Ann Epidemiol.
2004;14:786792.
5. Verdolini K, Ramig LO. Review: occupational risks for voice problems.
Logoped Phoniatr Vocol. 2001;26:3746.
6. Boletn Oficial del Estado (BOE). Real decreto 1299/2006, de 10 de noviembre. Madrid, Spain: BOE; 2006:4448744546. 302.

Silvia Ubillos, et al

Protective and Risk Factors in Voice Strain

7. Angelillo M, Di Maio G, Costa G, Angelillo N, Barillari U. Prevalence

of occupational voice disorders in teachers. J Prev Med Hyg. 2009;50:
2632.
8. Barbero-Daz FJ, Ruiz-Frutos C, del Barrio A, Bejarano E, Alarc
on A. Incapacidad vocal en docentes de la provincia de Huelva [Voice inability in
teachers in the province of Huelva]. Medicina y Seguridad en el Trabajo.
2010;56:3948.
9. Behlau M, Zambon F, Guerrieri AC, Roy N. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects.
J Voice. 2012;26:665.e9665.e18.
10. Ga~
net RE, Serrano M, Gallego C. Patologa vocal en trabajadores docentes:
influencia de factores laborales y extralaborales [Voice pathology in the
teaching staff: influence of work and outside work related factors].
Archivo de Prevenci

on de Riesgos Laborales. 2007;10:1217.
11. Preciado J, P
erez C, Calzada M, Preciado P. Frecuencia y factores de riesgo
de los trastornos de la voz en el personal docente de La Rioja. Estudio transversal de 527 docentes: cuestionario, examen de la funci
on vocal, an
alisis
ac

ustico y vdeolaringoestroscopia [Risk factors and frequency of voice
disorders among the teaching staff in La Rioja. Cross sectional study of
527 teachers: questionnaire, exam of the vocal function, acoustical analysis
and laryngeal video-stroboscopy]. Acta Otorrinolaringol
ogica Espa~nola.
2005;56:161170.
12. Russell A, Oates J, Greenwood K. Prevalence of voice problems in teachers. J Voice. 1998;12:467479.
13. Urrutikoetxea A, Ispizua A, Matellanes F. Pathologie vocale chez les
professeurs: une
etude vid
eo-laryngo-stroboscopique de 1.046 professeurs
[Vocal pathology in teachers: a laryngeal video-stroboscopy study of 1.046
teachers]. Rev Laryngol Otol Rhinol (Bord). 1995;116:255262.
14. Garcia Martins RH, Neves Pereira ERB, Bosque Hidalgo C, Mendes
Tavares EL. Voice disorders in teachers. A review. J Voice. 2014; 28:716724.
15. Mattiske JA, Oatesa JM, Greenwooda KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice.
1998;12:489499.
16. Ranchal A, Vaquero M. Protocolo para la vigilancia de la salud del profesorado con atenci

on a la enfermedad profesional [Protocol for the observation of the teaching staff health regarding work-related illness]. Medicina y
Seguridad Del Trabajo. 2008;54:4760.
17. Holmqvist S, Santtila P, Lindstrom E, Sala E, Simberg S. The association
between possible stress markers and vocal symptoms. J Voice. 2013;27:
787.e1787.e10.
18. Hunter EJ, Tanner K, Smith ME. Gender differences affecting vocal health
of women in vocally demanding careers. Logoped Phoniatr Vocol. 2011;36:
128136.
19. Smith E, Lester H, Taylor M, Hoffman H, Lemke JH. Voice problems
among teachers: differences by gender and teaching characteristics. J Voice.
1998;12:328334.
20. Palomino Moreno MP, Hoyo Rodrguez A, Garca L
opez V, Losantos
Martnez JT. Disfonas y Nodulos de las Cuerdas Vocales en Personal
Docente de Navarra. Arch Prev Riesgos Labor. 2013;16:182186.
21. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general
population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:19881995.
22. Tejeda P. Importancia de la voz en la profesi
on docente. Indivisa: boletn de
estudios e investigaci

on: Monografa I [The importance of the voice in
the teaching profession]. Madrid, Spain: Escuela Universitaria La Salle;
2001:109.
23. van Houtte E, Claeys S, Wuyts F, van Lierde K. Voice disorders in teachers:
occupational risk factors and psycho-emotional factors. Logoped Phoniatr
Vocol. 2012;37:107116.
24. Fritzell B. Voice disorders and occupations. Logoped Phoniatr Vocol. 1996;
21:712.
25. Higgins KP, Smith AB. Prevalence and characteristics of voice disorders in
a sample of university teaching faculty. Contemp Issues Commun Sci Disord. 2012;39:6975.
26. Preciado JA. Estudio de la prevalencia de los trastornos de la voz en el
personal docente de Logro~no. An
alisis multidimensional de la voz en
los profesionales de la ense~nanza [A study of the prevalence of voice
disorders in the teaching staff of Logro~no. Multi-dimensional analysis

27.

28.

29.
30.
31.
32.

33.

34.
35.

36.

37.

38.
39.

40.

41.

42.

43.

44.

45.
46.

261.e11

of the voice of the teaching professionals]. Zuba Monogr
afico. 2000;

12:111146.
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;46:143155.
Escalona E. Programa para la preservaci
on de la voz en docentes de educaci
on b
asica [Program for the care of the voice in elementary school teachers]. Salud de los Trabajadores. 2006;14:3149.
Kooijman PGC, Thomas G, Graamans K, de Jong FICRS. Psychosocial
impact of the teachers voice throughout the career. J Voice. 2007;21:316324.
Chen SH, Chiang S-C, Chung Y-M, Hsiao L-C, Hsiao T-Y. Risk factors and
effects of voice problems for teachers. J Voice. 2010;24:183192.
Tavares ELM, Martins RHG. Vocal evaluation in teachers with or without
symptoms. J Voice. 2007;21:407414.
Alves LP, Ara
ujo LTR, Xavier Neto JA. Preval^encia de queixas vocais e estudo de fatores associados em uma amostra de professores de ensino fundamental em Macei
o, Alagoas, Brasil sample of elementary school teachers in
Macei
o, Brazil [Prevalence of voice disorders and study of the associated factors in a sample of elementary school teachers in Macei

o, Alagoas, Brasil
sample of elementary school teachers in Macei
o, Brazil]. Revista Brasileira
de Sa
ude Ocupacional. 2010;35:168175.
Radosz J. The influence of classroom acoustics on the level of background
noise in selected Polish primary schools. 41st International Congress and
Exposition on Noise Control Engineering. 2012;6:46814691.
Sapir S, Keidar A, Van Velzen D. Vocal attrition in teachers: survey findings. Eur J Disord Commun. 1993;28:177185.

Ahlander VL, Rydell R, Anders Lofqvist A. Speakers comfort in teaching
environments: voice problems in Swedish teaching staff. J Voice. 2011;25:
430440.
De Medeiros A, Barreto S, Assuncao A. Voice disorders (dysphonia) in
public school female teachers working in Belo Horizonte: prevalence and
associated factors. J Voice. 2008;22:676687.
Kankare E, Geneid A, Laukkanen AM, Vilkman E. Subjective evaluation of
voice and working conditions and phoniatric examination in kindergarten
teachers. Folia Phoniatr Logop. 2012;64:1219.
Lee SY-Y, Lao XQ, Yu IT-S. Review: occupational risks for voice problems.
J Occup Health. 2010;52:344352.
Pizolato RA, Mialhe FL, Cortellazi KL, Bovi Ambrosano GM, Beltrati
CornacchioniRehder MI, Pereira AC. Avaliac~ao dos fatores de risco para
dist
urbios de voz em professores e an
alise ac
ustica vocal como instrumento
de avaliac~ao epidemiol
ogica. [Evaluation of risk factors for voice disorders
in teachers and vocal acoustic analysis as an instrument of epidemiological
assessment]. Revista CEFAC. 2013;15:957966.
Rantala LM, Hakala SJ, Holmqvist S, Sala E. Connections between voice
ergonomic risk factors and voice symptoms, voice handicap, and respiratory tract diseases. J Voice. 2012;26:819.e13819.e19.
Calera A, Esteve L, Roel JM, Uberti-Bona V. La salud laboral en el sector
docente [Occupational health in the teaching sector]. Alicante: Junta de
Comunidades de Castilla-La Mancha en coedici
on con el ISTAS. 2002;51.
Berm
udez de Alvear RM, Bar
on FJ, Martnez-Arquero AG. School teachers
vocal use, risk factors, and voice disorder prevalence: guidelines to detect
teachers with current voice problems. Folia Phoniatr Logop. 2011;63:
209215.
Hern
andez A, Morales MJ, P
erez L. Comportamiento de algunos factores
de riesgo de disfona en maestros del municipio Camaguey [Behavior of
some dysphonia risk factors in teachers in the town of Camaguey]. Archivo
M
edico de Camaguey. 2007;11.
Petter V, Barros de Oliveira PA, Fischer PD. Relaci

on entre disfona
referida y potenciales factores de riesgo en el trabajo de profesores de
la ense~nanza fundamental, Porto AlegreRS [Relation between referred
dysphonia and the potential work-related risk factors of elementary school
teachers, Porto AlegreRS.]. Salud de los Trabajadores. 2006;14.
Akinbode R, Lam KB, Ayres JG, Sadhra S. Voice disorders in Nigerian primary school teachers. Occup Med (Lond). 2014;64:382386.
Ferreira LP, Dias de Oliveira Latorre MdR, Pimentel Pinto S, de Assis
Moura AC, de Fraga e Karmann D, Egerland Silva E, Figueira S. Influence
of abusive vocal habits, hydration, mastication, and sleep in the occurrence
of vocal symptoms in teachers. J Voice. 2010;24:8692.

261.e12
47. Bele IV. The teachers voice:v training in teacher education. Scand J Educ
Res. 2008;52:4157.
48. de Jong FI, Kooijman PG, Thomas G, Huinck WJ, Graamans K,
Schutte HK. Epidemiology of voice problems in Dutch teachers. Folia Phoniatr Logop. 2006;58:186198.
49. Villanueva-Reyes A. Voice disorders in the metropolitan area of San Juan,
Puerto Rico: profiles of occupational groups. J Voice. 2011;25:8387.
50. Gassull C, Godall P, Martorell M. La educaci
on de la voz y la salud vocal en
la formaci

on de los maestros [Voice training and voice health in the training
of teachers]. Revista Electr
onica Europea de M
usica en la Educaci
on
(LEEME). 2000;5:15.
51. Arboleda BMW, Frederick AL. Considerations for maintenance of postural
alignment for voice production. J Voice. 2008;22:9099.
52. Castej

on Fern
andez L. Prevenci
on de disfonas funcionales en el profesorado universitario: tres niveles de acci
on preventiva [Prevention of
functional dysphonia in university teachers: three levels of preventive action]. Aula Abierta. 2014;42:914.
53. Moore C. Reflections on clinical applications of yoga in voice therapy with
MTD. Logoped Phoniatr Vocol. 2012;37:144150.
54. Scivetti AR. El sustrato anat
omico y funcional de la voz profesional.
In: Bustos I, ed. La voz. La t
ecnica y la expresi
on [The anatomical
and functional substratum of the professional voice. In: Bustos I, ed.

Journal of Voice, Vol. 29, No. 2, 2015

55.

56.

57.
58.

59.
60.

61.

The voice. The technique and the expression]. Barcelona, Spain: Paidotribo; 2006:4363.
Preciado-L
opez J, P
erez-Fern
andez C, Calzada-Uriondo M, PreciadoRuiz P. Epidemiological study of voice disorders among teaching professionals of La Rioja. Spain J Voice. 2008;22:489508.
CC.OO. Las enfermedades de la voz. Estudio sobre factores de riesgo predictivos de patologas relacionadas con la seguridad y salud de los
trabajadores docentes [Voice pathologies. A study on predictive risk factors related to the teaching staff health and safety]. Madrid, Spain: Federaci
on Estatal de Ense~nanza de CCOO; 2010.
Jackson-Menaldi C. La voz patol
ogica [The pathological voice]. Madrid,
Spain: Editorial M
edica Panamericana; 2002.


Alvarez
B. La demanda atendida de consultas m
edicas y servicios urgentes
[The attended demand of medical appointments and emergency services].
Revista Investigaciones Econ
omicas. 2001;25:93138.
Da Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school
teachers and barriers to care. J Voice. 2010;26:6976.
Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who
rely on voice as a primary tool of trade: a preliminary report. J Voice.
1997;11:254259.
Ohlsson AC, Andersson EV, Sodersten M, et al. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629634.