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Prevalence of Voice Problems in Priests and Some Risk Factors Contributing to Them
Prevalence of Voice Problems in Priests and Some Risk Factors Contributing to Them Finland Ann-Marie Hagelberg and Susanna Simberg, Abo,
Summary: Objectives. The purpose of this questionnaire study was to explore the prevalence and possible risk factors for voice problems in priests. Methods. About 2044 evangelical Lutheran priests received a link to an electronic questionnaire and 44.1% (n ¼ 901) completed it. Of the participants, 53% were males and 47% were females. Results. The results showed that the prevalence of voice problems in priests was high. Of the participants, 24.5% had sought help for voice problems and 18% reported that they had been diagnosed with a voice disorder by a physician. Twenty-one percent considered themselves as having current voice problems, and 26.7% reported frequently occurring vocal symptoms. Voice-related absenteeism was reported by 11.6%. Significantly, more females than males reported voice problems. There were significant associations between frequently occurring vocal symptoms and several environmental- and health-related risk factors. More than half of the participants considered that they had received less than 5 hours of information on the voice and voice use. The association between frequently occurring vocal symptoms and the number of hours of information on the voice and voice use was significant. Conclusions. The results of this study indicate that the prevalence of voice problems among priests is high. Prevention of voice problems for priests is recommended. Voice training programs should be included in the curriculum for all those who are studying to become priests. For those already working as priests, practical courses on voice training could be arranged. Additionally, priests should get information on voice-related issues from the occupational health care or other health care services. Key Words: Voice problems–Priests–Risk factors. INTRODUCTION Voice problems are common in persons working in vocally demanding occupations.1–4 Environmental risk factors for occupational voice users are, for example, talking for long periods, talking over background noise, and talking in rooms with poor acoustics and air quality.1,4,5 Health-related risk factors include frequent colds and sinus infections, reflux, respiratory allergies, and asthma.4,6,7 Persons who are at risk for having voice problems may be teachers, lawyers, singers, and priests.1–3 Priests are recognized as occupational voice users, and their work includes, for example, leading sermons and singing or chanting.1 Priests also speak in noisy environments8 and give religious teaching and spiritual counseling.9 To our knowledge, there are only a few modern studies on the prevalence of voice problems in priests. In some of the studies, the study populations are quite small. The results of the perceptual evaluation in a study on six female priests showed that they had deviant voice quality.8 Additionally, the researchers concluded that the priests had vocally abusive behavior. Neto et al9 conducted a questionnaire study on vocal health in 56 male priests and found the prevalence of vocal complaints to be high. The most common vocal symptom when speaking for long times was throat clearing reported by 78.5%. Other symptoms were hoarseness reported by 57.1% and pain or irritation in the throat reported by 51.8%. Of those who suffered Accepted for publication August 25, 2014. From the *Department of Psychology and Logopedics, Abo Akademi University, Abo, Finland. Address correspondence and reprint requests to Ann-Marie Hagelberg, Speech and Language Pathology, Abo Akademi University, Fabriksgatan 2, 20500 Abo, Finland. E-mail: [email protected] Journal of Voice, Vol. 29, No. 3, pp. 389.e11-389.e18 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.08.015
from hoarseness, 87% reported the hoarseness to be episodic and related to vocal loading. The results showed that many of the priests worked long hours, some even more than 10 hours a day.9 Hapner and Gilman10 conducted a questionnaire study on 75 Jewish cantors, 34% males and 66% females, to explore the occurrence of laryngeal symptoms. Jewish cantors have similar responsibilities to priests and have several voicedemanding duties and act both as spiritual and musical leaders. The results showed that 65% had voice problems that had a negative effect on their ability to work. Most cantors used their voice at least 45 hours a week. Risk factors for voice problems were, for example, high vocal loading and demands, too little voice rest, and health-related risk factors such as allergies and reflux.10 Hocevar-Boltezar11 conducted a questionnaire study on a larger population to explore the prevalence of voice problems in Catholic priests. Of 600 priests, 340 answered the questionnaire. The results showed that 85.6% had suffered from voice problems at some point of their career and 15.9% had frequent voice problems. Voice-related absenteeism was reported by 12.1%. Repeated throat clearing was reported by 55.8%. Other risk factors were symptoms of reflux reported by 32.9%, asthma and allergy reported by 15.5%, and smoking reported by 7.6%. Of the participants who had voice disorders, respiratory infections were reported by 41.5%. Of the participants, 76.1% reported that they were speaking loudly at work, 48.7% reported lack of knowledge of correct voice use, and 29.9% reported vocal load during spare time. Current voice problems were reported by 15.7%. The results of previous studies on voice problems in priests indicate that voice problems are common in this occupation. The primary purpose of this study was to extend the literature by investigating the prevalence of voice problems in a large
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TABLE 1. Number of Participants Who Had Sought Help for Voice Problems, Who Had Been Diagnosed With a Voice Disorder, Who Considered Themselves as Having Current Voice Problems (n ¼ 869–885) and a Comparison Between Female (n ¼ 407–413) and Male Participants (n ¼ 458–468) All Participants Variable Had sought help for voice problems Had been diagnosed with a voice disorder Considered themselves as having current voice problems
Females
Males
n
%
n
%
n
%
c2
217 156 186
24.5 18 21
128 92 105
31 22.6 25.6
89 64 80
19 14 17.1
c2(1) ¼ 16.949, P < 0.001 c2(1) ¼ 10.859, P < 0.001 c2(1) ¼ 9.529, P ¼ 0.002
group of priests and to identify possible risk factors for voice problems. Another purpose was to explore possible gender differences in the prevalence of voice problems.
MATERIALS AND METHODS Participants A link to an electronic questionnaire was sent to 2115 of the totally 2155 evangelical Lutheran priests in Finland, of which 94.8% (n ¼ 2044) received the e-mail. The addresses were acquired by the Finnish Association for evangelical Lutheran priests. The questionnaire was available on the Internet for a month, and altogether 901 priests completed it. The overall response rate was 44.1%. Of the 901 participants, 12 were excluded because they did not work with typical priest tasks or because they did not work as priests at all at the moment. The final sample consisted of 889 priests. Of them, 53% were males and 47% were females. The percentage of male and female participants is well in line with the statistics from Evangelical Lutheran Church of Finland because 43% of the priests in 2013 were females.12 The participants had worked as priests between less than a year and 41 years (mean ¼ 16.8, standard deviation ¼ 10.8). Of the participants, 7.3% were 20–30 years old, 31.8% were 31–45 years old, 49.2% were 46–60 years old, and 11.2% were older than 60 years. Participation in the study was voluntary, and anonymity was guaranteed. Approval to conduct the study was given by the Ethics Committee of the Department of Psychology at Abo Akademi University.
Data collection The data were obtained with an electronic questionnaire containing 33 multiple-choice (two, three, or four answering alternatives) and open-end questions. The questionnaire was self-explanatory, and no explanations or definitions were provided. The questions chosen were based on previous studies on voice disorders in various populations.6,7,13–16 The questionnaire included demographic questions and questions about voice problems during the career and present voice problems. Questions on vocal symptoms occurring during the past year were also asked. The vocal symptoms were voice becomes strained or tires, voice becomes low or hoarse, voice breaks while talking, difficulty in being heard, throat clearing or coughing while talking, and sensation of pain or lump in the throat. The frequency alternatives for the occurrence of the symptoms were daily, weekly, seldom, or never. Questions concerning work-related factors that might have an impact on the voice, such as time of vocal load during a workday and voice-demanding activities such as preaching and singing, were queried. Other questions about the working environment were about speaking to a large audience, speaking to an audience that is at a distance, speaking in noisy or reverberant environments, and speaking outdoors. One question on the use of voice amplification was included. The health-related questions included questions about occurrence of rhinitis, allergies, reflux, asthma, and asthma medication. Work absence because of voice problems and a question about smoking habits were also enquired. The questionnaire included a question inquiring whether the vocal symptoms had an effect on the participant’s mood.
TABLE 2. Number of Participants (n ¼ 884) Having Frequently Occurring Vocal Symptoms and a Comparison Between Females (n ¼ 412) and Males (n ¼ 467) All Participants Vocal Symptoms Seldom or never occurring symptoms One frequently occurring symptom Two or more frequently occurring symptoms c2(2) ¼ 18.459, P < 0.001.
Females
Males
n
%
n
%
n
%
494 154 235
55.9 17.4 26.7
213 61 138
51.7 14.8 33.5
280 90 97
60 19.3 20.8
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TABLE 3. The Six Vocal Symptoms Reported by All Participants (n ¼ 873–885) Frequently Occurring Symptoms
Seldom or Never Occurring Symptoms
n
%
n
%
281 203 162 127 68 59
32 23.1 18.3 14.5 7.8 6.7
597 676 721 750 805 826
68 76.9 81.7 85.5 92.2 93.3
Vocal Symptoms Throat clearing or coughing while talking The voice becomes strained or tires The voice becomes low or hoarse Sensation of pain or lump in the throat Difficulty in being heard Voice breaks while talking
more common for female participants to consider that they had current voice problems. Eight hundred sixty-nine participants answered the question on whether they had been diagnosed with a voice disorder by a physician. Of the participants, 17.9% (n ¼ 159) had consulted a laryngologist. Of the participants, 17.3% (n ¼ 157) answered to an openend question about which diagnosis they had received. They could report more than one diagnosis. The most common answer was voice problems because of various infections and viruses. This was reported by 41.4% (n ¼ 65), whereas 37.6% (n ¼ 59) reported various symptoms, such as hoarseness, loss of voice, and vocal fatigue. Of the participants, 10.2% (n ¼ 16) reported voice problems related to allergy or asthma and 3.8% (n ¼ 6) reported a functional voice disorder. Of the participants, 2.5% (n ¼ 4) had been diagnosed with vocal nodules, 1.9% (n ¼ 3) with hypothyroidism, and 1.9% (n ¼ 3) reported minor changes on the vocal folds. Diagnoses reported by single participants were polyps, tumor in the larynx, diplophonia, ulcers, and stress. Of the participants, 26.7% (n ¼ 235) reported two or more frequently occurring vocal symptoms, 17.4% (n ¼ 154) reported one symptom, and 55.9% (n ¼ 494) reported seldom or never occurring vocal symptoms. Females reported significantly more frequently occurring vocal symptoms than males (Table 2). Of the 156 participants who had been diagnosed with a voice disorder, 44.8% (n ¼ 69) had two or more frequently occurring vocal symptoms, 20.1% (n ¼ 31) had one frequently occurring symptom, and 35.1% (n ¼ 54) had seldom or never occurring vocal symptoms. Of those who
Additionally, questions about received information on voice and voice use during the time of study and knowledge on the own voice were included. Analysis IBM SPSS Statistics 20 software (IBM, Armonk, NY) was used for all statistical analyses. Cross tabulations and chi-square tests were used to perform bivariate analyses between selected variables. The participants answered to a question whether they had been diagnosed with a voice disorder by a physician and an open-end question about which diagnosis they received. This question was difficult to answer, probably because of memory factors. Some participants could answer the question using the proper medical diagnosis, whereas others reported ‘‘a cold,’’ ‘‘hoarseness,’’ or other symptoms. Therefore, answers to the question about the prevalence of frequently occurring vocal symptoms during the past year were used for statistical calculations. Symptoms occurring weekly or daily during the past year were defined as frequently occurring symptoms. RESULTS Prevalence of voice problems Of the participants, 24.5% (n ¼ 217) had sought help for voice problems and 18% (n ¼ 156) reported that they had been diagnosed with a voice disorder by a physician. Twenty-one percent (n ¼ 186) considered themselves as having current voice problems. The female participants had sought help significantly more than the males (Table 1). There were also more female participants who had been diagnosed with a voice disorder, and it was
TABLE 4. A Comparison of Frequently Occurring Vocal Symptoms Between Females (n ¼ 406–412) and Males (n ¼ 461–468) Females Vocal Symptoms Throat clearing or coughing while talking The voice becomes strained or tires The voice becomes low or hoarse Sensation of pain or lump in the throat Difficulty in being heard Voice breaks
Males
n
%
n
%
c2
146 118 92 82 42 42
36 28.9 22.3 20 10.3 10.2
133 85 69 45 24 17
28.5 18.2 14.8 9.7 5.2 3.6
c2(1) ¼ 5.590, P ¼ 0.018 c2(1) ¼ 13.763, P < 0.001 c2(1) ¼ 8.351, P ¼ 0.004 c2(1) ¼ 18.376, P < 0.001 c2(1) ¼ 7.984, P ¼ 0.005 c2(1) ¼ 15.082, P < 0.001
389.e14 c (2) ¼ 6.292, P ¼ 0.043 c2(2) ¼ 12.489, P ¼ 0.002 c2(2) ¼ 7.876, P ¼ 0.019 c2(2) ¼ 46.469, P < 0.001 c2(2) ¼ 42.217, P < 0.001 NS NS
had not been diagnosed with a voice disorder, 22.7% (n ¼ 161) had two or more frequently occurring vocal symptoms, 16.3% (n ¼ 116) had one symptom, and 61% (n ¼ 433) had seldom or never occurring vocal symptoms. The participants who reported that they had been diagnosed with a voice disorder had significantly more vocal symptoms (c2 ¼ 39.435, P < 0.001). The most frequent symptoms in the whole population were throat clearing or coughing while talking reported by 32%, the voice becomes strained or tires reported by 23.1%, and the voice becomes low or hoarse reported by 18.3% of the participants (Table 3). All vocal symptoms were significantly more often reported by female participants (Table 4).
25.3 23.1 20.0 15.4 26.9 24.1 18.4 193 139 61 49 86 90 23 Abbreviation: NS, not significant.
Speaking outdoors Speaking in noisy environments Speaking to an audience at distance Working in a room with dry air Working in a draughty room Speaking in a room with reverberation Speaking to a large audience
49 132 310 234 185 277 417
45.4 48.4 53.3 47.9 47.1 54.6 55.2
22 49 99 80 60 85 127
20.4 17.9 17 16.4 15.3 16.8 16.8
37 92 173 175 148 145 212
34.3 33.7 29.7 35.8 37.3 28.6 28
443 360 178 253 301 214 76
58 59.9 61 66.2 55.9 57.4 60.8
128 102 53 70 89 69 26
16.8 17 18.2 18.3 17.1 18.5 20.8
% n % n % n % Working Conditions
%
% n n
n
Two or More Symptoms One Symptom No Symptoms Two or More Symptoms One Symptom
Number of Symptoms Number of Symptoms
No Symptoms
Occasionally Frequently
TABLE 5. The Connection Between Frequently Occurring Vocal Symptoms and Some Working Conditions (n ¼ 874–886)
2
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Work-related and environmental risk factors Of the participants, 76.1% (n ¼ 668) reported that they used their voice considerably during a workday, whereas 13.6% (n ¼ 121) were of the opinion that they did not do so and 10% (n ¼ 89) could not tell whether they used their voice considerably or not. Regarding the frequently occurring vocal symptoms, there was no significant difference between those who reported that they used their voice considerably and those who reported that they did not do that. Forty-two percent (n ¼ 370) estimated that they used their voice 1–3 hours a day, whereas 58% (n ¼ 511) reported that they used their voice for 4 hours or more. There was no significant difference in the prevalence of frequently occurring vocal symptoms between those who reported an estimated speaking time of 1–3 hours and those who reported 4 hours or more. Besides using the voice considerably during working days, 26% (n ¼ 231) of the participants also had voice-demanding leisure activities, for example, singing and leading groups of children or adults in various activities. Regarding the vocal symptoms, there was no significant difference between those who had vocally demanding leisure activities and those who did not. Singing was considered to be an important part of the work by 79% (n ¼ 701) of the participants, and 18.9% (n ¼ 167) reported that they had more difficulties singing nowadays. Of those who considered that it had become more difficult to sing, 60.8% (n ¼ 101) reported two or more frequently occurring symptoms, compared with 18.6% (n ¼ 118) of those who did not think it had become more difficult. The difference was significant (c2 ¼ 122.679, P < 0.001). Forty-four percent (n ¼ 387) of the participants felt that they had to raise their voice during workdays. The most common vocally demanding duties were singing reported by 32.4% (n ¼ 288), preaching reported by 28.6% (n ¼ 254), services reported by 25.4% (n ¼ 226), and ceremonies reported by 20% (n ¼ 178). About half of the population, 50.2% (n ¼ 446), reported that they always used a voice amplifier when preaching and 42.3% (n ¼ 372) reported that they used one often or quite often, whereas 7% (n ¼ 62) reported that they seldom or never used amplification. Other risk factors queried were speaking to a large audience, speaking to an audience at a distance, speaking in noisy environments, and speaking outdoors. Speaking frequently to a
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TABLE 6. The Connections Between Frequently Occurring Vocal Symptoms and Health-Related Risk Factors (n ¼ 861–880) No Symptoms
One Symptom
Two or More Symptoms
Health-Related Risk Factors
n
%
n
%
n
%
c2
Prolonged rhinitis Respiratory allergy Reflux Asthma Use of asthma medication
81 75 26 29 27
16.5 15.3 5.4 6 5.6
40 24 14 16 11
26.1 15.6 9.2 10.5 7.5
88 56 46 30 31
37.8 23.8 19.9 13 13.3
c2(2) ¼ 39.740, P < 0.001 c2(2) ¼ 8.545, P ¼ 0.014 c2(2) ¼ 36.877, P < 0.001 c2(2) ¼ 10.290, P ¼ 0.006 c2(2) ¼ 12.698, P ¼ 0.002
large audience was reported by altogether 85.6% (n ¼ 759), and 66.5% (n ¼ 584) spoke frequently to an audience at distance. Speaking frequently in noisy environments was reported by 31.3% (n ¼ 275), and speaking frequently outdoors was reported by 12.3% (n ¼ 108). Of the participants, 56% (n ¼ 492) frequently worked in a room with dry air, 45.1% (n ¼ 394) frequently worked in a draughty room, and 57.5% (n ¼ 509) frequently spoke in a room with reverberation. There was a significant association between frequently occurring vocal symptoms and five of the seven working conditions (Table 5). Health-related risk factors The most common health-related risk factor for voice problems was prolonged rhinitis, which was reported by 23.6% (n ¼ 210). Of the participants, 17.7% (n ¼ 157) had been diagnosed with respiratory allergies. The most common allergies were allergy to pollen, dust, animals, and mold. Reflux was reported by 9.8% (n ¼ 87), asthma by 8.5% (n ¼ 76), and the use of asthma medication by 7.9% (n ¼ 70). Of the study population, 5.5% (n ¼ 49) were smokers. All the health-related risk factors, except smoking, had a significant association with frequently occurring vocal symptoms (Table 6). Voice-related absenteeism once or several times a year was reported by 11.6% (n ¼ 103). The association between frequently occurring vocal symptoms and being absent from work was significant (Table 7). Altogether, 12.4% (n ¼ 107) reported that their mood was considerably or moderately affected by their voice problem, whereas most participants, 87.6% (n ¼ 756) felt that their mood was affected little or not at all (Table 8).
Of the participants, 63.1% (n ¼ 561) had received information on the voice and voice use during their education and 61.4% (n ¼ 546) had received information in some other context. There was no significant difference in the prevalence of frequently occurring vocal symptoms between those who had received information and those who had not. In this study, 33.3% considered that they had enough voice knowledge, whereas 66.7% (n ¼ 580) reported that they did not know enough of their voice. More than half of the participants, 57.2% (n ¼ 338), considered that they in total had received less than 5 hours of information on the voice and voice use. The connection between frequently occurring vocal symptoms and the number of hours of information on the voice and voice use was significant (Table 9). DISCUSSION The aim of this study was to explore the prevalence of voice problems in priests and to investigate possible risk factors associated with voice problems. The results showed that the prevalence of voice problems in this population was high. In a normal population, the estimated prevalence of voice disorders varies from 3% to 9%.17 The definition of a voice disorder varies in the literature. It can, for example, be defined as any time the voice does not work or sound as it should so that the communication is interfered,6 as a voice symptom for which the patient seeks help,18 or as having two or more frequently occurring vocal symptoms.7 Depending on which definition is used, the prevalence of voice problems or voice disorders in the participants in this study varies from 18% who reported that they had been diagnosed with a voice disorder to 24.5% who had sought help for voice problems or 26.7% who reported
TABLE 7. The Connection Between Frequently Occurring Vocal Symptoms and Work Absence (n ¼ 881)
Work Absence Due to Voice Problems Every year or more often Seldom or never c2(2) ¼ 23.771, P < 0.001.
Two or More Symptoms
No Symptoms
One Symptom
n
%
n
%
n
%
36 457
35 58.7
21 131
20.4 16.8
46 190
44.7 24.4
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TABLE 8. The Connection Between Frequently Occurring Vocal Symptoms and the Effect on the Participant’s Mood (n ¼ 860) No Symptoms
Two or More Symptoms
One Symptom
Effect on the Mood
n
%
n
%
Considerably or moderately affected Little or not at all affected
23
21.7
17
452
59.9
135
16 17.9
n
%
66
62.3
167
22.1
c (2) ¼ 80.001, P < 0.001. 2
two or more frequently occurring symptoms. Twenty-one percent of the participants in this study reported that they had current voice problems, which is more than in the studies on teachers’ voice problems.6,19 It is well documented that teachers have a high prevalence of voice problems.2,4,7,16,19,20 It is possible that priests are even more at risk of having voice problems than teachers. It is also possible that priests are more aware of the voice as an occupational tool than teachers and therefore better recognize voice problems. The response rate in this study was 44.1%. It is of course possible that the priests who felt that they had experienced problems with their voices were more motivated to fill out the questionnaire, which might have had an impact on the results. Still, the results of this study were in line with previously conducted research on voice problems in priests9–11 suggesting that the priests participating in this study were representative of the entire population of priests. In this study, the number of female and male participants was equal, 53% males and 47% females. Women generally have more voice problems than men.2,5,14,20–22 The results of this study are well in accordance with previous studies addressing gender differences. The female participants were significantly more active in seeking help for their voice problems, had significantly more often been diagnosed with a voice disorder, and significantly more often considered themselves as having current voice problems compared with males. All vocal symptoms were significantly more frequently reported by female participants, although the number of male participants with vocal symptoms was also high. Of the 156 participants who reported that they had been diagnosed with a voice disorder, 41.4% reported suffering from
voice problems related to viruses and infections. This result is consistent with the results of the study on voice problems in priests by Hocevar-Boltezar.11 The results of a study on voice problems in day care center teachers implied that teachers are frequently exposed to viruses associated with upper respiratory tract infections.7 This might also be the case with priests because their work includes frequent close contacts with people. Voice problems related to colds might be temporary. Still, respiratory infections might lead to persistent voice problems.4,5,18 Therefore, it is important that persons working in vocally demanding occupations take proper actions to prevent colds. The prevalence of the six vocal symptoms examined in this study has been investigated in a number of studies.7,14,16,23,24 The results of this study showed that 26.7% of the participants reported two or more frequently occurring vocal symptoms. Earlier studies involving teachers and day care center teachers showed that 20% of the teachers reported two or more symptoms,16 whereas 37% of the day care center teachers reported that.7 The priests in this study had more frequently occurring vocal symptoms than teachers but less than day care center teachers. In the study on day care center teachers, all participants underwent an examination of the vocal folds. The results showed that those who reported two or more frequently occurring vocal symptoms often had visible changes on their vocal folds.7 This might indicate that many participants in this study could have changes on their vocal folds. The results of prevalence studies relying on data obtained by questionnaires can be reliable and valid.25 Still, questions can be interpreted in various ways. A study including a perceptual assessment and a videolaryngoscopic examination of the vocal folds would give
TABLE 9. The Connection Between Frequently Occurring Vocal Symptoms and Number of Hours of Information on the Voice and Voice Use (n ¼ 586)
Hours of Information on the Voice and Voice Use Less than 5 hours Five hours or more c2(2) ¼ 8.590, P ¼ 0.014.
No Symptoms
Two or More Symptoms
One Symptom
n
%
n
%
n
%
173 157
51.5 62.8
71 34
21.1 13.6
92 59
27.4 23.6
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Prevalence of Voice Problems in Priests
exact information of diagnosis. In this study, there were no financial resources for such examinations. The most common frequently occurring vocal symptoms in this study were throat clearing or coughing while talking, the voice becomes strained or tires, and the voice becomes low or hoarse. In total, 32% of the participants reported the symptom throat clearing and coughing as frequently occurring. This is in accordance with several previous studies.7,9,11,14,23,24 The symptom the voice becomes strained or tires was reported as frequently occurring by 23.1% of the participants. This implies that the priests suffer from vocal fatigue because of vocal loading. Another symptom that might be related to vocal loading is hoarseness. Of the participants, 18.3% reported the symptom the voice becomes low or hoarse. In an earlier study on priests, 57.1% reported prevalence of hoarseness, which was connected to vocal loading.9 Most participants in this study, 76.1%, considered that they used their voice considerably during a workday. Using the voice considerably during working days did not have a significant connection with frequently occurring vocal symptoms, which might be because of the fact that almost all participants used their voice often. The answers to the question on daily voice use may not be adequate because subjective estimation of speaking time is difficult. The participants reported that their work tasks were vocally demanding. This is well in accordance with previous studies on priests.8–11 The results also confirm that the environment in which priests work is vocally demanding (Table 5). Speaking outdoors, speaking in noisy environments, speaking to an audience at distance, working in a room with dry air, and working in a draughty room had a significant connection with frequently occurring vocal symptoms. In this study, speaking to large groups did not have a significant connection with vocal symptoms, which could be because of the fact that more than 90% of the participants actively used voice amplification. More than half of the participants reported that they frequently spoke in a room with reverberation. Surprisingly, speaking in reverberant rooms did not have a significant association with vocal symptoms, which also could be because of the active use of voice amplification or good speaking skills. The participants who reported prolonged rhinitis, respiratory allergy, and asthma also had significantly more vocal symptoms (Table 6). This is in accordance with the results of a study by Roy et al5 that showed that those who reported respiratory allergies, asthma, sinus infections, colds, and postnasal drip also had a higher frequency or voice disorders. About 10% of the participants reported that they had been diagnosed with reflux. This is less than in the study on voice problems in priests by Hocevar-Boltezar.11 In this population, reflux might be underdiagnosed because 32% reported throat clearing and coughing, which are common symptom for reflux.26 The questionnaire could perhaps have included a question of the prevalence of heartburn. Not all those who have reflux suffer from heartburn.26 Still, it could have provided some information about possible underdiagnosed reflux. Altogether, 11.6% of the participants had been absent from work once or several times a year because of voice problems.
389.e17
This result is almost the same as it was in the study of Hocevar-Boltezar.11 There was a significant association between frequently occurring vocal symptoms and the absence from work. The participants in this study and in that of Hocevar-Boltezar11 reported less absenteeism because of voice problems than teachers,13,20,27,28 which might indicate that some of the work tasks of priests might be difficult to postpone or to get a substitute. Of the participants, 12.4% reported that their mood was considerably or moderately affected by the voice problems, and there was a significant association with the prevalence of two or more frequently occurring vocal symptoms. The question inquiring whether the vocal symptoms had an effect on the mood was not a very exact one as it does not necessarily address the degree of concern. In further studies on voice problems in priests, the psychosocial impact of voice disorders should preferably be evaluated with, for example, the Voice Handicap Index. In this study, 33.3% of the participants reported that they had enough knowledge of their voice, whereas 66.7% considered that they had too little voice knowledge. Several authors have addressed the importance of prevention of voice disorders among those working in vocally demanding occupations.2,3,14,19,27,28 The conclusions from studies involving priests address the importance of prevention of voice problems in this occupational group.8–11 In this study, those who had received less than 5 hours of information on the voice and voice use had significantly more vocal symptoms than those who had received more than 5 hours of information. These results are in line with the results of another study on priests where the lack of voice ergonomic information was connected to voice problems.11 CONCLUSIONS The results of this study indicate that the prevalence of voice problems among priests is high and no less than, for example, in teachers, which is an occupation known to have a high prevalence of voice problems. Because voice problems are common among priests, regular voice screening tests and voice training programs should be included in the curriculum for all those who are studying to become priests. Additionally, access to voice therapy and vocal medical care should be offered to the students. For those already working as priests, practical courses on voice training could be arranged. Additionally, priests should get information on voice-related issues from the occupational health care or other health care services. REFERENCES 1. Titze IR, Lemke J, Montequin D. Population in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. 1997;11: 254–259. 2. Fritzell B. Voice disorders and occupations. Logoped Phoniatr Vocol. 1996; 21:7–12. 3. Verdolini K, Ramig L. Review: occupational risks for voice problems. Logoped Phoniatr Vocol. 2001;26:37–46. 4. Vilkman E. Occupational safety and health aspects of voice and speech professions. Folia Phoniatr Logop. 2004;56:220–253.
389.e18 5. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988–1995. 6. 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;47:281–293. 7. Sala E, Laine A, Simberg S, Pentti J, Suonp€a€a J. The prevalence of voice disorders among day care center teachers compared with nurses: a questionnaire and clinical study. J Voice. 2001;15:413–423. 8. Middleton RL, Hinton VA. A preliminary investigation of the vocal behaviors and characteristics of female pastors. J Voice. 2009;23:594–602. 9. Neto FXP, Silva IPC, Madeira AV, Menezes CRT, Rodrigues G, Navarro LM. Analysis of the vocal health of the preachers of the Seventhday Adventist churches. Int Arch Otorhinolaryngol. 2009;13:407–412. 10. Hapner E, Gilman M. The vocal load of reform Jewish cantors in the USA. J Voice. 2011;26:201–204. 11. Hocevar-Boltezar I. Prevalence and risk factors for voice problems in priests. Wien Klin Wochenschr. 2009;121:276–281. 12. Statistics from Evangelical Lutheran Church of Finland (in Finnish). Naisten osuus kirkon henkil€ost€ost€a. Available at: http://sakasti.evl.fi/sakasti.nsf/ sp?open&cid¼Content3A1AB1. 2014. Accessed July 15, 2014. 13. Lyberg- Ahlander V, Rydell R, L€ofqvist A. Speaker’s comfort in teaching environments: voice problems in Swedish teaching staff. J Voice. 2009; 25:430–440. 14. Ohlsson A-C, Andersson EM, S€odersten M, Simberg S, Barreg ard L. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629–634. 15. Simberg S, Sala E, Laine A, R€onnemaa A-M. A fast and easy screening method for voice disorders among teacher students. Logoped Phoniatr Vocol. 2001;26:10–16. 16. Simberg S, Sala E, Vehmas K, Laine A. Changes in the prevalence of vocal symptoms among teachers during a twelve-year period. J Voice. 2005;19:95–102.
Journal of Voice, Vol. 29, No. 3, 2015 17. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41:101–116. 18. Herteg ard S. Voice problems in a small Swedish town: a retrospective study of the prevalence and a follow-up. J Voice. 1988;1:336–340. 19. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467–479. 20. 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. 21. Coyle SM, Weinrich BD, Stemple JC. Shifts in relative prevalence of laryngeal pathology in a treatment-seeking population. J Voice. 2001;15: 424–440. 22. Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Description of laryngeal pathologies by age, sex, and occupation in a treatment-seeking sample. J Speech Hear Disord. 1988;53:57–64. 23. Holmqvist S, Santtila P, Lindstr€om E, Sala E, Simberg S. The association between possible stress markers and vocal symptoms. J Voice. 2013;27: 787–797. 24. Simberg S, Sala E, Tuomainen J, R€onnemaa A-M. Vocal symptoms and allergy—a pilot study. J Voice. 2009;23:136–139. 25. Mattiske JA, Oates JM, Greenwood KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice. 1998;12: 489–499. 26. Koufman J, Sataloff RT, Toohill R. Laryngopharyngeal reflux: consensus conference report. J Voice. 1996;10:215–216. 27. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of teachers’ voice problems. J Voice. 1997;11:81–87. 28. Roy N, Merrill RM, Thibeault S, Gray SD, Smith EM. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551.
Summary: Objectives. The purpose of this questionnaire study was to explore the prevalence and possible risk factors for voice problems in priests. Methods. About 2044 evangelical Lutheran priests received a link to an electronic questionnaire and 44.1% (n ¼ 901) completed it. Of the participants, 53% were males and 47% were females. Results. The results showed that the prevalence of voice problems in priests was high. Of the participants, 24.5% had sought help for voice problems and 18% reported that they had been diagnosed with a voice disorder by a physician. Twenty-one percent considered themselves as having current voice problems, and 26.7% reported frequently occurring vocal symptoms. Voice-related absenteeism was reported by 11.6%. Significantly, more females than males reported voice problems. There were significant associations between frequently occurring vocal symptoms and several environmental- and health-related risk factors. More than half of the participants considered that they had received less than 5 hours of information on the voice and voice use. The association between frequently occurring vocal symptoms and the number of hours of information on the voice and voice use was significant. Conclusions. The results of this study indicate that the prevalence of voice problems among priests is high. Prevention of voice problems for priests is recommended. Voice training programs should be included in the curriculum for all those who are studying to become priests. For those already working as priests, practical courses on voice training could be arranged. Additionally, priests should get information on voice-related issues from the occupational health care or other health care services. Key Words: Voice problems–Priests–Risk factors. INTRODUCTION Voice problems are common in persons working in vocally demanding occupations.1–4 Environmental risk factors for occupational voice users are, for example, talking for long periods, talking over background noise, and talking in rooms with poor acoustics and air quality.1,4,5 Health-related risk factors include frequent colds and sinus infections, reflux, respiratory allergies, and asthma.4,6,7 Persons who are at risk for having voice problems may be teachers, lawyers, singers, and priests.1–3 Priests are recognized as occupational voice users, and their work includes, for example, leading sermons and singing or chanting.1 Priests also speak in noisy environments8 and give religious teaching and spiritual counseling.9 To our knowledge, there are only a few modern studies on the prevalence of voice problems in priests. In some of the studies, the study populations are quite small. The results of the perceptual evaluation in a study on six female priests showed that they had deviant voice quality.8 Additionally, the researchers concluded that the priests had vocally abusive behavior. Neto et al9 conducted a questionnaire study on vocal health in 56 male priests and found the prevalence of vocal complaints to be high. The most common vocal symptom when speaking for long times was throat clearing reported by 78.5%. Other symptoms were hoarseness reported by 57.1% and pain or irritation in the throat reported by 51.8%. Of those who suffered Accepted for publication August 25, 2014. From the *Department of Psychology and Logopedics, Abo Akademi University, Abo, Finland. Address correspondence and reprint requests to Ann-Marie Hagelberg, Speech and Language Pathology, Abo Akademi University, Fabriksgatan 2, 20500 Abo, Finland. E-mail: [email protected] Journal of Voice, Vol. 29, No. 3, pp. 389.e11-389.e18 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.08.015
from hoarseness, 87% reported the hoarseness to be episodic and related to vocal loading. The results showed that many of the priests worked long hours, some even more than 10 hours a day.9 Hapner and Gilman10 conducted a questionnaire study on 75 Jewish cantors, 34% males and 66% females, to explore the occurrence of laryngeal symptoms. Jewish cantors have similar responsibilities to priests and have several voicedemanding duties and act both as spiritual and musical leaders. The results showed that 65% had voice problems that had a negative effect on their ability to work. Most cantors used their voice at least 45 hours a week. Risk factors for voice problems were, for example, high vocal loading and demands, too little voice rest, and health-related risk factors such as allergies and reflux.10 Hocevar-Boltezar11 conducted a questionnaire study on a larger population to explore the prevalence of voice problems in Catholic priests. Of 600 priests, 340 answered the questionnaire. The results showed that 85.6% had suffered from voice problems at some point of their career and 15.9% had frequent voice problems. Voice-related absenteeism was reported by 12.1%. Repeated throat clearing was reported by 55.8%. Other risk factors were symptoms of reflux reported by 32.9%, asthma and allergy reported by 15.5%, and smoking reported by 7.6%. Of the participants who had voice disorders, respiratory infections were reported by 41.5%. Of the participants, 76.1% reported that they were speaking loudly at work, 48.7% reported lack of knowledge of correct voice use, and 29.9% reported vocal load during spare time. Current voice problems were reported by 15.7%. The results of previous studies on voice problems in priests indicate that voice problems are common in this occupation. The primary purpose of this study was to extend the literature by investigating the prevalence of voice problems in a large
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TABLE 1. Number of Participants Who Had Sought Help for Voice Problems, Who Had Been Diagnosed With a Voice Disorder, Who Considered Themselves as Having Current Voice Problems (n ¼ 869–885) and a Comparison Between Female (n ¼ 407–413) and Male Participants (n ¼ 458–468) All Participants Variable Had sought help for voice problems Had been diagnosed with a voice disorder Considered themselves as having current voice problems
Females
Males
n
%
n
%
n
%
c2
217 156 186
24.5 18 21
128 92 105
31 22.6 25.6
89 64 80
19 14 17.1
c2(1) ¼ 16.949, P < 0.001 c2(1) ¼ 10.859, P < 0.001 c2(1) ¼ 9.529, P ¼ 0.002
group of priests and to identify possible risk factors for voice problems. Another purpose was to explore possible gender differences in the prevalence of voice problems.
MATERIALS AND METHODS Participants A link to an electronic questionnaire was sent to 2115 of the totally 2155 evangelical Lutheran priests in Finland, of which 94.8% (n ¼ 2044) received the e-mail. The addresses were acquired by the Finnish Association for evangelical Lutheran priests. The questionnaire was available on the Internet for a month, and altogether 901 priests completed it. The overall response rate was 44.1%. Of the 901 participants, 12 were excluded because they did not work with typical priest tasks or because they did not work as priests at all at the moment. The final sample consisted of 889 priests. Of them, 53% were males and 47% were females. The percentage of male and female participants is well in line with the statistics from Evangelical Lutheran Church of Finland because 43% of the priests in 2013 were females.12 The participants had worked as priests between less than a year and 41 years (mean ¼ 16.8, standard deviation ¼ 10.8). Of the participants, 7.3% were 20–30 years old, 31.8% were 31–45 years old, 49.2% were 46–60 years old, and 11.2% were older than 60 years. Participation in the study was voluntary, and anonymity was guaranteed. Approval to conduct the study was given by the Ethics Committee of the Department of Psychology at Abo Akademi University.
Data collection The data were obtained with an electronic questionnaire containing 33 multiple-choice (two, three, or four answering alternatives) and open-end questions. The questionnaire was self-explanatory, and no explanations or definitions were provided. The questions chosen were based on previous studies on voice disorders in various populations.6,7,13–16 The questionnaire included demographic questions and questions about voice problems during the career and present voice problems. Questions on vocal symptoms occurring during the past year were also asked. The vocal symptoms were voice becomes strained or tires, voice becomes low or hoarse, voice breaks while talking, difficulty in being heard, throat clearing or coughing while talking, and sensation of pain or lump in the throat. The frequency alternatives for the occurrence of the symptoms were daily, weekly, seldom, or never. Questions concerning work-related factors that might have an impact on the voice, such as time of vocal load during a workday and voice-demanding activities such as preaching and singing, were queried. Other questions about the working environment were about speaking to a large audience, speaking to an audience that is at a distance, speaking in noisy or reverberant environments, and speaking outdoors. One question on the use of voice amplification was included. The health-related questions included questions about occurrence of rhinitis, allergies, reflux, asthma, and asthma medication. Work absence because of voice problems and a question about smoking habits were also enquired. The questionnaire included a question inquiring whether the vocal symptoms had an effect on the participant’s mood.
TABLE 2. Number of Participants (n ¼ 884) Having Frequently Occurring Vocal Symptoms and a Comparison Between Females (n ¼ 412) and Males (n ¼ 467) All Participants Vocal Symptoms Seldom or never occurring symptoms One frequently occurring symptom Two or more frequently occurring symptoms c2(2) ¼ 18.459, P < 0.001.
Females
Males
n
%
n
%
n
%
494 154 235
55.9 17.4 26.7
213 61 138
51.7 14.8 33.5
280 90 97
60 19.3 20.8
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Prevalence of Voice Problems in Priests
TABLE 3. The Six Vocal Symptoms Reported by All Participants (n ¼ 873–885) Frequently Occurring Symptoms
Seldom or Never Occurring Symptoms
n
%
n
%
281 203 162 127 68 59
32 23.1 18.3 14.5 7.8 6.7
597 676 721 750 805 826
68 76.9 81.7 85.5 92.2 93.3
Vocal Symptoms Throat clearing or coughing while talking The voice becomes strained or tires The voice becomes low or hoarse Sensation of pain or lump in the throat Difficulty in being heard Voice breaks while talking
more common for female participants to consider that they had current voice problems. Eight hundred sixty-nine participants answered the question on whether they had been diagnosed with a voice disorder by a physician. Of the participants, 17.9% (n ¼ 159) had consulted a laryngologist. Of the participants, 17.3% (n ¼ 157) answered to an openend question about which diagnosis they had received. They could report more than one diagnosis. The most common answer was voice problems because of various infections and viruses. This was reported by 41.4% (n ¼ 65), whereas 37.6% (n ¼ 59) reported various symptoms, such as hoarseness, loss of voice, and vocal fatigue. Of the participants, 10.2% (n ¼ 16) reported voice problems related to allergy or asthma and 3.8% (n ¼ 6) reported a functional voice disorder. Of the participants, 2.5% (n ¼ 4) had been diagnosed with vocal nodules, 1.9% (n ¼ 3) with hypothyroidism, and 1.9% (n ¼ 3) reported minor changes on the vocal folds. Diagnoses reported by single participants were polyps, tumor in the larynx, diplophonia, ulcers, and stress. Of the participants, 26.7% (n ¼ 235) reported two or more frequently occurring vocal symptoms, 17.4% (n ¼ 154) reported one symptom, and 55.9% (n ¼ 494) reported seldom or never occurring vocal symptoms. Females reported significantly more frequently occurring vocal symptoms than males (Table 2). Of the 156 participants who had been diagnosed with a voice disorder, 44.8% (n ¼ 69) had two or more frequently occurring vocal symptoms, 20.1% (n ¼ 31) had one frequently occurring symptom, and 35.1% (n ¼ 54) had seldom or never occurring vocal symptoms. Of those who
Additionally, questions about received information on voice and voice use during the time of study and knowledge on the own voice were included. Analysis IBM SPSS Statistics 20 software (IBM, Armonk, NY) was used for all statistical analyses. Cross tabulations and chi-square tests were used to perform bivariate analyses between selected variables. The participants answered to a question whether they had been diagnosed with a voice disorder by a physician and an open-end question about which diagnosis they received. This question was difficult to answer, probably because of memory factors. Some participants could answer the question using the proper medical diagnosis, whereas others reported ‘‘a cold,’’ ‘‘hoarseness,’’ or other symptoms. Therefore, answers to the question about the prevalence of frequently occurring vocal symptoms during the past year were used for statistical calculations. Symptoms occurring weekly or daily during the past year were defined as frequently occurring symptoms. RESULTS Prevalence of voice problems Of the participants, 24.5% (n ¼ 217) had sought help for voice problems and 18% (n ¼ 156) reported that they had been diagnosed with a voice disorder by a physician. Twenty-one percent (n ¼ 186) considered themselves as having current voice problems. The female participants had sought help significantly more than the males (Table 1). There were also more female participants who had been diagnosed with a voice disorder, and it was
TABLE 4. A Comparison of Frequently Occurring Vocal Symptoms Between Females (n ¼ 406–412) and Males (n ¼ 461–468) Females Vocal Symptoms Throat clearing or coughing while talking The voice becomes strained or tires The voice becomes low or hoarse Sensation of pain or lump in the throat Difficulty in being heard Voice breaks
Males
n
%
n
%
c2
146 118 92 82 42 42
36 28.9 22.3 20 10.3 10.2
133 85 69 45 24 17
28.5 18.2 14.8 9.7 5.2 3.6
c2(1) ¼ 5.590, P ¼ 0.018 c2(1) ¼ 13.763, P < 0.001 c2(1) ¼ 8.351, P ¼ 0.004 c2(1) ¼ 18.376, P < 0.001 c2(1) ¼ 7.984, P ¼ 0.005 c2(1) ¼ 15.082, P < 0.001
389.e14 c (2) ¼ 6.292, P ¼ 0.043 c2(2) ¼ 12.489, P ¼ 0.002 c2(2) ¼ 7.876, P ¼ 0.019 c2(2) ¼ 46.469, P < 0.001 c2(2) ¼ 42.217, P < 0.001 NS NS
had not been diagnosed with a voice disorder, 22.7% (n ¼ 161) had two or more frequently occurring vocal symptoms, 16.3% (n ¼ 116) had one symptom, and 61% (n ¼ 433) had seldom or never occurring vocal symptoms. The participants who reported that they had been diagnosed with a voice disorder had significantly more vocal symptoms (c2 ¼ 39.435, P < 0.001). The most frequent symptoms in the whole population were throat clearing or coughing while talking reported by 32%, the voice becomes strained or tires reported by 23.1%, and the voice becomes low or hoarse reported by 18.3% of the participants (Table 3). All vocal symptoms were significantly more often reported by female participants (Table 4).
25.3 23.1 20.0 15.4 26.9 24.1 18.4 193 139 61 49 86 90 23 Abbreviation: NS, not significant.
Speaking outdoors Speaking in noisy environments Speaking to an audience at distance Working in a room with dry air Working in a draughty room Speaking in a room with reverberation Speaking to a large audience
49 132 310 234 185 277 417
45.4 48.4 53.3 47.9 47.1 54.6 55.2
22 49 99 80 60 85 127
20.4 17.9 17 16.4 15.3 16.8 16.8
37 92 173 175 148 145 212
34.3 33.7 29.7 35.8 37.3 28.6 28
443 360 178 253 301 214 76
58 59.9 61 66.2 55.9 57.4 60.8
128 102 53 70 89 69 26
16.8 17 18.2 18.3 17.1 18.5 20.8
% n % n % n % Working Conditions
%
% n n
n
Two or More Symptoms One Symptom No Symptoms Two or More Symptoms One Symptom
Number of Symptoms Number of Symptoms
No Symptoms
Occasionally Frequently
TABLE 5. The Connection Between Frequently Occurring Vocal Symptoms and Some Working Conditions (n ¼ 874–886)
2
c2
Journal of Voice, Vol. 29, No. 3, 2015
Work-related and environmental risk factors Of the participants, 76.1% (n ¼ 668) reported that they used their voice considerably during a workday, whereas 13.6% (n ¼ 121) were of the opinion that they did not do so and 10% (n ¼ 89) could not tell whether they used their voice considerably or not. Regarding the frequently occurring vocal symptoms, there was no significant difference between those who reported that they used their voice considerably and those who reported that they did not do that. Forty-two percent (n ¼ 370) estimated that they used their voice 1–3 hours a day, whereas 58% (n ¼ 511) reported that they used their voice for 4 hours or more. There was no significant difference in the prevalence of frequently occurring vocal symptoms between those who reported an estimated speaking time of 1–3 hours and those who reported 4 hours or more. Besides using the voice considerably during working days, 26% (n ¼ 231) of the participants also had voice-demanding leisure activities, for example, singing and leading groups of children or adults in various activities. Regarding the vocal symptoms, there was no significant difference between those who had vocally demanding leisure activities and those who did not. Singing was considered to be an important part of the work by 79% (n ¼ 701) of the participants, and 18.9% (n ¼ 167) reported that they had more difficulties singing nowadays. Of those who considered that it had become more difficult to sing, 60.8% (n ¼ 101) reported two or more frequently occurring symptoms, compared with 18.6% (n ¼ 118) of those who did not think it had become more difficult. The difference was significant (c2 ¼ 122.679, P < 0.001). Forty-four percent (n ¼ 387) of the participants felt that they had to raise their voice during workdays. The most common vocally demanding duties were singing reported by 32.4% (n ¼ 288), preaching reported by 28.6% (n ¼ 254), services reported by 25.4% (n ¼ 226), and ceremonies reported by 20% (n ¼ 178). About half of the population, 50.2% (n ¼ 446), reported that they always used a voice amplifier when preaching and 42.3% (n ¼ 372) reported that they used one often or quite often, whereas 7% (n ¼ 62) reported that they seldom or never used amplification. Other risk factors queried were speaking to a large audience, speaking to an audience at a distance, speaking in noisy environments, and speaking outdoors. Speaking frequently to a
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Prevalence of Voice Problems in Priests
TABLE 6. The Connections Between Frequently Occurring Vocal Symptoms and Health-Related Risk Factors (n ¼ 861–880) No Symptoms
One Symptom
Two or More Symptoms
Health-Related Risk Factors
n
%
n
%
n
%
c2
Prolonged rhinitis Respiratory allergy Reflux Asthma Use of asthma medication
81 75 26 29 27
16.5 15.3 5.4 6 5.6
40 24 14 16 11
26.1 15.6 9.2 10.5 7.5
88 56 46 30 31
37.8 23.8 19.9 13 13.3
c2(2) ¼ 39.740, P < 0.001 c2(2) ¼ 8.545, P ¼ 0.014 c2(2) ¼ 36.877, P < 0.001 c2(2) ¼ 10.290, P ¼ 0.006 c2(2) ¼ 12.698, P ¼ 0.002
large audience was reported by altogether 85.6% (n ¼ 759), and 66.5% (n ¼ 584) spoke frequently to an audience at distance. Speaking frequently in noisy environments was reported by 31.3% (n ¼ 275), and speaking frequently outdoors was reported by 12.3% (n ¼ 108). Of the participants, 56% (n ¼ 492) frequently worked in a room with dry air, 45.1% (n ¼ 394) frequently worked in a draughty room, and 57.5% (n ¼ 509) frequently spoke in a room with reverberation. There was a significant association between frequently occurring vocal symptoms and five of the seven working conditions (Table 5). Health-related risk factors The most common health-related risk factor for voice problems was prolonged rhinitis, which was reported by 23.6% (n ¼ 210). Of the participants, 17.7% (n ¼ 157) had been diagnosed with respiratory allergies. The most common allergies were allergy to pollen, dust, animals, and mold. Reflux was reported by 9.8% (n ¼ 87), asthma by 8.5% (n ¼ 76), and the use of asthma medication by 7.9% (n ¼ 70). Of the study population, 5.5% (n ¼ 49) were smokers. All the health-related risk factors, except smoking, had a significant association with frequently occurring vocal symptoms (Table 6). Voice-related absenteeism once or several times a year was reported by 11.6% (n ¼ 103). The association between frequently occurring vocal symptoms and being absent from work was significant (Table 7). Altogether, 12.4% (n ¼ 107) reported that their mood was considerably or moderately affected by their voice problem, whereas most participants, 87.6% (n ¼ 756) felt that their mood was affected little or not at all (Table 8).
Of the participants, 63.1% (n ¼ 561) had received information on the voice and voice use during their education and 61.4% (n ¼ 546) had received information in some other context. There was no significant difference in the prevalence of frequently occurring vocal symptoms between those who had received information and those who had not. In this study, 33.3% considered that they had enough voice knowledge, whereas 66.7% (n ¼ 580) reported that they did not know enough of their voice. More than half of the participants, 57.2% (n ¼ 338), considered that they in total had received less than 5 hours of information on the voice and voice use. The connection between frequently occurring vocal symptoms and the number of hours of information on the voice and voice use was significant (Table 9). DISCUSSION The aim of this study was to explore the prevalence of voice problems in priests and to investigate possible risk factors associated with voice problems. The results showed that the prevalence of voice problems in this population was high. In a normal population, the estimated prevalence of voice disorders varies from 3% to 9%.17 The definition of a voice disorder varies in the literature. It can, for example, be defined as any time the voice does not work or sound as it should so that the communication is interfered,6 as a voice symptom for which the patient seeks help,18 or as having two or more frequently occurring vocal symptoms.7 Depending on which definition is used, the prevalence of voice problems or voice disorders in the participants in this study varies from 18% who reported that they had been diagnosed with a voice disorder to 24.5% who had sought help for voice problems or 26.7% who reported
TABLE 7. The Connection Between Frequently Occurring Vocal Symptoms and Work Absence (n ¼ 881)
Work Absence Due to Voice Problems Every year or more often Seldom or never c2(2) ¼ 23.771, P < 0.001.
Two or More Symptoms
No Symptoms
One Symptom
n
%
n
%
n
%
36 457
35 58.7
21 131
20.4 16.8
46 190
44.7 24.4
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Journal of Voice, Vol. 29, No. 3, 2015
TABLE 8. The Connection Between Frequently Occurring Vocal Symptoms and the Effect on the Participant’s Mood (n ¼ 860) No Symptoms
Two or More Symptoms
One Symptom
Effect on the Mood
n
%
n
%
Considerably or moderately affected Little or not at all affected
23
21.7
17
452
59.9
135
16 17.9
n
%
66
62.3
167
22.1
c (2) ¼ 80.001, P < 0.001. 2
two or more frequently occurring symptoms. Twenty-one percent of the participants in this study reported that they had current voice problems, which is more than in the studies on teachers’ voice problems.6,19 It is well documented that teachers have a high prevalence of voice problems.2,4,7,16,19,20 It is possible that priests are even more at risk of having voice problems than teachers. It is also possible that priests are more aware of the voice as an occupational tool than teachers and therefore better recognize voice problems. The response rate in this study was 44.1%. It is of course possible that the priests who felt that they had experienced problems with their voices were more motivated to fill out the questionnaire, which might have had an impact on the results. Still, the results of this study were in line with previously conducted research on voice problems in priests9–11 suggesting that the priests participating in this study were representative of the entire population of priests. In this study, the number of female and male participants was equal, 53% males and 47% females. Women generally have more voice problems than men.2,5,14,20–22 The results of this study are well in accordance with previous studies addressing gender differences. The female participants were significantly more active in seeking help for their voice problems, had significantly more often been diagnosed with a voice disorder, and significantly more often considered themselves as having current voice problems compared with males. All vocal symptoms were significantly more frequently reported by female participants, although the number of male participants with vocal symptoms was also high. Of the 156 participants who reported that they had been diagnosed with a voice disorder, 41.4% reported suffering from
voice problems related to viruses and infections. This result is consistent with the results of the study on voice problems in priests by Hocevar-Boltezar.11 The results of a study on voice problems in day care center teachers implied that teachers are frequently exposed to viruses associated with upper respiratory tract infections.7 This might also be the case with priests because their work includes frequent close contacts with people. Voice problems related to colds might be temporary. Still, respiratory infections might lead to persistent voice problems.4,5,18 Therefore, it is important that persons working in vocally demanding occupations take proper actions to prevent colds. The prevalence of the six vocal symptoms examined in this study has been investigated in a number of studies.7,14,16,23,24 The results of this study showed that 26.7% of the participants reported two or more frequently occurring vocal symptoms. Earlier studies involving teachers and day care center teachers showed that 20% of the teachers reported two or more symptoms,16 whereas 37% of the day care center teachers reported that.7 The priests in this study had more frequently occurring vocal symptoms than teachers but less than day care center teachers. In the study on day care center teachers, all participants underwent an examination of the vocal folds. The results showed that those who reported two or more frequently occurring vocal symptoms often had visible changes on their vocal folds.7 This might indicate that many participants in this study could have changes on their vocal folds. The results of prevalence studies relying on data obtained by questionnaires can be reliable and valid.25 Still, questions can be interpreted in various ways. A study including a perceptual assessment and a videolaryngoscopic examination of the vocal folds would give
TABLE 9. The Connection Between Frequently Occurring Vocal Symptoms and Number of Hours of Information on the Voice and Voice Use (n ¼ 586)
Hours of Information on the Voice and Voice Use Less than 5 hours Five hours or more c2(2) ¼ 8.590, P ¼ 0.014.
No Symptoms
Two or More Symptoms
One Symptom
n
%
n
%
n
%
173 157
51.5 62.8
71 34
21.1 13.6
92 59
27.4 23.6
Ann-Marie Hagelberg and Susanna Simberg
Prevalence of Voice Problems in Priests
exact information of diagnosis. In this study, there were no financial resources for such examinations. The most common frequently occurring vocal symptoms in this study were throat clearing or coughing while talking, the voice becomes strained or tires, and the voice becomes low or hoarse. In total, 32% of the participants reported the symptom throat clearing and coughing as frequently occurring. This is in accordance with several previous studies.7,9,11,14,23,24 The symptom the voice becomes strained or tires was reported as frequently occurring by 23.1% of the participants. This implies that the priests suffer from vocal fatigue because of vocal loading. Another symptom that might be related to vocal loading is hoarseness. Of the participants, 18.3% reported the symptom the voice becomes low or hoarse. In an earlier study on priests, 57.1% reported prevalence of hoarseness, which was connected to vocal loading.9 Most participants in this study, 76.1%, considered that they used their voice considerably during a workday. Using the voice considerably during working days did not have a significant connection with frequently occurring vocal symptoms, which might be because of the fact that almost all participants used their voice often. The answers to the question on daily voice use may not be adequate because subjective estimation of speaking time is difficult. The participants reported that their work tasks were vocally demanding. This is well in accordance with previous studies on priests.8–11 The results also confirm that the environment in which priests work is vocally demanding (Table 5). Speaking outdoors, speaking in noisy environments, speaking to an audience at distance, working in a room with dry air, and working in a draughty room had a significant connection with frequently occurring vocal symptoms. In this study, speaking to large groups did not have a significant connection with vocal symptoms, which could be because of the fact that more than 90% of the participants actively used voice amplification. More than half of the participants reported that they frequently spoke in a room with reverberation. Surprisingly, speaking in reverberant rooms did not have a significant association with vocal symptoms, which also could be because of the active use of voice amplification or good speaking skills. The participants who reported prolonged rhinitis, respiratory allergy, and asthma also had significantly more vocal symptoms (Table 6). This is in accordance with the results of a study by Roy et al5 that showed that those who reported respiratory allergies, asthma, sinus infections, colds, and postnasal drip also had a higher frequency or voice disorders. About 10% of the participants reported that they had been diagnosed with reflux. This is less than in the study on voice problems in priests by Hocevar-Boltezar.11 In this population, reflux might be underdiagnosed because 32% reported throat clearing and coughing, which are common symptom for reflux.26 The questionnaire could perhaps have included a question of the prevalence of heartburn. Not all those who have reflux suffer from heartburn.26 Still, it could have provided some information about possible underdiagnosed reflux. Altogether, 11.6% of the participants had been absent from work once or several times a year because of voice problems.
389.e17
This result is almost the same as it was in the study of Hocevar-Boltezar.11 There was a significant association between frequently occurring vocal symptoms and the absence from work. The participants in this study and in that of Hocevar-Boltezar11 reported less absenteeism because of voice problems than teachers,13,20,27,28 which might indicate that some of the work tasks of priests might be difficult to postpone or to get a substitute. Of the participants, 12.4% reported that their mood was considerably or moderately affected by the voice problems, and there was a significant association with the prevalence of two or more frequently occurring vocal symptoms. The question inquiring whether the vocal symptoms had an effect on the mood was not a very exact one as it does not necessarily address the degree of concern. In further studies on voice problems in priests, the psychosocial impact of voice disorders should preferably be evaluated with, for example, the Voice Handicap Index. In this study, 33.3% of the participants reported that they had enough knowledge of their voice, whereas 66.7% considered that they had too little voice knowledge. Several authors have addressed the importance of prevention of voice disorders among those working in vocally demanding occupations.2,3,14,19,27,28 The conclusions from studies involving priests address the importance of prevention of voice problems in this occupational group.8–11 In this study, those who had received less than 5 hours of information on the voice and voice use had significantly more vocal symptoms than those who had received more than 5 hours of information. These results are in line with the results of another study on priests where the lack of voice ergonomic information was connected to voice problems.11 CONCLUSIONS The results of this study indicate that the prevalence of voice problems among priests is high and no less than, for example, in teachers, which is an occupation known to have a high prevalence of voice problems. Because voice problems are common among priests, regular voice screening tests and voice training programs should be included in the curriculum for all those who are studying to become priests. Additionally, access to voice therapy and vocal medical care should be offered to the students. For those already working as priests, practical courses on voice training could be arranged. Additionally, priests should get information on voice-related issues from the occupational health care or other health care services. REFERENCES 1. Titze IR, Lemke J, Montequin D. Population in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. 1997;11: 254–259. 2. Fritzell B. Voice disorders and occupations. Logoped Phoniatr Vocol. 1996; 21:7–12. 3. Verdolini K, Ramig L. Review: occupational risks for voice problems. Logoped Phoniatr Vocol. 2001;26:37–46. 4. Vilkman E. Occupational safety and health aspects of voice and speech professions. Folia Phoniatr Logop. 2004;56:220–253.
389.e18 5. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988–1995. 6. 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;47:281–293. 7. Sala E, Laine A, Simberg S, Pentti J, Suonp€a€a J. The prevalence of voice disorders among day care center teachers compared with nurses: a questionnaire and clinical study. J Voice. 2001;15:413–423. 8. Middleton RL, Hinton VA. A preliminary investigation of the vocal behaviors and characteristics of female pastors. J Voice. 2009;23:594–602. 9. Neto FXP, Silva IPC, Madeira AV, Menezes CRT, Rodrigues G, Navarro LM. Analysis of the vocal health of the preachers of the Seventhday Adventist churches. Int Arch Otorhinolaryngol. 2009;13:407–412. 10. Hapner E, Gilman M. The vocal load of reform Jewish cantors in the USA. J Voice. 2011;26:201–204. 11. Hocevar-Boltezar I. Prevalence and risk factors for voice problems in priests. Wien Klin Wochenschr. 2009;121:276–281. 12. Statistics from Evangelical Lutheran Church of Finland (in Finnish). Naisten osuus kirkon henkil€ost€ost€a. Available at: http://sakasti.evl.fi/sakasti.nsf/ sp?open&cid¼Content3A1AB1. 2014. Accessed July 15, 2014. 13. Lyberg- Ahlander V, Rydell R, L€ofqvist A. Speaker’s comfort in teaching environments: voice problems in Swedish teaching staff. J Voice. 2009; 25:430–440. 14. Ohlsson A-C, Andersson EM, S€odersten M, Simberg S, Barreg ard L. Prevalence of voice symptoms and risk factors in teacher students. J Voice. 2012;26:629–634. 15. Simberg S, Sala E, Laine A, R€onnemaa A-M. A fast and easy screening method for voice disorders among teacher students. Logoped Phoniatr Vocol. 2001;26:10–16. 16. Simberg S, Sala E, Vehmas K, Laine A. Changes in the prevalence of vocal symptoms among teachers during a twelve-year period. J Voice. 2005;19:95–102.
Journal of Voice, Vol. 29, No. 3, 2015 17. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41:101–116. 18. Herteg ard S. Voice problems in a small Swedish town: a retrospective study of the prevalence and a follow-up. J Voice. 1988;1:336–340. 19. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467–479. 20. 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. 21. Coyle SM, Weinrich BD, Stemple JC. Shifts in relative prevalence of laryngeal pathology in a treatment-seeking population. J Voice. 2001;15: 424–440. 22. Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Description of laryngeal pathologies by age, sex, and occupation in a treatment-seeking sample. J Speech Hear Disord. 1988;53:57–64. 23. Holmqvist S, Santtila P, Lindstr€om E, Sala E, Simberg S. The association between possible stress markers and vocal symptoms. J Voice. 2013;27: 787–797. 24. Simberg S, Sala E, Tuomainen J, R€onnemaa A-M. Vocal symptoms and allergy—a pilot study. J Voice. 2009;23:136–139. 25. Mattiske JA, Oates JM, Greenwood KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice. 1998;12: 489–499. 26. Koufman J, Sataloff RT, Toohill R. Laryngopharyngeal reflux: consensus conference report. J Voice. 1996;10:215–216. 27. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of teachers’ voice problems. J Voice. 1997;11:81–87. 28. Roy N, Merrill RM, Thibeault S, Gray SD, Smith EM. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551.