- Email: [email protected]
Perceived Control, Voice Handicap, and Barriers to Voice Therapy
ARTICLE IN PRESS
Perceived Control, Voice Handicap, and Barriers to Voice Therapy *Viann N. Nguyen-Feng, †Patricia A. Frazier, ‡Nelson Roy, §Seth Cohen, and ║Stephanie Misono, *Duluth, and
y║Minneapolis, Minnesota, zSalt Lake City, Utah, and xDurham, North Carolina
SUMMARY: Objective. To characterize the associations of perceived control with voice outcomes and self-reported likelihood of attending voice therapy using a national practice-based research network. Study design. Cross-sectional study of prospectively enrolled adult patients seen for dysphonia. Setting. Creating Healthcare Excellence through Education and Research (CHEER) network of community and academic practice sites. Subjects and methods. Data collected included patient-reported demographics, outcome measures of voice (Voice Handicap Index-10), perceived control (present control subscale of voice-specific Perceived Control over Stressful Events Scale), personality (Ten Item Personality Inventory), likelihood of attending voice therapy if recommended, and barriers to attending voice therapy. Results. Patients (N = 247) were enrolled over 12 months from 10 sites, of whom 170 received a recommendation for voice therapy. The majority (85%) of this group planned to attend voice therapy. Voice-specific perceived control and VHI-10 were inversely related (r = 0.31, P < 0.001), even when controlling for personality. No study variables were associated with self-reported likelihood of attending voice therapy, but perceived control was the most consistent correlate of specific barriers to attending voice therapy (eg, “hard to translate into everyday use”) and was inversely related to these barriers. Conclusions. Patients scoring higher on a voice-specific measure of perceived control reported less voice handicap, independent of personality, and higher perceived control was associated with having fewer concerns about voice therapy goals and process. Perceived control is a potential target for intervention in patients with voice disorders. Key Words: Dysphonia−Voice therapy−Perceived control−Voice handicap−Personality.
INTRODUCTION Voice disorders are relatively common, with a 30% lifetime prevalence rate in the general population.1 Voice disorders can have detrimental impacts across various life domains, such as daily communication, social and occupational functioning, quality of life, and well-being.1−6 Voice disorders may result in voice handicap, which can be defined as a social, economic, or environmental disadvantage from a voice impairment or disability.7 An important component of treatment for voice disorders is consideration of associated psychological factors, given the high prevalence of distress among voice patients8,9 as well as differences in personality and psychological characteristics across different voice disorders.10,11 Accepted for publication September 4, 2019. Funding: This work was supported by funding from the National Institutes of Health (NIH), including grants K23DC016335, 3R33DC008632-05S1, UL1TR000114, KL2 RR0333182, and ULI RR033183. The NIH did not play a role in the research, and opinions expressed herein are the authors’ and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States government. From the *Department of Psychology, University of Minnesota Duluth, Duluth, Minnesota; yDepartment of Psychology, College of Liberal Arts, University of Minnesota Twin Cities, Minneapolis, Minnesota; zDepartment of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah; xDepartment of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina; and the ║Department of Otolaryngology − Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota. Address correspondence and reprint requests to Stephanie Misono, Department of Otolaryngology − Head and Neck Surgery, University of Minnesota, 420 Delaware St SE, MMC 396, Minneapolis MN 55455. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.002
Perceived present control is one psychological factor particularly related to voice disorders. Perceived present control12,13 is defined as beliefs about what one can currently control about a stressor, such as one’s thoughts or behaviors related to the stressor. We focused on this aspect of control because perceived control over specific stressors, such as health concerns, has been demonstrated to predict outcomes more strongly than general control beliefs.14−16 Both cross-sectional17 and longitudinal18 studies with voice patients have indicated that higher perceived present control was associated with less voice handicap, with moderate-to-large effect sizes. Furthermore, perceived present control was more strongly related to voice handicap than was distress (eg, depression, anxiety).17 In a longitudinal study,18 baseline perceived present control predicted voice handicap symptoms 3 weeks later, even after controlling for distress and general control beliefs. A qualitative study19 also suggested that patients who reported greater voice-related perceived present control used more adaptive emotional and behavioral responses to voice disorder symptoms. Based on these findings, we developed a web-based intervention20 focused on teaching perceived present control. Preliminary evidence suggests that it was effective in reducing voice handicap among individuals with voice disorders.20 These studies highlight the importance of considering perceived present control in working with patients with voice disorders. The purpose of this current study was to extend this research in several ways. The first aim was to examine the relation between perceived present control and voice disorder symptoms in a
ARTICLE IN PRESS 2 broader national sample. Although our prior research examining voice-related perceived present control has shown consistent findings with respect to the relation between perceived control and voice handicap,17,18 these studies have all been conducted in one academic tertiary care clinic. Thus, in the present study we examined the relations between perceived present control and voice outcomes in a broad sample of patients from the Creating Healthcare Excellence through Education and Research (CHEER) network to assess the replicability and generalizability of previous findings. The second aim was to examine whether the relation between perceived present control and voice handicap remained significant controlling for personality. This is important for two reasons. First, perceived present control is positively related to the personality traits of extraversion and emotional stability (the opposite of neuroticism or emotional instability), with small to moderate effect sizes.12,21 Thus, if personality variables are also associated with voice handicap, the relations between perceived present control and voice handicap may be reduced if personality variables are taken in to account. Second, personality variables are thought to contribute to voice disorders such as functional dysphonia and vocal nodules,22 and prior work has suggested possible associations between personality and voice handicap.22,23 Moreover, previous research has found differences in extraversion and emotional stability between individuals with different types of voice disorders.22,24−27 Thus, we examined whether the relations between perceived present control and voice handicap remained after controlling for the effects of two key personality variables − extraversion and emotional stability. The final aim was to examine relations between perceived present control, personality, and barriers to voice therapy. Voice therapy is effective for a variety of voice disorders,28−32 and was recommended for most patients with voice disorders in prior research on this sample of patients from the CHEER network.33 Patients who indicated that they did not intend to pursue voice therapy despite the recommendation cited barriers to participation including that they did not understand the purpose of voice therapy.34 Following the theory of planned behavior,35 prior research in psychology has shown that participants with greater perceived control are more likely to seek help.36,37 Here we examined whether perceived present control was related to the self-reported likelihood of pursuing voice therapy and barriers to voice therapy. As an exploratory question, we also examined the relations between personality and both help-seeking likelihood and barriers, as previous studies38−42 have demonstrated that personality was related to help-seeking behaviors. These questions are important for understanding patient perspectives on participation in voice care. In summary, the purpose of the present study was to further explore the role of perceived present control in voice outcomes. The first aim was to replicate the prior findings of a significant relation between perceived present control and voice handicap in a different, broader patient group
Journal of Voice, Vol. &&, No. &&, 2019
recruited from the CHEER network. Second, we aimed to assess whether this finding remained when controlling for personality, a potential confounding variable. Third, we aimed to move beyond self-reported voice handicap to assess the relation between both perceived present control and personality and the self-reported likelihood of attending voice therapy as well as barriers to attending voice therapy. METHOD Participants Participants (N = 247) were recruited from 10 voice clinics throughout the United States that are part of the CHEER network.33,43 New patients with voice complaints were invited to participate in the study in the clinics. Consenting patients completed brief surveys at the end of their clinic visit. Patients with missing data in the VHI-10 were excluded (n = 10, or 4%). Participants were mostly women (68%) and white (84%), with a mean age of 53.25 (SD = 14.93). The majority of the sample (53%) had at least a 4-year college degree. This is similar to the demographics of prior voice studies from our group.17,44,45 Duke University’s Institutional Review Board approved the study and extended approval to CHEER community sites. Approvals were also obtained from CHEER community sites that required independent institutional review board approval. Measures Voice handicap Voice handicap was assessed using the Voice Handicap Index-10 (VHI-107). The VHI-10 is a ten-item scale that assesses patients’ opinions regarding how their voice has affected their quality of life. Patients were asked to indicate the frequency with which statements such as “My voice difficulties restrict my personal and social life” were applicable to their life, ranging from 0 (Never) to 4 (Always). Scores on the VHI-10 have demonstrated reliability in similar samples.7,18,46 Scores on this measure had a Cronbach’s alpha of 0.90 in the present sample. Perceived control Perceived control was assessed using the eight-item Perceived Present Control Subscale of the Perceived Control over Stressful Events Scale12,21 modified for use by patients with voice problems.17 Patients were asked to rate their agreement with statements such as “When I am upset about the voice problem, I can find a way to feel better” from 1 (Strongly disagree) to 4 (Strongly agree). Scores on this adapted measure have demonstrated reliability in similar samples17,18 and had a Cronbach’s alpha of 0.79 in this sample. Personality Personality was assessed using the Ten Item Personality Inventory (TIPI47). The TIPI has five two-item subscales assessing the Big Five personality factors: extraversion,
ARTICLE IN PRESS Viann N. Nguyen-Feng, et al
3
Perceived Control, Voice Handicap, and Barriers to Voice Therapy
agreeableness, conscientiousness, emotional stability, and openness to experience. Participants rated the extent to which pairs of traits applied to them (eg, extraverted, enthusiastic) on a scale from 1 (Disagree strongly) to 7 (Agree strongly). Although the alpha coefficients were not high (extraversion a = 0.66; emotional stability a = 0.56) in this sample, consistent with previous research,46 scores on the TIPI have been found to correlate highly with scores on longer measures of personality (average r = 0.77).47 Likelihood of attending voice therapy Likelihood of attending voice therapy was assessed through the statement, “I am likely to go to voice therapy.” Participants indicated their agreement with this item on a 1 (Strongly disagree) to 5 (Strongly agree) scale. Barriers to attending therapy Patients who were recommended to attend voice therapy were asked to rate the extent to which certain factors would prevent them from attending on a 1 (Strongly disagree) to 5 (Strongly agree) scale. The four barriers previously found to be related to self-reported likelihood of attending voice therapy in this sample were used in these analyses: hard to translate into everyday use, want to see if it goes away, exercises seem strange, and do not understand the purpose.17 Demographics Patients reported their age, race, gender, level of education, and voice-related diagnosis. Race was dichotomized into a binary variable of white or not white. Education was dichotomized into having a 4-year college degree (BA/BS) or more and having less than a 4-year college degree. More than half of the participants (54%) reported having a single voice diagnosis.17 Vocal strain/excessive tension (43%), reflux (36%), and benign bumps, masses, and lesions (21%) were the most common diagnoses. Analytic methods Bivariate correlations were used to evaluate the relations between self-reported perceived present control, personality, voice handicap, likelihood of attending voice therapy, and barriers to attending voice therapy. Hierarchical multiple regression analyses were run to assess the relations between personality and perceived present control (predictor variables) and voice handicap, likelihood of attending voice therapy, and barriers to attending voice therapy (dependent variables). The hierarchical regressions provided information on whether perceived present control explained variance in the dependent variables after accounting for personality. Findings with marginal significance (P = 0.05) are included in addition to significant findings (P < 0.05) because there are relatively few data in the literature on this topic.
RESULTS Descriptive statistics Means and standard deviations for all variables are in Table 1. The mean total score on the VHI-10 was 18.01 (SD = 7.84), which was similar to other samples9,17 and well above the total score of 11 which is considered to be abnormal.48 The mean score on the perceived present control scale was 3.13 (SD = 0.55), similar to previous research17,20 which corresponds to a rating of “somewhat agree.” The most to least commonly reported barriers to attending therapy were: “hard to translate the exercises into everyday use,” “want to see if the voice issues go away on their own,” “exercises seem strange,” and “do not understand the purpose of the exercises.” Aim 1: Examine relation between perceived present control and voice disorder symptoms in a broader national sample See Table 2 for a summary of bivariate correlations. Patients who reported more perceived present control reported lower voice handicap, with a moderate effect size (r = 0.31, P < 0.001). This correlation was virtually identical to previously observed correlations; eg, r = 0.31; N = 1,129.18 Higher levels of perceived present control were also correlated with higher levels of extraversion (r = 0.19, P = 0.004) and emotional stability (r = 0.36, P < 0.001). Aim 2: Examine whether the relation between perceived present control and voice handicap remains significant controlling for personality Hierarchical multiple regression analyses (see Table 3) were used to assess the relation between perceived present control and voice handicap, controlling for personality (ie, extraversion, emotional stability). The measures of extraversion and TABLE 1. Means and Standard Deviations for Study Variables
Extraversion Emotional stability Present control Voice handicap (total) Likelihood of attending voice therapy Barrier: hard to translate Barrier: want to see if it goes away Barrier: exercises seem strange Barrier: do not understand purpose
M (SD)
N
4.71 (1.64) 5.13 (1.41) 3.14 (.55) 18.01 (7.84) 4.27 (1.29)
247 247 242 237 162
2.22 (1.26) 2.02 (1.34) 1.95 (1.12) 1.78 (1.22)
168 171 167 165
Note: Extraversion and emotional stability were measured with the Ten Item Personality Inventory on a scale from 1 (Disagree strongly) to 7 (Agree strongly). Present control was measured with the Perceived Control over Stressful Events Scale on a scale from 1 (Strongly disagree) to 4 (Strongly agree). Voice handicap was measured with the Voice Handicap Index-10 on a scale from 0 (Never) to 4 (Always). Likelihood of attending voice therapy and barriers were measured on a scale from 1 (Strongly disagree) to 5 (Strongly agree).
ARTICLE IN PRESS 4
Journal of Voice, Vol. &&, No. &&, 2019
TABLE 2. Correlations Among Study Variables Barriers
PPC PPC VHI TIPI, E TIPI, ES
− − − −
VHI
TIPI, E
TIPI, ES
0.31*** 0.19** 0.36*** − 0.06 0.10 − − 0.15* − − −
Likelihood of Attending Voice Therapy 0.01 0.05 0.05 0.04
Hard to Translate Into Want to See if Exercises Everyday Use it Goes Away Seem Strange 0.28*** 0.07 0.23** 0.15
0.18* 0.03 0.07 0.10
0.29*** 0.04 0.21** 0.08
Do not Understand the Purpose 0.20* 0.02 0.18* 0.14
* P < 0.05. ** P < 0.01. *** P < 0.001. Ns, 156−247. PPC, perceived present control; TIPI, E, Ten Item Personality Measure, Extraversion subscale; TIPI, ES,= Ten Item Personality Measure, Emotional Stability subscale; VHI, Voice Handicap Index-10.
TABLE 3. Hierarchical Regression Analysis Predicting Voice Handicap Index-10 Total Score Step 2 Variable
B
Step 1. Extraversion Emotional stability Step 2. Perceived present control
0.60 0.07 4.84
SE B
b
0.10, 1.21
0.37
0.12
0.67, 0.80
0.37
0.01
6.72, 2.95
0.96
95% CI
0.34***
*** P < 0.001. N = 233; R2 = 0.11; R2 Change = 0.10 after adding perceived present control (Step 2). + P = 0.05.
emotional stability were entered in the first step, and perceived present control was entered in the second step. Present perceived control explained significant variance in voice handicap controlling for personality. In the final step, only perceived present control was significantly associated with lower voice handicap (b = .34, P < 0.001).
Aim 3: Examine relations between perceived present control, personality, and barriers to voice therapy Although voice therapy was not recommended for everyone, the majority (85% of 159 participants given a recommendation) reported they were “likely” or “very likely” to attend voice therapy. Bivariate correlations (see Table 2) indicated that perceived present control was not significantly related to self-reported likelihood of attending voice therapy among those for whom it was recommended. Perceived present control was, however, significantly negatively
correlated with each of the barriers: hard to translate into everyday use, want to see if it goes away, exercises seem strange, and do not understand the purpose. Extraversion was significantly negatively correlated with three of the barriers: hard to translate into everyday use, exercises seem strange, and do not understand the purpose. Emotional stability did not correlate with any of the barriers. Similar to the analyses in Aim 2, hierarchical multiple regression analyses were used to assess the relation between perceived present control and the barriers to attending voice therapy, controlling for personality (ie, extraversion, emotional stability). No variables significantly predicted likelihood of attending voice therapy in the regression analyses. Separate regressions were run for each barrier to attending voice therapy (see Table 4). Controlling for personality, perceived present control was negatively related to two of the barriers: “hard to translate into everyday use” (b = 0.23, P = 0.004) and “exercises seem strange” (b = 0.27, P < 0.001). DISCUSSION The purpose of the present study was to explore the role of perceived present control in voice outcomes in a broad, national sample. Regarding the study aims, prior findings of a significant relation between perceived present control and voice handicap were replicated in this patient group recruited from the national CHEER network. This significant relation between perceived present control and voice handicap remained after controlling for two aspects of personality measures (ie, extraversion and emotional stability, the original two broad dimensions of personality).49 Although perceived present control was not related to the overall self-reported likelihood of attending voice therapy, potentially because the vast majority of patients indicated they planned to attend voice therapy, perceived control was significantly negatively correlated with all of the barriers to treatment. Extraversion was significantly correlated with three out of four barriers to
ARTICLE IN PRESS
0.91, 0.17 0.54
Perceived Control, Voice Handicap, and Barriers to Voice Therapy + P < 0.10. * P < 0.05.**P < 0.01. *** P < 0.001. Ns, 162−168. “Hard to translate into everyday use” R2 = 0.10; R2 Change = 0.05. “Want to see if it goes away” R2 = 0.04; R2 Change = 0.02. “Exercises seem strange” R2 = 0.10; R2 Change = 0.06. “Do not understand the purpose” R2 = 0.07; R2 Change = 0.02.
0.40 0.81, 0.01 0.21 0.16+ 0.57 0.91, 0.23 0.17 0.27*** 0.32 0.69, 0.06 0.19 0.14+ 0.23*
0.05 0.14 0.06 0.04 0.03 0.16, 0.10 0.07 0.04 0.09 0.19, 0.01 0.04 0.19, 0.12 0.08 0.04 0.03 0.9, 0.15 0.15 0.04 0.06 0.07 0.23, 0.001 0.18, 0.10
Extraversion Emotional stability Perceived present control
0.12 0.04
0.19
0.11 0.23, 0.01 0.06 0.15+ 0.06 0.20, 0.07 0.07 0.08
b SE B B 95% CI B b SE B B 95% CI b SE B B 95% CI B
+
b SE B B 95% CI B Variable
“Hard to Translate Into Everyday Use” “Want to See if it Goes Away”
TABLE 4. Summary of Hierarchical Regression Analysis Step 2 for Voice Therapy Barriers
B
“Exercises Seem Strange”
+
“Do not Understand the Purpose”
Viann N. Nguyen-Feng, et al
5
treatment whereas emotional stability did not correlate with any of the barriers. The negative relation between perceived present control and voice handicap observed in the current study is comparable to that identified in prior studies based out of a large Midwestern academic voice clinic,17,18 suggesting that this relation is robust to geographic location and practice setting. As in other studies,12,21 perceived present control was positively associated with extraversion and emotional stability; however, the relation between perceived present control and voice handicap remained significant controlling for these two key aspects of personality. This relation between more voice-related perceived present control and less voice handicap is also consistent with the association of general and disease-specific measures of perceived control with better health outcomes in other samples.50−53 In our regression analyses, though not in correlations, we identified a small association between extraversion and VHI scores, wherein greater extraversion was related to greater voice-related handicap. A small nonsignificant positive correlation was also reported in a study of personality and the VHI-30.23 This differs from other health-related conditions wherein extraversion (possibly due to its underlying core of sociability, positive emotionality, energy, and optimism) serves as a protective factor.54 Neuroticism or emotional instability is often associated with lower health-related QOL.55−57 Contrary to Karlsen et al23 who reported a significant correlation between neuroticism and VHI-30 scores, we did not find a significant association between emotional stability and VHI-10 scores. This may be due, in part, to different instruments used to assess personality and voicerelated handicap; for example, Karlsen et al23 used a longer personality measure and the VHI-30.7,58 The relation between perceived present control and certain barriers to voice therapy treatment has potential implications for working with voice disorder patients. Prior investigations have noted barriers impacting voice therapy attendance and follow-through such as time commitment, travel, cost, clinician skill and personality, patient motivation, and treatment duration.34,59−63 The association of perceived present control with the barriers “hard to translate into everyday use” and “exercises seem strange” may reveal new opportunities to engage patients in voice therapy. If patients feel uneasy about voice therapy and unclear about its rationale and benefits, they may be less likely to pursue voice therapy if recommended and may be more likely to have persistent voice problems. As previously discussed, patients are more likely to seek help for their health problem if they have greater perceived present control. Whether interventions aimed at improving voice-specific perceived present control improves patient buy-in, motivation, and adherence to voice care recommendations is worthy of investigation.35−37 For patients who may not be responding to current treatment strategies, focus on increasing perceived present control could potentially be helpful. This study is not without its limitations. Although the sample size was relatively large and nationally recruited
ARTICLE IN PRESS 6 from multiple practice types, the data were cross-sectional, so we were unable to assess attrition between intention to attend and actual attendance at voice therapy. The sample was largely female, white, and educated, potentially limiting generalizability. In addition, our assessment used brief versions of measures to reduce participant burden and avoid response fatigue. Further study is needed to understand how enhancing perceived present control impacts voice therapy treatment and voice outcomes among patients with voice disorders. There are potentially other factors influencing self-reported likelihood of attending therapy that should be examined. The impact of personality, such as extraversion and emotional stability, may be better captured through longer measures. Future work will also need to incorporate longitudinal data to further characterize these findings with respect to voice treatment adherence and outcomes. The importance of psychological factors in voice care was studied here with respect to voice therapy; further investigations will need to examine whether these factors are associated with decision-making and behaviors associated with phonosurgery as well.
CONCLUSIONS Patients who reported less perceived control over their voice disorders also reported more voice handicap, independent of personality. Lower perceived control also was associated with greater concerns about voice therapy goals and process. Given preliminary evidence that an intervention targeting perceived control reduced voice-handicap,20 it may also be valuable to target perceived control to reduce barriers to participation in speech therapy.
ACKNOWLEDGEMENTS We are very appreciative of study management by Kristine Schulz, DrPH, MPH; administrative support from Erika Juhlin; regulatory and coordinator support from Amy Walker. David Witsell, MD, MHS, and Debara Tucci, MD, MBA, MS, were principal investigators for the parent CHEER grant. We are especially grateful to CHEER site investigators, coordinators, and patients for their generous participation in the research network.
REFERENCES 1. Roy N, Merrill RM, Gray SD, et al. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988–1995. https://doi.org/10.1097/01.mlg. 0000179174.32345.41. 2. Ma EP-M, Yiu EM-L. Voice activity and participation Profile.:14. 3. Cohen SM, Dupont WD, Courey MS. Quality-of-life impact of nonneoplastic voice disorders: a meta-analysis. Ann Otol Rhinol Laryngol. 2006;115:128–134. https://doi.org/10.1177/000348940611500209. 4. Roy N, Merrill RM, Thibeault S, et al. 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. https://doi.org/10.1044/1092-4388(2004/042).
Journal of Voice, Vol. &&, No. &&, 2019 5. Williams NR. Occupational groups at risk of voice disorders: a review of the literature. Occup Med. 2003;53:456–460. https://doi.org/10.1093/ occmed/kqg113. 6. Mirza N, Ruiz C, Baum E, et al. The prevalence of major psychiatric pathologies in patients with voice disorders. Ear Nose Throat J. 2003;82:808–814. 7. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice handicap index-10: the laryngoscope. 2004;114:1549−1556. https://doi.org/10.1097/00005537-200409000-00009. 8. Dietrich M, Verdolini Abbott K, Gartner-Schmidt J, et al. The frequency of perceived stress, anxiety, and depression in patients with common pathologies affecting voice. J Voice. 2008;22:472–488. https:// doi.org/10.1016/j.jvoice.2006.08.007. 9. Misono S, Peterson CB, Meredith L, et al. Psychosocial distress in patients presenting with voice concerns. J Voice. 2014;28:753–761. https://doi.org/10.1016/j.jvoice.2014.02.010. 10. Roy N, Bless DM, Heisey D. Personality and voice disorders: a multitrait-multidisorder analysis. J Voice. 2000;14:521–548. https://doi.org/ 10.1016/S0892-1997(00)80009-0. 11. Roy N, Bless DM, Heisey D. Personality and voice disorders: a multitrait-multidisorder analysis. J Voice. 2000;14:521–548. https://doi.org/ 10.1016/S0892-1997(00)80009-0. 12. Frazier P, Keenan N, Anders S, et al. Perceived past, present, and future control and adjustment to stressful life events. J Pers Soc Psychol. 2011;100:749–765. https://doi.org/10.1037/a0022405. 13. Frazier P, Berman M, Steward J. Perceived control and posttraumatic stress: a temporal model. Appl Prev Psychol. 2001;10:207–223. https:// doi.org/10.1016/S0962-1849(01)80015-9. 14. Beckjord EB, Glinder J, Langrock A. Measuring multiple dimensions of perceived control in women with newly diagnosed breast cancer. Psychol Health. 2009;24:423–438. https://doi.org/10.1080/08870440701832634. 15. Reed GM, Taylor SE, Kemeny ME. Perceived control and psychological adjustment in gay men with AIDS1. J Appl Soc Psychol. 1993;23:791–824. https://doi.org/10.1111/j.1559-1816.1993.tb01007.x. 16. Newsom JT, Knapp JE, Schulz R. Longitudinal analysis of specific domains of internal control and depressive symptoms in patients with recurrent cancer. 1996:9. 17. Misono S, Meredith L, Peterson CB, et al. New perspective on psychosocial distress in patients with dysphonia: the moderating role of perceived control. J Voice. 2016;30:172–176. https://doi.org/10.1016/j. jvoice.2015.02.002. 18. Frazier P, Merians A, Misono S. Perceived control and voice handicap in patients with voice disorders. Health Psychol. 2017;36:1105–1108. https://doi.org/10.1037/hea0000520. 19. Misono S, Haut C, Meredith L, et al. Dysphonia, perceived control, and psychosocial distress: a qualitative study. J Voice. 2018. https:// doi.org/10.1016/j.jvoice.2018.04.003. 20. Nguyen-Feng VN, Frazier PA, Stockness A, et al. Web-based perceived present control intervention for voice disorders: a pilot study. J Voice. 2018. https://doi.org/10.1016/j.jvoice.2018.08.006. 21. Frazier P, Anders S, Shallcross S, et al. Further development of the temporal model of control. J Couns Psychol. 2012;59:623–630. https:// doi.org/10.1037/a0029702. 22. Roy N, Bless DM, Heisey D. Personality and voice disorders: a superfactor trait analysis.:20. 23. Karlsen T, Sandvik L, Heimdal J-H, et al. Health-related quality of life as studied by EORTC QLQ and voice handicap index among various patients with laryngeal disease. J Voice. 2017;31:251.e17–251.e26. https://doi.org/10.1016/j.jvoice.2016.07.009. 24. Millar A, Deary IJ, Wilson JA, et al. Is an organic/functional distinction psychologically meaningful in patients with dysphonia? J Psychosom Res. 1999;46:497–505. https://doi.org/10.1016/S0022-3999(99) 00026-4. 25. Willinger U, Aschauer HN. Personality, anxiety and functional dysphonia. Personal Individ Differ. 2005;39:1441–1449. https://doi.org/ 10.1016/j.paid.2005.06.011. 26. Deary IJ, Wilson JA, Carding PN, et al. The dysphonic voice heard by me, you and it: differential associations with personality and
ARTICLE IN PRESS Viann N. Nguyen-Feng, et al
27.
28.
29.
30. 31.
32.
33.
34.
35. 36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
Perceived Control, Voice Handicap, and Barriers to Voice Therapy
psychological distress. Clin Otolaryngol Allied Sci. 2003;28:374–378. https://doi.org/10.1046/j.1365-2273.2003.00730.x. Roy N, McGrory JJ, Tasko SM, et al. Psychological correlates of functional dysphonia: an investigation using the Minnesota multiphasic personality inventory. J Voice. 1997;11:443–451. https://doi.org/ 10.1016/S0892-1997(97)80041-0. Watts CR, Hamilton A, Toles L, et al. A randomized controlled trial of stretch-and-flow voice therapy for muscle tension Dysphonia: stretch-and-flow voice therapy. Laryngoscope. 2015;125:1420–1425. https://doi.org/10.1002/lary.25155. Vashani K, Murugesh M, Hattiangadi G, et al. Effectiveness of voice therapy in reflux-related voice disorders. Dis Esophagus. 2010;23:27– 32. https://doi.org/10.1111/j.1442-2050.2009.00992.x. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41. https://doi.org/10.1044/jslhr.4101.s101. Mau T, Jacobson BH, Garrett CG. Factors associated with voice therapy outcomes in the treatment of presbyphonia. Laryngoscope. 2010. NA-NA. https://doi.org/10.1002/lary.20890. Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Neck Surg. 2007;136:742–746. https://doi.org/10.1016/j.otohns.2006.12.009. Misono S, Marmor S, Roy N, et al. Multi-institutional study of voice disorders and voice therapy referral: report from the CHEER network. Otolaryngol Neck Surg. 2016;155:33–41. https://doi.org/10.1177/ 0194599816639244. Misono S, Marmor S, Roy N, et al. Factors influencing likelihood of voice therapy attendance: report from the CHEER network. Otolaryngol Neck Surg. 2017;156:518–524. https://doi.org/10.1177/ 0194599816679941. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. https://doi.org/10.1016/0749-5978(91)90020-T. Mesidor JK, Sly KF. Mental health help-seeking intentions among International and African American College Students: an application of the theory of planned behavior. 2014;4:13. Page GL, Scalora MJ. The utility of locus of control for assessing juvenile amenability to treatment. Aggress Violent Behav. 2004;9:523–534. https://doi.org/10.1016/S1359-1789(03)00047-8. Goodwin RD, Hoven CW, Lyons JS, et al. Mental health service utilization in the United States. Soc Psychiatry Psychiatr Epidemiol. 2002;37:561–566. https://doi.org/10.1007/s00127-002-0563-6. Friedman B, Veazie PJ, Chapman BP, et al. Is personality associated with health care use by older adults? Personality and health care use by older adults. Milbank Q. 2013;91:491–527. https://doi.org/10.1111/14680009.12024. Chapman BP, Shah M, Friedman B, et al. Personality traits predict emergency department utilization over 3 years in older patients. Am J Geriatr Psychiatry. 2009;17:526–535. https://doi.org/ 10.1097/JGP.0b013e3181a2fbb1. Lawton EM, Oltmanns TF. Personality pathology and mental health treatment seeking in a community sample of older adults: personality pathology and treatment seeking. Personal Ment Health. 2013;7:203– 212. https://doi.org/10.1002/pmh.1198. Schomerus G, Appel K, Meffert PJ, et al. Personality-related factors as predictors of help-seeking for depression: a population-based study applying the Behavioral Model of Health Services Use. Soc Psychiatry Psychiatr Epidemiol. 2013;48:1809–1817. https://doi.org/10.1007/ s00127-012-0643-1. Witsell DL, Rauch SD, Tucci DL, et al. The otology data collection project: report from the CHEER network. Otolaryngol Neck Surg. 2011;145:572–580. https://doi.org/10.1177/0194599811416063. Marmor S, Misono S. Treatment receipt and outcomes of self-reported voice problems in the US population aged ≥65 Years. OTO Open. 2018;2. https://doi.org/10.1177/2473974X18774023. 2473974X1877402. Cohen SM, Kim J, Roy N, et al. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012;122:343– 348. https://doi.org/10.1002/lary.22426.
7
46. Deary IJ, Webb A, Mackenzie K, et al. Short, self-report voice symptom scales: psychometric characteristics of the voice handicap index-10 and the vocal performance questionnaire. Otolaryngol Neck Surg. 2004;131:232–235. https://doi.org/10.1016/j. otohns.2004.02.048. 47. Gosling SD, Rentfrow PJ, Swann WB. A very brief measure of the BigFive personality domains. J Res Personal. 2003;37:504–528. https:// doi.org/10.1016/S0092-6566(03)00046-1. 48. Arffa RE, Krishna P, Gartner-Schmidt J, et al. Normative values for the voice handicap index-10. J Voice. 2012;26:462–465. https://doi.org/ 10.1016/j.jvoice.2011.04.006. 49. Emmons RA, Diener E. An interactional approach to the study of personality and emotion. J Pers. 1986;54:371–384. https://doi.org/ 10.1111/j.1467-6494.1986.tb00400.x. 50. Olajos-Clow J, Costello E, Lougheed MD. Perceived control and quality of life in asthma: impact of asthma education. J Asthma. 2005;42:751–756. https://doi.org/10.1080/02770900500308080. 51. Infurna FJ, Gerstorf D. Perceived control relates to better functional health and lower cardio-metabolic risk: The mediating role of physical activity. Health Psychol. 2014;33:85–94. https://doi.org/10.1037/ a0030208. 52. Gonzalez JS, Shreck E, Psaros C, et al. Distress and type 2 diabetestreatment adherence: a mediating role for perceived control. Health Psychol. 2015;34:505–513. https://doi.org/10.1037/hea0000131. 53. Hill PhD LK, Sims Wright PhD R, Aiken-Morgan PhD AT. Perceived control predicts pulse pressure in african american men: the baltimore study of black aging. Ethn Dis. 2015;25:263. https://doi.org/10.18865/ ed.25.3.263. 54. Ironson GH, O’Cleirigh C, Weiss A, et al. Personality and HIV disease progression: role of neo-pi-r openness, extraversion, and profiles of engagement. Psychosom Med. 2008;70:245–253. https://doi.org/ 10.1097/PSY.0b013e31816422fc. 55. AL-Omiri MK, Karasneh J. Relationship between oral health-related quality of life, satisfaction, and personality in patients with prosthetic rehabilitations. J Prosthodont. 2010;19:2–9. https://doi.org/10.1111/ j.1532-849X.2009.00518.x. 56. Aarstad AKH, Beisland E, Osthus AA, et al. Distress, quality of life, neuroticism and psychological coping are related in head and neck cancer patients during follow-up. Acta Oncol. 2011;50:390–398. https:// doi.org/10.3109/0284186X.2010.504227. 57. Muigg F, Bliem HR, Holzner B, et al. Do personality factors assessed before cochlear implantation predict hearing-related quality of life after cochlear implantation in postlingually deafened adults? Ear Hear. 2019;40:418–425. https://doi.org/10.1097/AUD. 0000000000000626. 58. Jacobson BH, Johnson A, Grywalski C, et al. The voice handicap index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–70. https://doi.org/10.1044/1058-0360.0603.66. 59. Litts JK, Gartner-Schmidt JL, Clary MS, et al. Impact of laryngologist and speech pathologist coassessment on outcomes and billing revenue: Laryngologist and SLP Coassessment. Laryngoscope. 2015;125:2139– 2142. https://doi.org/10.1002/lary.25349. 60. Starmer HM, Liu Z, Akst LM, et al. Attendance in voice therapy: can an interdisciplinary care model have an impact? Ann Otol Rhinol Laryngol. 2014;123:117–123. https://doi.org/10.1177/ 0003489414523708. 61. Smith BE, Kempster GB, Sims HS. Patient factors related to voice therapy attendance and outcomes. J Voice. 2010;24:694–701. https:// doi.org/10.1016/j.jvoice.2009.03.004. 62. van Leer E, Connor NP. Predicting and influencing voice therapy adherence using social−cognitive factors and mobile video. Am J Speech Lang Pathol. 2015;24:164–176. https://doi.org/10.1044/ 2015_AJSLP-12-0123. 63. Portone C, Johns MM, Hapner ER. A review of patient adherence to the recommendation for voice therapy. J Voice. 2008;22:192–196. https://doi.org/10.1016/j.jvoice.2006.09.009.
Perceived Control, Voice Handicap, and Barriers to Voice Therapy *Viann N. Nguyen-Feng, †Patricia A. Frazier, ‡Nelson Roy, §Seth Cohen, and ║Stephanie Misono, *Duluth, and
y║Minneapolis, Minnesota, zSalt Lake City, Utah, and xDurham, North Carolina
SUMMARY: Objective. To characterize the associations of perceived control with voice outcomes and self-reported likelihood of attending voice therapy using a national practice-based research network. Study design. Cross-sectional study of prospectively enrolled adult patients seen for dysphonia. Setting. Creating Healthcare Excellence through Education and Research (CHEER) network of community and academic practice sites. Subjects and methods. Data collected included patient-reported demographics, outcome measures of voice (Voice Handicap Index-10), perceived control (present control subscale of voice-specific Perceived Control over Stressful Events Scale), personality (Ten Item Personality Inventory), likelihood of attending voice therapy if recommended, and barriers to attending voice therapy. Results. Patients (N = 247) were enrolled over 12 months from 10 sites, of whom 170 received a recommendation for voice therapy. The majority (85%) of this group planned to attend voice therapy. Voice-specific perceived control and VHI-10 were inversely related (r = 0.31, P < 0.001), even when controlling for personality. No study variables were associated with self-reported likelihood of attending voice therapy, but perceived control was the most consistent correlate of specific barriers to attending voice therapy (eg, “hard to translate into everyday use”) and was inversely related to these barriers. Conclusions. Patients scoring higher on a voice-specific measure of perceived control reported less voice handicap, independent of personality, and higher perceived control was associated with having fewer concerns about voice therapy goals and process. Perceived control is a potential target for intervention in patients with voice disorders. Key Words: Dysphonia−Voice therapy−Perceived control−Voice handicap−Personality.
INTRODUCTION Voice disorders are relatively common, with a 30% lifetime prevalence rate in the general population.1 Voice disorders can have detrimental impacts across various life domains, such as daily communication, social and occupational functioning, quality of life, and well-being.1−6 Voice disorders may result in voice handicap, which can be defined as a social, economic, or environmental disadvantage from a voice impairment or disability.7 An important component of treatment for voice disorders is consideration of associated psychological factors, given the high prevalence of distress among voice patients8,9 as well as differences in personality and psychological characteristics across different voice disorders.10,11 Accepted for publication September 4, 2019. Funding: This work was supported by funding from the National Institutes of Health (NIH), including grants K23DC016335, 3R33DC008632-05S1, UL1TR000114, KL2 RR0333182, and ULI RR033183. The NIH did not play a role in the research, and opinions expressed herein are the authors’ and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States government. From the *Department of Psychology, University of Minnesota Duluth, Duluth, Minnesota; yDepartment of Psychology, College of Liberal Arts, University of Minnesota Twin Cities, Minneapolis, Minnesota; zDepartment of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah; xDepartment of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina; and the ║Department of Otolaryngology − Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota. Address correspondence and reprint requests to Stephanie Misono, Department of Otolaryngology − Head and Neck Surgery, University of Minnesota, 420 Delaware St SE, MMC 396, Minneapolis MN 55455. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.002
Perceived present control is one psychological factor particularly related to voice disorders. Perceived present control12,13 is defined as beliefs about what one can currently control about a stressor, such as one’s thoughts or behaviors related to the stressor. We focused on this aspect of control because perceived control over specific stressors, such as health concerns, has been demonstrated to predict outcomes more strongly than general control beliefs.14−16 Both cross-sectional17 and longitudinal18 studies with voice patients have indicated that higher perceived present control was associated with less voice handicap, with moderate-to-large effect sizes. Furthermore, perceived present control was more strongly related to voice handicap than was distress (eg, depression, anxiety).17 In a longitudinal study,18 baseline perceived present control predicted voice handicap symptoms 3 weeks later, even after controlling for distress and general control beliefs. A qualitative study19 also suggested that patients who reported greater voice-related perceived present control used more adaptive emotional and behavioral responses to voice disorder symptoms. Based on these findings, we developed a web-based intervention20 focused on teaching perceived present control. Preliminary evidence suggests that it was effective in reducing voice handicap among individuals with voice disorders.20 These studies highlight the importance of considering perceived present control in working with patients with voice disorders. The purpose of this current study was to extend this research in several ways. The first aim was to examine the relation between perceived present control and voice disorder symptoms in a
ARTICLE IN PRESS 2 broader national sample. Although our prior research examining voice-related perceived present control has shown consistent findings with respect to the relation between perceived control and voice handicap,17,18 these studies have all been conducted in one academic tertiary care clinic. Thus, in the present study we examined the relations between perceived present control and voice outcomes in a broad sample of patients from the Creating Healthcare Excellence through Education and Research (CHEER) network to assess the replicability and generalizability of previous findings. The second aim was to examine whether the relation between perceived present control and voice handicap remained significant controlling for personality. This is important for two reasons. First, perceived present control is positively related to the personality traits of extraversion and emotional stability (the opposite of neuroticism or emotional instability), with small to moderate effect sizes.12,21 Thus, if personality variables are also associated with voice handicap, the relations between perceived present control and voice handicap may be reduced if personality variables are taken in to account. Second, personality variables are thought to contribute to voice disorders such as functional dysphonia and vocal nodules,22 and prior work has suggested possible associations between personality and voice handicap.22,23 Moreover, previous research has found differences in extraversion and emotional stability between individuals with different types of voice disorders.22,24−27 Thus, we examined whether the relations between perceived present control and voice handicap remained after controlling for the effects of two key personality variables − extraversion and emotional stability. The final aim was to examine relations between perceived present control, personality, and barriers to voice therapy. Voice therapy is effective for a variety of voice disorders,28−32 and was recommended for most patients with voice disorders in prior research on this sample of patients from the CHEER network.33 Patients who indicated that they did not intend to pursue voice therapy despite the recommendation cited barriers to participation including that they did not understand the purpose of voice therapy.34 Following the theory of planned behavior,35 prior research in psychology has shown that participants with greater perceived control are more likely to seek help.36,37 Here we examined whether perceived present control was related to the self-reported likelihood of pursuing voice therapy and barriers to voice therapy. As an exploratory question, we also examined the relations between personality and both help-seeking likelihood and barriers, as previous studies38−42 have demonstrated that personality was related to help-seeking behaviors. These questions are important for understanding patient perspectives on participation in voice care. In summary, the purpose of the present study was to further explore the role of perceived present control in voice outcomes. The first aim was to replicate the prior findings of a significant relation between perceived present control and voice handicap in a different, broader patient group
Journal of Voice, Vol. &&, No. &&, 2019
recruited from the CHEER network. Second, we aimed to assess whether this finding remained when controlling for personality, a potential confounding variable. Third, we aimed to move beyond self-reported voice handicap to assess the relation between both perceived present control and personality and the self-reported likelihood of attending voice therapy as well as barriers to attending voice therapy. METHOD Participants Participants (N = 247) were recruited from 10 voice clinics throughout the United States that are part of the CHEER network.33,43 New patients with voice complaints were invited to participate in the study in the clinics. Consenting patients completed brief surveys at the end of their clinic visit. Patients with missing data in the VHI-10 were excluded (n = 10, or 4%). Participants were mostly women (68%) and white (84%), with a mean age of 53.25 (SD = 14.93). The majority of the sample (53%) had at least a 4-year college degree. This is similar to the demographics of prior voice studies from our group.17,44,45 Duke University’s Institutional Review Board approved the study and extended approval to CHEER community sites. Approvals were also obtained from CHEER community sites that required independent institutional review board approval. Measures Voice handicap Voice handicap was assessed using the Voice Handicap Index-10 (VHI-107). The VHI-10 is a ten-item scale that assesses patients’ opinions regarding how their voice has affected their quality of life. Patients were asked to indicate the frequency with which statements such as “My voice difficulties restrict my personal and social life” were applicable to their life, ranging from 0 (Never) to 4 (Always). Scores on the VHI-10 have demonstrated reliability in similar samples.7,18,46 Scores on this measure had a Cronbach’s alpha of 0.90 in the present sample. Perceived control Perceived control was assessed using the eight-item Perceived Present Control Subscale of the Perceived Control over Stressful Events Scale12,21 modified for use by patients with voice problems.17 Patients were asked to rate their agreement with statements such as “When I am upset about the voice problem, I can find a way to feel better” from 1 (Strongly disagree) to 4 (Strongly agree). Scores on this adapted measure have demonstrated reliability in similar samples17,18 and had a Cronbach’s alpha of 0.79 in this sample. Personality Personality was assessed using the Ten Item Personality Inventory (TIPI47). The TIPI has five two-item subscales assessing the Big Five personality factors: extraversion,
ARTICLE IN PRESS Viann N. Nguyen-Feng, et al
3
Perceived Control, Voice Handicap, and Barriers to Voice Therapy
agreeableness, conscientiousness, emotional stability, and openness to experience. Participants rated the extent to which pairs of traits applied to them (eg, extraverted, enthusiastic) on a scale from 1 (Disagree strongly) to 7 (Agree strongly). Although the alpha coefficients were not high (extraversion a = 0.66; emotional stability a = 0.56) in this sample, consistent with previous research,46 scores on the TIPI have been found to correlate highly with scores on longer measures of personality (average r = 0.77).47 Likelihood of attending voice therapy Likelihood of attending voice therapy was assessed through the statement, “I am likely to go to voice therapy.” Participants indicated their agreement with this item on a 1 (Strongly disagree) to 5 (Strongly agree) scale. Barriers to attending therapy Patients who were recommended to attend voice therapy were asked to rate the extent to which certain factors would prevent them from attending on a 1 (Strongly disagree) to 5 (Strongly agree) scale. The four barriers previously found to be related to self-reported likelihood of attending voice therapy in this sample were used in these analyses: hard to translate into everyday use, want to see if it goes away, exercises seem strange, and do not understand the purpose.17 Demographics Patients reported their age, race, gender, level of education, and voice-related diagnosis. Race was dichotomized into a binary variable of white or not white. Education was dichotomized into having a 4-year college degree (BA/BS) or more and having less than a 4-year college degree. More than half of the participants (54%) reported having a single voice diagnosis.17 Vocal strain/excessive tension (43%), reflux (36%), and benign bumps, masses, and lesions (21%) were the most common diagnoses. Analytic methods Bivariate correlations were used to evaluate the relations between self-reported perceived present control, personality, voice handicap, likelihood of attending voice therapy, and barriers to attending voice therapy. Hierarchical multiple regression analyses were run to assess the relations between personality and perceived present control (predictor variables) and voice handicap, likelihood of attending voice therapy, and barriers to attending voice therapy (dependent variables). The hierarchical regressions provided information on whether perceived present control explained variance in the dependent variables after accounting for personality. Findings with marginal significance (P = 0.05) are included in addition to significant findings (P < 0.05) because there are relatively few data in the literature on this topic.
RESULTS Descriptive statistics Means and standard deviations for all variables are in Table 1. The mean total score on the VHI-10 was 18.01 (SD = 7.84), which was similar to other samples9,17 and well above the total score of 11 which is considered to be abnormal.48 The mean score on the perceived present control scale was 3.13 (SD = 0.55), similar to previous research17,20 which corresponds to a rating of “somewhat agree.” The most to least commonly reported barriers to attending therapy were: “hard to translate the exercises into everyday use,” “want to see if the voice issues go away on their own,” “exercises seem strange,” and “do not understand the purpose of the exercises.” Aim 1: Examine relation between perceived present control and voice disorder symptoms in a broader national sample See Table 2 for a summary of bivariate correlations. Patients who reported more perceived present control reported lower voice handicap, with a moderate effect size (r = 0.31, P < 0.001). This correlation was virtually identical to previously observed correlations; eg, r = 0.31; N = 1,129.18 Higher levels of perceived present control were also correlated with higher levels of extraversion (r = 0.19, P = 0.004) and emotional stability (r = 0.36, P < 0.001). Aim 2: Examine whether the relation between perceived present control and voice handicap remains significant controlling for personality Hierarchical multiple regression analyses (see Table 3) were used to assess the relation between perceived present control and voice handicap, controlling for personality (ie, extraversion, emotional stability). The measures of extraversion and TABLE 1. Means and Standard Deviations for Study Variables
Extraversion Emotional stability Present control Voice handicap (total) Likelihood of attending voice therapy Barrier: hard to translate Barrier: want to see if it goes away Barrier: exercises seem strange Barrier: do not understand purpose
M (SD)
N
4.71 (1.64) 5.13 (1.41) 3.14 (.55) 18.01 (7.84) 4.27 (1.29)
247 247 242 237 162
2.22 (1.26) 2.02 (1.34) 1.95 (1.12) 1.78 (1.22)
168 171 167 165
Note: Extraversion and emotional stability were measured with the Ten Item Personality Inventory on a scale from 1 (Disagree strongly) to 7 (Agree strongly). Present control was measured with the Perceived Control over Stressful Events Scale on a scale from 1 (Strongly disagree) to 4 (Strongly agree). Voice handicap was measured with the Voice Handicap Index-10 on a scale from 0 (Never) to 4 (Always). Likelihood of attending voice therapy and barriers were measured on a scale from 1 (Strongly disagree) to 5 (Strongly agree).
ARTICLE IN PRESS 4
Journal of Voice, Vol. &&, No. &&, 2019
TABLE 2. Correlations Among Study Variables Barriers
PPC PPC VHI TIPI, E TIPI, ES
− − − −
VHI
TIPI, E
TIPI, ES
0.31*** 0.19** 0.36*** − 0.06 0.10 − − 0.15* − − −
Likelihood of Attending Voice Therapy 0.01 0.05 0.05 0.04
Hard to Translate Into Want to See if Exercises Everyday Use it Goes Away Seem Strange 0.28*** 0.07 0.23** 0.15
0.18* 0.03 0.07 0.10
0.29*** 0.04 0.21** 0.08
Do not Understand the Purpose 0.20* 0.02 0.18* 0.14
* P < 0.05. ** P < 0.01. *** P < 0.001. Ns, 156−247. PPC, perceived present control; TIPI, E, Ten Item Personality Measure, Extraversion subscale; TIPI, ES,= Ten Item Personality Measure, Emotional Stability subscale; VHI, Voice Handicap Index-10.
TABLE 3. Hierarchical Regression Analysis Predicting Voice Handicap Index-10 Total Score Step 2 Variable
B
Step 1. Extraversion Emotional stability Step 2. Perceived present control
0.60 0.07 4.84
SE B
b
0.10, 1.21
0.37
0.12
0.67, 0.80
0.37
0.01
6.72, 2.95
0.96
95% CI
0.34***
*** P < 0.001. N = 233; R2 = 0.11; R2 Change = 0.10 after adding perceived present control (Step 2). + P = 0.05.
emotional stability were entered in the first step, and perceived present control was entered in the second step. Present perceived control explained significant variance in voice handicap controlling for personality. In the final step, only perceived present control was significantly associated with lower voice handicap (b = .34, P < 0.001).
Aim 3: Examine relations between perceived present control, personality, and barriers to voice therapy Although voice therapy was not recommended for everyone, the majority (85% of 159 participants given a recommendation) reported they were “likely” or “very likely” to attend voice therapy. Bivariate correlations (see Table 2) indicated that perceived present control was not significantly related to self-reported likelihood of attending voice therapy among those for whom it was recommended. Perceived present control was, however, significantly negatively
correlated with each of the barriers: hard to translate into everyday use, want to see if it goes away, exercises seem strange, and do not understand the purpose. Extraversion was significantly negatively correlated with three of the barriers: hard to translate into everyday use, exercises seem strange, and do not understand the purpose. Emotional stability did not correlate with any of the barriers. Similar to the analyses in Aim 2, hierarchical multiple regression analyses were used to assess the relation between perceived present control and the barriers to attending voice therapy, controlling for personality (ie, extraversion, emotional stability). No variables significantly predicted likelihood of attending voice therapy in the regression analyses. Separate regressions were run for each barrier to attending voice therapy (see Table 4). Controlling for personality, perceived present control was negatively related to two of the barriers: “hard to translate into everyday use” (b = 0.23, P = 0.004) and “exercises seem strange” (b = 0.27, P < 0.001). DISCUSSION The purpose of the present study was to explore the role of perceived present control in voice outcomes in a broad, national sample. Regarding the study aims, prior findings of a significant relation between perceived present control and voice handicap were replicated in this patient group recruited from the national CHEER network. This significant relation between perceived present control and voice handicap remained after controlling for two aspects of personality measures (ie, extraversion and emotional stability, the original two broad dimensions of personality).49 Although perceived present control was not related to the overall self-reported likelihood of attending voice therapy, potentially because the vast majority of patients indicated they planned to attend voice therapy, perceived control was significantly negatively correlated with all of the barriers to treatment. Extraversion was significantly correlated with three out of four barriers to
ARTICLE IN PRESS
0.91, 0.17 0.54
Perceived Control, Voice Handicap, and Barriers to Voice Therapy + P < 0.10. * P < 0.05.**P < 0.01. *** P < 0.001. Ns, 162−168. “Hard to translate into everyday use” R2 = 0.10; R2 Change = 0.05. “Want to see if it goes away” R2 = 0.04; R2 Change = 0.02. “Exercises seem strange” R2 = 0.10; R2 Change = 0.06. “Do not understand the purpose” R2 = 0.07; R2 Change = 0.02.
0.40 0.81, 0.01 0.21 0.16+ 0.57 0.91, 0.23 0.17 0.27*** 0.32 0.69, 0.06 0.19 0.14+ 0.23*
0.05 0.14 0.06 0.04 0.03 0.16, 0.10 0.07 0.04 0.09 0.19, 0.01 0.04 0.19, 0.12 0.08 0.04 0.03 0.9, 0.15 0.15 0.04 0.06 0.07 0.23, 0.001 0.18, 0.10
Extraversion Emotional stability Perceived present control
0.12 0.04
0.19
0.11 0.23, 0.01 0.06 0.15+ 0.06 0.20, 0.07 0.07 0.08
b SE B B 95% CI B b SE B B 95% CI b SE B B 95% CI B
+
b SE B B 95% CI B Variable
“Hard to Translate Into Everyday Use” “Want to See if it Goes Away”
TABLE 4. Summary of Hierarchical Regression Analysis Step 2 for Voice Therapy Barriers
B
“Exercises Seem Strange”
+
“Do not Understand the Purpose”
Viann N. Nguyen-Feng, et al
5
treatment whereas emotional stability did not correlate with any of the barriers. The negative relation between perceived present control and voice handicap observed in the current study is comparable to that identified in prior studies based out of a large Midwestern academic voice clinic,17,18 suggesting that this relation is robust to geographic location and practice setting. As in other studies,12,21 perceived present control was positively associated with extraversion and emotional stability; however, the relation between perceived present control and voice handicap remained significant controlling for these two key aspects of personality. This relation between more voice-related perceived present control and less voice handicap is also consistent with the association of general and disease-specific measures of perceived control with better health outcomes in other samples.50−53 In our regression analyses, though not in correlations, we identified a small association between extraversion and VHI scores, wherein greater extraversion was related to greater voice-related handicap. A small nonsignificant positive correlation was also reported in a study of personality and the VHI-30.23 This differs from other health-related conditions wherein extraversion (possibly due to its underlying core of sociability, positive emotionality, energy, and optimism) serves as a protective factor.54 Neuroticism or emotional instability is often associated with lower health-related QOL.55−57 Contrary to Karlsen et al23 who reported a significant correlation between neuroticism and VHI-30 scores, we did not find a significant association between emotional stability and VHI-10 scores. This may be due, in part, to different instruments used to assess personality and voicerelated handicap; for example, Karlsen et al23 used a longer personality measure and the VHI-30.7,58 The relation between perceived present control and certain barriers to voice therapy treatment has potential implications for working with voice disorder patients. Prior investigations have noted barriers impacting voice therapy attendance and follow-through such as time commitment, travel, cost, clinician skill and personality, patient motivation, and treatment duration.34,59−63 The association of perceived present control with the barriers “hard to translate into everyday use” and “exercises seem strange” may reveal new opportunities to engage patients in voice therapy. If patients feel uneasy about voice therapy and unclear about its rationale and benefits, they may be less likely to pursue voice therapy if recommended and may be more likely to have persistent voice problems. As previously discussed, patients are more likely to seek help for their health problem if they have greater perceived present control. Whether interventions aimed at improving voice-specific perceived present control improves patient buy-in, motivation, and adherence to voice care recommendations is worthy of investigation.35−37 For patients who may not be responding to current treatment strategies, focus on increasing perceived present control could potentially be helpful. This study is not without its limitations. Although the sample size was relatively large and nationally recruited
ARTICLE IN PRESS 6 from multiple practice types, the data were cross-sectional, so we were unable to assess attrition between intention to attend and actual attendance at voice therapy. The sample was largely female, white, and educated, potentially limiting generalizability. In addition, our assessment used brief versions of measures to reduce participant burden and avoid response fatigue. Further study is needed to understand how enhancing perceived present control impacts voice therapy treatment and voice outcomes among patients with voice disorders. There are potentially other factors influencing self-reported likelihood of attending therapy that should be examined. The impact of personality, such as extraversion and emotional stability, may be better captured through longer measures. Future work will also need to incorporate longitudinal data to further characterize these findings with respect to voice treatment adherence and outcomes. The importance of psychological factors in voice care was studied here with respect to voice therapy; further investigations will need to examine whether these factors are associated with decision-making and behaviors associated with phonosurgery as well.
CONCLUSIONS Patients who reported less perceived control over their voice disorders also reported more voice handicap, independent of personality. Lower perceived control also was associated with greater concerns about voice therapy goals and process. Given preliminary evidence that an intervention targeting perceived control reduced voice-handicap,20 it may also be valuable to target perceived control to reduce barriers to participation in speech therapy.
ACKNOWLEDGEMENTS We are very appreciative of study management by Kristine Schulz, DrPH, MPH; administrative support from Erika Juhlin; regulatory and coordinator support from Amy Walker. David Witsell, MD, MHS, and Debara Tucci, MD, MBA, MS, were principal investigators for the parent CHEER grant. We are especially grateful to CHEER site investigators, coordinators, and patients for their generous participation in the research network.
REFERENCES 1. Roy N, Merrill RM, Gray SD, et al. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988–1995. https://doi.org/10.1097/01.mlg. 0000179174.32345.41. 2. Ma EP-M, Yiu EM-L. Voice activity and participation Profile.:14. 3. Cohen SM, Dupont WD, Courey MS. Quality-of-life impact of nonneoplastic voice disorders: a meta-analysis. Ann Otol Rhinol Laryngol. 2006;115:128–134. https://doi.org/10.1177/000348940611500209. 4. Roy N, Merrill RM, Thibeault S, et al. 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. https://doi.org/10.1044/1092-4388(2004/042).
Journal of Voice, Vol. &&, No. &&, 2019 5. Williams NR. Occupational groups at risk of voice disorders: a review of the literature. Occup Med. 2003;53:456–460. https://doi.org/10.1093/ occmed/kqg113. 6. Mirza N, Ruiz C, Baum E, et al. The prevalence of major psychiatric pathologies in patients with voice disorders. Ear Nose Throat J. 2003;82:808–814. 7. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice handicap index-10: the laryngoscope. 2004;114:1549−1556. https://doi.org/10.1097/00005537-200409000-00009. 8. Dietrich M, Verdolini Abbott K, Gartner-Schmidt J, et al. The frequency of perceived stress, anxiety, and depression in patients with common pathologies affecting voice. J Voice. 2008;22:472–488. https:// doi.org/10.1016/j.jvoice.2006.08.007. 9. Misono S, Peterson CB, Meredith L, et al. Psychosocial distress in patients presenting with voice concerns. J Voice. 2014;28:753–761. https://doi.org/10.1016/j.jvoice.2014.02.010. 10. Roy N, Bless DM, Heisey D. Personality and voice disorders: a multitrait-multidisorder analysis. J Voice. 2000;14:521–548. https://doi.org/ 10.1016/S0892-1997(00)80009-0. 11. Roy N, Bless DM, Heisey D. Personality and voice disorders: a multitrait-multidisorder analysis. J Voice. 2000;14:521–548. https://doi.org/ 10.1016/S0892-1997(00)80009-0. 12. Frazier P, Keenan N, Anders S, et al. Perceived past, present, and future control and adjustment to stressful life events. J Pers Soc Psychol. 2011;100:749–765. https://doi.org/10.1037/a0022405. 13. Frazier P, Berman M, Steward J. Perceived control and posttraumatic stress: a temporal model. Appl Prev Psychol. 2001;10:207–223. https:// doi.org/10.1016/S0962-1849(01)80015-9. 14. Beckjord EB, Glinder J, Langrock A. Measuring multiple dimensions of perceived control in women with newly diagnosed breast cancer. Psychol Health. 2009;24:423–438. https://doi.org/10.1080/08870440701832634. 15. Reed GM, Taylor SE, Kemeny ME. Perceived control and psychological adjustment in gay men with AIDS1. J Appl Soc Psychol. 1993;23:791–824. https://doi.org/10.1111/j.1559-1816.1993.tb01007.x. 16. Newsom JT, Knapp JE, Schulz R. Longitudinal analysis of specific domains of internal control and depressive symptoms in patients with recurrent cancer. 1996:9. 17. Misono S, Meredith L, Peterson CB, et al. New perspective on psychosocial distress in patients with dysphonia: the moderating role of perceived control. J Voice. 2016;30:172–176. https://doi.org/10.1016/j. jvoice.2015.02.002. 18. Frazier P, Merians A, Misono S. Perceived control and voice handicap in patients with voice disorders. Health Psychol. 2017;36:1105–1108. https://doi.org/10.1037/hea0000520. 19. Misono S, Haut C, Meredith L, et al. Dysphonia, perceived control, and psychosocial distress: a qualitative study. J Voice. 2018. https:// doi.org/10.1016/j.jvoice.2018.04.003. 20. Nguyen-Feng VN, Frazier PA, Stockness A, et al. Web-based perceived present control intervention for voice disorders: a pilot study. J Voice. 2018. https://doi.org/10.1016/j.jvoice.2018.08.006. 21. Frazier P, Anders S, Shallcross S, et al. Further development of the temporal model of control. J Couns Psychol. 2012;59:623–630. https:// doi.org/10.1037/a0029702. 22. Roy N, Bless DM, Heisey D. Personality and voice disorders: a superfactor trait analysis.:20. 23. Karlsen T, Sandvik L, Heimdal J-H, et al. Health-related quality of life as studied by EORTC QLQ and voice handicap index among various patients with laryngeal disease. J Voice. 2017;31:251.e17–251.e26. https://doi.org/10.1016/j.jvoice.2016.07.009. 24. Millar A, Deary IJ, Wilson JA, et al. Is an organic/functional distinction psychologically meaningful in patients with dysphonia? J Psychosom Res. 1999;46:497–505. https://doi.org/10.1016/S0022-3999(99) 00026-4. 25. Willinger U, Aschauer HN. Personality, anxiety and functional dysphonia. Personal Individ Differ. 2005;39:1441–1449. https://doi.org/ 10.1016/j.paid.2005.06.011. 26. Deary IJ, Wilson JA, Carding PN, et al. The dysphonic voice heard by me, you and it: differential associations with personality and
ARTICLE IN PRESS Viann N. Nguyen-Feng, et al
27.
28.
29.
30. 31.
32.
33.
34.
35. 36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
Perceived Control, Voice Handicap, and Barriers to Voice Therapy
psychological distress. Clin Otolaryngol Allied Sci. 2003;28:374–378. https://doi.org/10.1046/j.1365-2273.2003.00730.x. Roy N, McGrory JJ, Tasko SM, et al. Psychological correlates of functional dysphonia: an investigation using the Minnesota multiphasic personality inventory. J Voice. 1997;11:443–451. https://doi.org/ 10.1016/S0892-1997(97)80041-0. Watts CR, Hamilton A, Toles L, et al. A randomized controlled trial of stretch-and-flow voice therapy for muscle tension Dysphonia: stretch-and-flow voice therapy. Laryngoscope. 2015;125:1420–1425. https://doi.org/10.1002/lary.25155. Vashani K, Murugesh M, Hattiangadi G, et al. Effectiveness of voice therapy in reflux-related voice disorders. Dis Esophagus. 2010;23:27– 32. https://doi.org/10.1111/j.1442-2050.2009.00992.x. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41. https://doi.org/10.1044/jslhr.4101.s101. Mau T, Jacobson BH, Garrett CG. Factors associated with voice therapy outcomes in the treatment of presbyphonia. Laryngoscope. 2010. NA-NA. https://doi.org/10.1002/lary.20890. Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Neck Surg. 2007;136:742–746. https://doi.org/10.1016/j.otohns.2006.12.009. Misono S, Marmor S, Roy N, et al. Multi-institutional study of voice disorders and voice therapy referral: report from the CHEER network. Otolaryngol Neck Surg. 2016;155:33–41. https://doi.org/10.1177/ 0194599816639244. Misono S, Marmor S, Roy N, et al. Factors influencing likelihood of voice therapy attendance: report from the CHEER network. Otolaryngol Neck Surg. 2017;156:518–524. https://doi.org/10.1177/ 0194599816679941. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. https://doi.org/10.1016/0749-5978(91)90020-T. Mesidor JK, Sly KF. Mental health help-seeking intentions among International and African American College Students: an application of the theory of planned behavior. 2014;4:13. Page GL, Scalora MJ. The utility of locus of control for assessing juvenile amenability to treatment. Aggress Violent Behav. 2004;9:523–534. https://doi.org/10.1016/S1359-1789(03)00047-8. Goodwin RD, Hoven CW, Lyons JS, et al. Mental health service utilization in the United States. Soc Psychiatry Psychiatr Epidemiol. 2002;37:561–566. https://doi.org/10.1007/s00127-002-0563-6. Friedman B, Veazie PJ, Chapman BP, et al. Is personality associated with health care use by older adults? Personality and health care use by older adults. Milbank Q. 2013;91:491–527. https://doi.org/10.1111/14680009.12024. Chapman BP, Shah M, Friedman B, et al. Personality traits predict emergency department utilization over 3 years in older patients. Am J Geriatr Psychiatry. 2009;17:526–535. https://doi.org/ 10.1097/JGP.0b013e3181a2fbb1. Lawton EM, Oltmanns TF. Personality pathology and mental health treatment seeking in a community sample of older adults: personality pathology and treatment seeking. Personal Ment Health. 2013;7:203– 212. https://doi.org/10.1002/pmh.1198. Schomerus G, Appel K, Meffert PJ, et al. Personality-related factors as predictors of help-seeking for depression: a population-based study applying the Behavioral Model of Health Services Use. Soc Psychiatry Psychiatr Epidemiol. 2013;48:1809–1817. https://doi.org/10.1007/ s00127-012-0643-1. Witsell DL, Rauch SD, Tucci DL, et al. The otology data collection project: report from the CHEER network. Otolaryngol Neck Surg. 2011;145:572–580. https://doi.org/10.1177/0194599811416063. Marmor S, Misono S. Treatment receipt and outcomes of self-reported voice problems in the US population aged ≥65 Years. OTO Open. 2018;2. https://doi.org/10.1177/2473974X18774023. 2473974X1877402. Cohen SM, Kim J, Roy N, et al. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012;122:343– 348. https://doi.org/10.1002/lary.22426.
7
46. Deary IJ, Webb A, Mackenzie K, et al. Short, self-report voice symptom scales: psychometric characteristics of the voice handicap index-10 and the vocal performance questionnaire. Otolaryngol Neck Surg. 2004;131:232–235. https://doi.org/10.1016/j. otohns.2004.02.048. 47. Gosling SD, Rentfrow PJ, Swann WB. A very brief measure of the BigFive personality domains. J Res Personal. 2003;37:504–528. https:// doi.org/10.1016/S0092-6566(03)00046-1. 48. Arffa RE, Krishna P, Gartner-Schmidt J, et al. Normative values for the voice handicap index-10. J Voice. 2012;26:462–465. https://doi.org/ 10.1016/j.jvoice.2011.04.006. 49. Emmons RA, Diener E. An interactional approach to the study of personality and emotion. J Pers. 1986;54:371–384. https://doi.org/ 10.1111/j.1467-6494.1986.tb00400.x. 50. Olajos-Clow J, Costello E, Lougheed MD. Perceived control and quality of life in asthma: impact of asthma education. J Asthma. 2005;42:751–756. https://doi.org/10.1080/02770900500308080. 51. Infurna FJ, Gerstorf D. Perceived control relates to better functional health and lower cardio-metabolic risk: The mediating role of physical activity. Health Psychol. 2014;33:85–94. https://doi.org/10.1037/ a0030208. 52. Gonzalez JS, Shreck E, Psaros C, et al. Distress and type 2 diabetestreatment adherence: a mediating role for perceived control. Health Psychol. 2015;34:505–513. https://doi.org/10.1037/hea0000131. 53. Hill PhD LK, Sims Wright PhD R, Aiken-Morgan PhD AT. Perceived control predicts pulse pressure in african american men: the baltimore study of black aging. Ethn Dis. 2015;25:263. https://doi.org/10.18865/ ed.25.3.263. 54. Ironson GH, O’Cleirigh C, Weiss A, et al. Personality and HIV disease progression: role of neo-pi-r openness, extraversion, and profiles of engagement. Psychosom Med. 2008;70:245–253. https://doi.org/ 10.1097/PSY.0b013e31816422fc. 55. AL-Omiri MK, Karasneh J. Relationship between oral health-related quality of life, satisfaction, and personality in patients with prosthetic rehabilitations. J Prosthodont. 2010;19:2–9. https://doi.org/10.1111/ j.1532-849X.2009.00518.x. 56. Aarstad AKH, Beisland E, Osthus AA, et al. Distress, quality of life, neuroticism and psychological coping are related in head and neck cancer patients during follow-up. Acta Oncol. 2011;50:390–398. https:// doi.org/10.3109/0284186X.2010.504227. 57. Muigg F, Bliem HR, Holzner B, et al. Do personality factors assessed before cochlear implantation predict hearing-related quality of life after cochlear implantation in postlingually deafened adults? Ear Hear. 2019;40:418–425. https://doi.org/10.1097/AUD. 0000000000000626. 58. Jacobson BH, Johnson A, Grywalski C, et al. The voice handicap index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–70. https://doi.org/10.1044/1058-0360.0603.66. 59. Litts JK, Gartner-Schmidt JL, Clary MS, et al. Impact of laryngologist and speech pathologist coassessment on outcomes and billing revenue: Laryngologist and SLP Coassessment. Laryngoscope. 2015;125:2139– 2142. https://doi.org/10.1002/lary.25349. 60. Starmer HM, Liu Z, Akst LM, et al. Attendance in voice therapy: can an interdisciplinary care model have an impact? Ann Otol Rhinol Laryngol. 2014;123:117–123. https://doi.org/10.1177/ 0003489414523708. 61. Smith BE, Kempster GB, Sims HS. Patient factors related to voice therapy attendance and outcomes. J Voice. 2010;24:694–701. https:// doi.org/10.1016/j.jvoice.2009.03.004. 62. van Leer E, Connor NP. Predicting and influencing voice therapy adherence using social−cognitive factors and mobile video. Am J Speech Lang Pathol. 2015;24:164–176. https://doi.org/10.1044/ 2015_AJSLP-12-0123. 63. Portone C, Johns MM, Hapner ER. A review of patient adherence to the recommendation for voice therapy. J Voice. 2008;22:192–196. https://doi.org/10.1016/j.jvoice.2006.09.009.