Prevalence and Risk Factors of Voice Disorders Among Teachers in Saudi Arabia

Introduction Voice is a crucial tool for communication, and voice problems are more likely to occur in professionals who frequently use their voice for work. Teachers, whose profession requires sustained vocal use, are particularly susceptible to occupation-related voice disorders. This study aimed to quantify the prevalence of voice disorders among teachers in Saudi Arabia, with the general population serving as a control group, and to identify associated risk factors. Methods A cross-sectional study was conducted utilizing an online self-administered questionnaire, which was completed by both teachers and the general population in Saudi Arabia. The latter group acted as a control. The questionnaire included sections on sociodemographic data, teaching patterns, symptoms of voice issues, and the Voice Handicap Index-10 (VHI-10) for assessing voice disorders among participants. Results The study included 640 participants, with 438 (68.4%) being teachers, the majority of whom were females (N = 406; 63.4%). The most common voice-related symptoms reported by teachers were hoarseness (N = 210; 37.9%) and dry throat (N = 147; 26.9%). Voice disorders, as determined by the VHI, affected 355 (55.5%) of the teachers. A high VHI score was associated with a diagnosis of voice disorders and GERD. There was no significant difference in the VHI scores between teachers and the general population (p > 0.05). Conclusion Teachers in Saudi Arabia exhibited a higher prevalence of voice disorders compared to the general population. Risk factors, such as smoking, longer teaching experience, and more teaching hours per week, were more common among teachers with voice disorders. Further investigative studies are warranted to elucidate the causal relationships between these variables and voice disorders.


Introduction
As an essential communication tool, voice is particularly critical for professionals requiring extensive vocal use [1].Among these professionals, teachers are at a heightened risk for voice disorders due to the vocal demands of their profession [2][3][4][5][6].Studies have shown that while voice problems may affect 6-15% of the general population, this prevalence increases to 20-50% and may reach as high as 80% among teachers [7][8][9][10].The impact of voice disorders on teachers is significant, impairing their ability to communicate effectively with students and perform efficiently, which can negatively influence students' academic success [3,5,11,12].
Various risk factors contribute to the development of voice disorders in teachers, such as extended teaching hours, years of experience, stressful environmental conditions, and a family history of vocal issues.In addition, personal attributes, such as age, gender, allergies, and smoking habits, along with speaking loudly, have been identified as contributing factors [3,11,13,14].Although voice disorders are not life-threatening, they can adversely affect an individual's quality of life [15].Early identification and management of voice disorders are vital to maintaining vocal health and preventing future complications [3,13].
In both research and clinical practice, self-assessment tools, such as the Voice Handicap Index (VHI), are widely used to evaluate the impact of voice disorders on the quality of life.The VHI includes 30 questions that assess the functional, physical, and emotional burdens of a voice disorder on a patient's life, with higher scores indicating greater disability [16].The VHI-10, a shortened version of the VHI with 10 critical items, has been validated and found to correlate strongly with the full version [17].The Arabic versions of the VHI and VHI-10 have also been validated, confirming their reliability in Arabic-speaking populations [18].
This study aims to estimate the prevalence of voice disorders among teachers in Saudi Arabia and to identify potential risk factors that may contribute to the development of such conditions.By examining these parameters, the study seeks to provide insights that could lead to better prevention strategies and targeted interventions to preserve the vocal health of teachers.

Materials And Methods
This cross-sectional study was initiated after obtaining ethical approval from Shaqra University's Institutional Review Board in June 2023 (approval number ERC_SU_20230035).The study aims to determine the prevalence of voice disorders among Saudi teachers and to determine any potential risk factors.
To calculate the appropriate number of samples for our study, we contacted the Ministry of Education and obtained the latest data.The latest information available from the Ministry's 2018 Census results estimated that Saudi Arabia has approximately 430,000 teachers.Using this population size, we determined that a sample of 384 teachers would be required for our study.This estimate is based on 95% confidence and a ±5% margin of error.
Teachers and the general population aged 22 and up were enrolled in the study after providing informed consent.Individuals under the age of 22 were excluded, as were any vocational voice users, such as lawyers, singers, actresses, and call center representatives, as well as those who had had neck, thyroid, or upper aerodigestive tract surgery.
A self-administered online survey was distributed to schools and education-related social media groups.
The Vocal Handicap Index (VHI), created by Jacobson et al. (1997), is a useful tool for assessing vocal problems [16].It analyzes the functional, physical, and emotional effects of these illnesses using a series of 30 questions, each reflecting how severe the patient's voice-related difficulties are.The VHI scores range from 0 (never affected) to 4 (always affected), with higher scores indicating more severe voice impairment.Rosen et al. later validated the Voice Handicap Index-10 (VHI-10), a more concise version of the VHI-30.This 10-item form has been proven to be highly correlated with its original, longer version (see Appendix A) [17].We used a validated Arabic version of the VHI, adapted by Saleem et al., to ensure that the assessment was culturally suitable for the participants (see Appendix B) [18].In our research, a voice disorder was identified at a VHI cut-off of 13.5, resulting in a sensitivity of 0.994 and specificity of 0.989 [19].
The survey is divided into four sections, beginning with general background information and progressing to particular professional specifics.It begins with a sociodemographic portion that contains the participants' age groups, marital status, education level, smoking history, and any pertinent surgical history, such as vocal cord surgery, thyroidectomy, or parathyroidectomy (see Appendix C).The second section includes detailed questions about teaching details, such as years of experience, grade levels taught, student gender composition, whether they teach in public or private institutions, subjects they specialize in, and weekly teaching load (see Appendix D).The third section focuses on identifying any symptoms of voice problems that the respondents might have experienced.The fourth section employs the Voice Handicap Index (VHI) to assess the severity of voice disorders, providing a quantitative measure of the impact on the participants' vocal health.
Version 26 of the Statistical Packages for the Social Sciences (SPSS) software was used to analyze the data.For categorical variables, descriptive statistics were reported as frequencies and percentages, whereas means and standard deviations were used for continuous variables.The Mann-Whitney U and Kruskal-Wallis H tests were used to compare VHI scores and domains based on socio-demographic factors and instructional experiences.The normality of distribution was examined using the Shapiro-Wilk and Kolmogorov-Smirnov tests, which revealed a non-normal distribution for VHI scores; hence, non-parametric tests were used.Statistical significance was defined as a p-value less than 0.05.

Results
In total, 640 participants were enrolled (438 teachers vs. 202 general population).Table 1 presents the sociodemographic characteristics of participants.Overall, 233 (36.4%) were aged between 40 and 49 years old, with females being dominant.Respondents who were living in the Western Region constituted 269 (42%).For marital status, 453 (70.8%) were married.In terms of education, 449 (70.2%) were bachelor's degree holders.Only 82 (12.8%) were smokers.The perceived voice disorder has been reported by 128 (20%) of participants (N = 107, 24.4% teachers vs. N = 21, 10.4% general population), while those who were diagnosed with gastroesophageal reflux disease (GERD) were 143 (22.3%).Further details of the sociodemographic characteristics between teachers and the general population are discussed in detail in Table 1.

Study data
Overall N (%) ( n=640) Teachers N (%) (n=438) General population N (%) (n=202)  The occupational information of the teachers, as presented in  In examining the VHI, an average score of 20.3 with a standard deviation of 13.3 was noted.The mean scores across the functional, physical, and emotional domains were 7.73, 6.27, and 6.29, respectively.A comparison of VHI scores between teachers and the general population showed no statistically significant differences across the functional, physical, and emotional domains or the total VHI score.For further details, refer to Table 3.

VHI domain Overall Mean ± SD (n=640)
Teacher P-value § Yes Mean ± SD [n=438]  No Mean ± SD [n=202]   Functional  Results are expressed as mean ± SD. § P-value has been calculated using Mann-Whitney Z-test.
The prevalence of voice disorders, as illustrated in Figure 1, indicates that 355 (55.5%) of the participants were affected based on the VHI criteria.Comparing teachers with the general population revealed a higher incidence of voice disorders among teachers, at 250 (57.1%), compared to 105 (52%) in the general population.

FIGURE 1: Prevalence of voice disorders between the teachers and the general population
Data are expressed as numbers and percentages (%).

FIGURE 2: Symptoms associated with voice problems
Data are expressed as numbers and percentages (%).
When measuring the association between VHI scores and the teachers' sociodemographic characteristics (Table 4), a higher VHI score was more associated with being a smoker (Z = 2.524, p = 0.012), having a voice disorder (Z = 9.004, p < 0.001), and being diagnosed with GERD (Z = 5.355, p < 0.001).Compared to the general population, a higher VHI score was more associated with having a voice disorder (Z = 5.334, p < 0.001) and being diagnosed with GERD (Z = 2.235, p = 0.025).

Factor
Teacher

TABLE 4: Association between the overall VHI score and sociodemographic characteristics of the participants (n = 640)
Results are expressed as mean ± SD.
a P-value has been calculated using Mann-Whitney Z-test.b P-value has been calculated using Kruskal-Wallis H-test.* Significant at the p < 0.05 level.Results are expressed as mean ± SD.

An analysis presented in
a P-value has been calculated using Mann-Whitney Z-test.b P-value has been calculated using Kruskal-Wallis H-test.*Significant at the p < 0.05 level.

Discussion
Researchers conducted this study to determine the prevalence of voice disorders among teachers in Saudi Arabia and identify any associated risk factors.The findings of this study revealed that based on the VHI questionnaire, the prevalence of voice disorder among teachers was 250 (57.1%), slightly higher than the general population (N = 105, 52%).A study conducted in China supported this finding [12].Using a similar questionnaire, the prevalence of voice disorders among Chinese teachers was 47.9%.Another study in Spain confirmed this, detecting a voice disorder prevalence of 59% among kindergarten and elementary education teachers [20].However, in Iran, the prevalence of voice problems per VHI criteria was 27.2%, which was lower than the previous reports [21].
Incidentally, Trinite et al. documented that two-thirds of the teachers had perceived voice problems, which was higher in females (68.2%) than males (48.8%).In our study, the difference in voice problems between male and female teachers was not significantly different (p = 0.148) [6].However, 20% of our respondents (N = 128) believed that they had voice problems, notably higher among teachers (N = 107, 24.4%) than the general population (N = 21, 10.4%).Similarly, Seifpanahi et al. (2016) showed that more than half of teachers complained of vocal problems at work compared to nonteachers [22].By contrast, a study done by Devadas et al. (2017) reported lower rates of self-reported voice problems at 17.4% [23].
Various risk factors contribute to voice problems.Byeon et al. (2019) identified gender, caffeine consumption, upper airway problems, speaking loudly, and number of classes per week as the most common risk factors for voice disorders and a contributing factor to resignation [3].These corroborated the reports of de Sousa et al. (2019), who found that an increasing number of students per class was associated with an increasing risk for voice disorder [4].Our results also reflected this, as we observed that an increase in the number of classes taught per week posed a risk factor for developing voice disorders.Furthermore, increasing years of teaching experience revealed a significant association with voice problems, which coincided with the study of Roy et al. (2004) [10].
Moreover, we have learned that smoking is another factor that increases the risk of developing voice problems.Alrahim et al. [11] and Malki et al. (2010) [13] have both observed this phenomenon.Risk factors for voice problems include smoking, acid reflux, a family history of hoarseness, and work-related stress.Byeon et al. (2019) found no significant difference between smoking, drinking alcohol, and water intake in relation to voice disorder [3].
Previous diagnoses of GERD increase the risk of voice disorders, with significant differences in both teachers and the general population (p < 0.05).Notwithstanding these results, Alva et al. ( 2017) found an association between voice disorders in terms of upper respiratory infections, deviated nasal septum, and GERD (p < 0.05) [14].A study conducted in Latvia identified an increased risk of voice disorders associated with throat clearing, neglecting personal health, chronic illnesses of the upper respiratory tract, allergies, and regular workplace stress [6].
Assessing the scores of VHI and its domains, our results indicate that the functional domain has the highest mean score (7.73) compared to the emotional (6.29) or physical (6.27) domains.The mean VHI score was 20.3 out of 80 points.When we compared these results between teachers and the general population, we found no significant differences between the study population in relation to VHI and its domains (p > 0.05).Contradicting these reports, Ghayoumi-Anaraki et al. (2020) found significant differences between VHI scores and its domains according to teachers with or without voice disorders (p < 0.05) [21].
In a study conducted in China, hoarseness was the most commonly reported complaint related to voice problems [12].However, chronic laryngitis, vocal cord polyps, and vocal cord nodules were the most commonly diagnosed voice disorders among Chinese teachers.In Spain, at the end of working duty, over 60% of the teachers complained of frequent vocal fatigue and 55% reported hoarseness, while in India, sore or dry throat, tired voice, neck tension, muscle pain, strain in voice, and difficulty in projecting voice were the most prominent symptoms of voice problems [20,23].In our study, the teachers' most common symptoms were hoarseness, followed by dry throat and pain in the throat, which coincided with the symptoms of the general population, such as hoarseness and dry throat.
Certain limitations have shaped the results of this study.The use of an online questionnaire may have introduced response biases, affecting the accuracy of the results due to the possibility of untruthful or misunderstood responses.The study's cross-sectional design only uncovers correlations, not causations, which limits our understanding of the direct impact of identified risk factors on voice disorders.Furthermore, the subjective nature of the self-reported VHI questionnaire may not accurately reflect the actual clinical severity of voice disorders.Reference: [18]

TABLE 1 : Sociodemographic characteristics between the teachers and the general population
Results are expressed as numbers and percentages (%).

Table 2
, indicates that 157 (35.8%) have 11-20 years of teaching experience.A significant portion (179, 40.9%) teaches at the primary school level, and nearly half of these educators (N = 215, 49.1%) predominantly teach female students.Notably, 381 (87%) are employed by government schools, and 198 (45.2%) of the sample teach in classrooms with 21-30 students.Mathematics is the most commonly taught subject by these teachers, representing 74 (16.9%) of the cohort.In addition, 265 (60.5%) of the teachers handle 10-20 classes weekly, with the majority (N = 346, 79%) having each class last 45 minutes or less, and 256 (58.4%) have experience teaching at different educational levels.

TABLE 2 : Teaching characteristics of the teachers
Results are expressed as numbers and percentages (%).

TABLE 3 : Descriptive statistics of the Voice Handicap Index between the teachers and the general population
VHI, Voice Handicap Index

Table 5
indicates a correlation between higher VHI scores and teachers with 5-10 years of experience (H = 8.247, p = 0.041), as well as those teaching a greater number of classes per week (H = 8.324, p = 0.016).However, no significant differences were found in VHI scores in relation to years of experience, educational level taught, gender composition of students, type of school, class size, subject taught, class duration, or experience teaching at various educational levels.Factor VHI score (