A Vocal Health Survey among Primary School Teachers in Klang Valley, Malaysia

Teachers are one of the highest demanding professional voice users. They are believed to have an increased risk of developing voice disorder, and the cause is often associated with several factors such as high vocal demands, unfavourable working conditions, lifestyle, and lack of knowledge in vocal health. Vocal disorder not only affects teachers in conducting and managing classes. It also affects their daily interaction with people and contributes to the decline of their physical and emotional health. This study aims to understand teachers' current vocal condition better and measure teachers' knowledge of vocal care. An online survey was conducted; 40 teachers, 33 females and 7 males, responded to the study. The study reviewed that teachers voice feels dry (51.22%), sore (24.39%) and pain (12.20%) after a day of teaching and 78% of the teachers experience at least once vocal discomfort in a year. In conclusion, the insights and perception of vocal health base on self-report information of voice condition and lifestyle of teachers pertinent to this geographical location will be helpful in the development of vocal health programs for teachers in Malaysia.


Introduction
An individual was considered to have a healthy voice if one can produce a voice with ease and meet personal, professional, and social expectations. If a voice is used heavily, it can result in voice symptoms such as hoarseness, change in quality, fatigue, decreased pitch, and breathiness. This culmination of voice symptoms, once prolong, may lead to voice disorder (Porcaro et al., 2019;Sathyanarayan et al., 2018). Among the professional voice users, teachers depend highly on their voice for communication in their profession. Therefore, there is a high risk of developing vocal disorders compared to the general population (Roy, 2004).
Research on the prevalence of voice disorder among teachers was conducted in many countries such as Finland, Germany, New Zealand, America, and Korea, leaving solid and comprehensive national data. These data revealed that more than 50% of teachers reported having a vocal problem at least once in their lifetime (Nazari et al., 2020;Nussec et al., 2020;Vertanen-Greis, Loyttyniemi, & Uitti, 2020), and the recurrent perceived of voice disorder after 3 years is 69.1% (Vertanen-Greis et al., 2020).
In Malaysia, there are 2 relevant data; a study in Sarawak indicated that 53.8% of primary school teachers suffer from voice disorder in 12 months (Abdul Rahman, 2016), and another local study documented the prevalence of voice disorder among secondary school teachers is 10.4% (Sundram et al., 2019).
Significant factors that contributed to an increased risk of voice disorder included speaking for long hours in a poor acoustic environment, speaking loudly across a high level of classroom noise, continue to strain and yell during the period of inflammation, excessive throat clearing and dry coughing and speaking with a higher pitch for teachers who teach in kindergarten and primary school (Devadas, Bellur, & Maruthy, 2017;Remacle, Morsomme, & Finck, 2014). In addition, lifestyle, and habits such as improper diet, smoking, excessive consumption of alcohol, constant dehydration, posture, and alignment may also be the cause (Nallamuthu et al., 2021).
Vocal problems affect teacher's communicative capacity, teaching performance, impaired social functioning, and daily activities. Consequently, research has shown that voice disorder degrades teachers' engagement in their work, bringing a negative educational effect on students' performance. Findings were stating that dysphonic voice makes it harder for the listener to understand; hence, it decreases students' motivation to learn. According to research, 24.1% of the teachers call in sick because of voice problems, leading to financial burden to teachers on treatment for voice disorder and burden to school where substituted teachers were required while teachers are on sick leaves (Nazari et al., 2020;Smith et al., 1997).
Multiple studies have shown that teachers with voice complaints have a higher level of physical and mental exhaustion leading to 77% higher risk of common mental disorders (Mota et al., 2019;Rocha et al., 2021).
Voice disorder affects a teacher physically, emotionally, and socially. At present, the vocal health among primary school teachers in Klang Valley is undetermined. Therefore, a survey was designed to understand teachers' current vocal condition better and measure teacher's knowledge on vocal care.

Materials and Methods
A survey design was conducted among primary school teachers who teaches in Klang Valley. The survey in digital form was distributed from April -August 2019, and a total of 40 samples (33 females, 7 males) who teachers in Selangor and Kuala Lumpur were collected. The survey was created using Google form and was posted online. Convenient sampling will be used in this research because of its primary emphasis on generalizability.
The questionnaire was self-administered, and it consists of 44 multipart questions covering 5 significant areas. The areas included information on demographics, teachers working conditions, their lifestyle factors, vocal symptoms teachers encounter during teaching via daily conversation, teacher's vocal care. Section A: General information including (a) gender, (b) age, (c) subjects taught, (c) total teaching hours per week, (d) years of service. Section B: Assess the working condition of teachers, which include questions such as (a) Number of students in class, (b)class flooring, (c)use of audio facilities, (d) use of ICT Facilities available Section C: This section investigates the teacher's lifestyle in the context of diet (a)do they consume alcohol, (b) eat spicy food, (c) water intake per day, and if they smoke and hours of sleeping per day.
Section D: Investigate through scales from always, frequently, sometimes, rarely, and never on teacher vocal condition during teaching and daily conversations. Such as (a) breathy, (b) stop a phrase, (c) fatigues, (d) speaks too loudly, (e)speaks too soft, (f) voice crack, (g) throat hurts (h)voice is consistent daily (i) voice sounds clear.
Section E: In this section, knowledge of vocal care and precautions taken by the teacher when they encounter vocal symptoms were assessed with questions such as (a) what are the negative symptoms urge teachers for medical attention (b) how long does it take before teachers seek for medical attention (c) how frequent teachers encounter vocal symptoms in a year (d) what precautions teachers do to take care of their voice (c) if teachers know where to seek help if their voice has problems.
Research Question: (1) Is there a difference between teachers' voices during teaching and daily conversation? (2) How are the teacher's vocal conditions after a day of teaching? (3) How long does it take for a teacher to seek medical attention once they encounter voice discomfort.
Alternately, respondents were asked how often they experience vocal discomfort in a year (Table 5). 78% respondents experience at least once vocal discomfort in a year with breakdown of 14 (35%, SD = 0.48) respondents feels discomfort for 1-2 times a year; 10 (25%, SD = 0.43)respondents feels discomfort for 3-4 times and 7 (17.5%, SD = 0.38) respondents feels discomfort for up to 5 times and above in a year.
In align with the data above, the following Table (Table 5) illustrate 27 (68%) of the respondents knows where to seek medical assistance when their voice is having a problem; 13 (31%) of the respondents are not aware of where to seek for medical help.

Discussion
Findings from this present study revealed that teachers felt fatigued, their throat hurts, and they often speak too loud during teaching compared to daily conversation. These symptoms most probably occurred as a consequence of the high noise levels in the class. The primary schools in Klang Valley are crowded because these enjoining cities and towns have a high population density, as confirmed by the participants in this research, noting that each class had approximately 35-50 students, resulting in high classroom noise.
According to a study by Noraidah (2020), the standard noise level recommended by WHO (1999) is 55dB(A) for an occupied classroom. However, the mean level of noise in the primary school classrooms in Malaysia ranged from 60dB(A) to 76dB(A) (Ismail, Karim, & Othman, 2020). Evidence from other studies was consistent with the present finding on the negative effect of high noise levels on voice symptoms (Kristiansen et al., 2014;Laukkanen et al., 2008). Further research can be done on the ideal number of students in a classroom to control the noise level.
This study also found that high percentage of teachers experience voice discomfort after a day of teaching. The most common symptoms were vocal dryness and soreness. These symptoms may cause increased tension in the larynx and develop inflammatory responses after long teaching hours (Remacle et al., 2018). Furthermore, the weather in Malaysia is hot and humid throughout the year since it is a country located near the equator, teachers may be dehydrated because of the weather or the use of air-conditional due to the weather (Santana, Masson, & Araújo, 2017). Dehydration causes the vocal fold to be under-hydrated, while increasing the driving force of vibration while speaking. The increased vibration may cause tissue damage and render our voice more susceptible to vocal problems, especially dryness and soreness (Sivasankar & Leydon, 2010).
This study concluded 68.28% of the teachers know where to seek medical attention; however, most teachers only seek medical help when the problem became severe or takes a long time to recover. The reason may be a lack of vocal hygiene knowledge. Teachers may not know how to start seeking help as the concept of vocal health was not very strong among teachers (Van Houtte, Claeys, Wuyts, & Van Lierde, 2011;Weekly, Carroll, Korovin, & Fleming, 2017). Worst, many teachers even consider vocal strain and discomfort part of the profession (Lee, Kim, & Lee, 2018).

Conclusion
The research found that teachers often experience vocal fatigue, their throat hurts, and often speak too loudly when they are teaching compared to their daily conversation. 78% of teachers experience vocal discomfort at least once a year, and the most common vocal symptoms teachers suffered include vocal dryness, soreness, and pain after full-day teaching. When such symptoms developed, 34.5% of teachers choose not to seek medical help, and many only seek medical attention when the symptoms were prolonged.
As a consequence of not seeking medical help, the chances of teachers developing voice disorder increased, which cause harm not only to their physical well-being but also their emotional and social well-being; some studies showed that voice disorders lower teachers' self-esteem and lead to social isolation and depression (Rocha et al., 2021;Yildiz et al., 2020). The outcome of this study revealed that this possible mental issue derive from vocal problem was taken lightly by many Malaysian teachers. Teachers should face this problem with positive attitude and to be more proactive in taking medical action at the start of their vocal symptoms.
Based on the outcomes from this research, an alarming alert should be raised to all educationists, including teachers, school administrators, and all the stakeholders. Vocal hygiene knowledge should be embedded into teachers' training programs, schools' admins should take note on the classroom size and help create or maintain a teaching environment with lower environmental noise, and architects should help build schools' classrooms with better acoustic considerations, policy makers should make relevant policies to reduce current noise level to the standards as recommended by WHO. With this effort, it will provide and encourage a healthy working environment for teachers.
Teachers should take proactive effort to improve their vocal problems; a vocal hygiene program covering the concept of vocal health and vocal health practices may effectively reduce or prevent teachers' vocal symptoms, teachers should engage themselves in programs as such and embedding it to their lifelong vocalizing habits. In addition, a voice rehabilitation protocol can be introduced to the teachers who are affected by vocal problems, research on the effectiveness on these therapeutic protocols should also be traced.