Occupational Vocal Health of Elite Sports Coaches: An Exploratory Pilot Study of Football Coaches *Katie L. Buckley, *Paul D. O’Halloran, and †Jennifer M. Oates, *yMelbourne, Victoria, Australia Summary: Objective. To explore the occupational voice use and vocal health of elite football coaches. Study Design. This pilot study explored coaches’ voice use patterns and vocal demands across workplace environments. Each coach’s experiences of voice symptoms and voice problems were also investigated. Methods. Twelve Australian professional football coaches participated in a mixed-methods data collection approach. Data were collected through acoustic voice measurement (Ambulatory Phonation Monitor), semistructured interviews, and a voice symptom questionnaire (Voice Capabilities Questionnaire). Results. Acoustic measures suggested heavy vocal loads for coaches during player training. All participants reported experiencing voice symptoms. They also suggested that the structure of their working week, workplace tasks, and vocal demands impacted on their voices. Despite this, participants reported little previous reflection or awareness of what impacted on their voices. Coaches typically did not consider how to support their voices during daily work and discussed experiencing voice symptoms as an inevitable part of their jobs. Conclusions. This study demonstrates that occupational vocal demands may negatively impact on sports coaches’ vocal health. This is particularly important, considering coaches’ heavy vocal loads across coaching tasks and reported negative occupational vocal health experience. Furthermore, coaches’ limited insight into voice use and vocal health management may impact on their vocal performance and health. Given the exploratory nature of this study, further research into coaches’ occupational vocal health is warranted. Key Words: Occupational voice user–Sports coach–Vocal health–Vocal load–Ambulatory phonation monitoring– Vocal health experiences–Voice use patterns. INTRODUCTION Vocal health is an important workplace consideration,1–3 especially for occupational voice users1,2,4,5 and their employers. These workers critically rely on dynamic voice performance as a pivotal part of their employment.6,7 This includes consistent voice performance to effectively undertake job tasks.3,8,9 Occupational voice users are more likely to experience voice symptoms and voice problems than the general working population.3,4 Furthermore, voice symptoms and voice problems may negatively impact on the work performance and general health of occupational voice users.4,10 To date, occupational voice research has primarily focused on schoolteachers. An estimated 50–90% of teachers will experience voice symptoms at work,10 such as hoarseness11 and vocal fatigue.12 Occupations such as performing artists,1 call center workers/telemarketers,13 the clergy,14 and aerobics instructors15 are also considered within occupational voice literature. This research base suggests that several commonly occurring risk factors appear to affect the vocal health of occupational voice users. These risk factors include long durations of voice use; loud talking and yelling over distances; suboptimal room acoustics; background noise; vocal tract irritants; lack of health awareness; stress; and workload demands.12,16,17 Accepted for publication September 15, 2014. From the *Department of Public Health, School of Public Health and Human Biosciences, La Trobe University, Melbourne, Victoria, Australia; and the yDepartment of Human Communication Sciences, La Trobe University, Melbourne, Victoria, Australia. Address correspondence and reprint requests to Katie L. Buckley, School of Public Health and Human Biosciences, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria 3086, Australia. E-mail: [email protected] Journal of Voice, Vol. 29, No. 4, pp. 476-483 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.09.017

Sports coaches’ vocal demands and workplace environments appear similar to other occupational voice users. As such, the risks of vocal health problems experienced by other occupations may be similar for coaches. Like other occupational voice users, sports coaches engage in various vocally demanding communication tasks. Vocal communication with athletes often occurs in groups, where coaches talk for long periods of time, without breaks. This vocal health risk may also be magnified by lengthy exposure to vocally demanding physical environments. Coaching in outdoor environments exposes coaches to loud background noise, long distances between coaches and their players, and weather elements (ie, rain and wind).18 These conditions are likely to require increased vocal effort while coaching. Furthermore, other coaching environments (such as basketball stadiums and gymnasiums) have consistently high reverberation times. Although similarities may exist between sports coaches and other occupational voice users, specific aspects of sports coaching may result in additional vocal demands and risks to vocal health. Research suggests that coaches’ ongoing focus on athlete excellence19 may intensify the stressful nature of coaches’ workplaces.20 This may be compounded by athletes’ heavy reliance on effective vocal communication by coaches to achieve performance success.21,22 Furthermore, the unregulated nature of the industry appears to result in coaches working long hours (frequently without regular scheduled days off), under intense periods of stress. As highlighted by O’Neill and McMenamin,18 the current evidence base strongly suggests that both psychoemotional factors and stress may increase risk of developing vocal overload and voice disorders.16,23 Currently, limited published research exists concerning the occupational vocal health of sports coaches. Two published studies have focused on coaches’ voice use and vocal health.

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Gorham-Rowan et al24 explored the benefits of providing coaches with a voice education program. The voice handicap index (VHI) was administered to seven volunteer soccer coaches before and after this education program. The VHI includes items concerning the participants’ experiences of voice symptoms. Gorham-Rowan et al24 noted that the majority of their participants reported some voice symptoms (although specific statistical data were not reported) such as hoarseness, temporary voice loss, voice strain, and vocal fatigue. One month after the education program, four of the seven coaches reported improvement in their vocal quality.24 The voluntary status of the coaches in the study reported by Gorham-Rowan et al24 makes these findings difficult to apply to elite sports coaches. Furthermore, the investigators’ intervention appears to be based on current general knowledge about occupational voice users rather than empirical evidence of the specific needs of sports coaches. A population-specific evidence base may build on the findings of Gorham-Rowan et al24 to strengthen future research into sports coaches as occupational voice users. This could include investigation of the nature of sports coaches’ vocal tasks. O’Neill and McMenamin18 also sought to extend the vocal health knowledge base by exploring the voice use and vocal health of ‘‘soccer managers’’ in Ireland. Although this role extends beyond coaching, much of the vocally demanding aspects of soccer managers’ roles mirror those of sports coaches. This includes overcoming background noise and long distances when communicating with players. The authors also noted the potential for phonotrauma due to lengthy voice use and psychoemotional factors at work. The purpose of the present pilot study was to explore elite sports coaches’ occupational voice use and vocal health. To this end, the study considered the following research questions: (1) What are the voice use patterns and vocal demands of elite sports coaches? (2) Do coaches experience specific voice symptoms or voice problems while at work? (3) Do coaches perceive that vocal demands and workplace environments influence their vocal health? (4) How do coaches manage their voices at work? METHODS Methodology A mixed-methods approach, involving quantitative and qualitative methods, was considered most appropriate for addressing the research questions of this study. Participants Twelve Australian football coaches participated in this study. These coaches worked within two national-level football competitions: the Australian Football League (AFL, n ¼ 9) and the Australian Rugby Union (ARU, n ¼ 3). While considered two different types of football, coaches engage in equivalent roles and tasks within both leagues. They were therefore considered a single group of participants. Participants’ ages ranged from 32–48 years (mean ¼ 39 years, standard deviation [SD] ¼ 6.7) and their coaching careers spanned 1–13 years (mean ¼ 5.8 years, SD ¼ 3.1).

Participants were recruited through the researchers’ industry connections within each sport. The AFL Coaches Association provided all members with an information flyer about the research. ARU coaches within Australian ‘‘Super-Series’’ clubs were sent the flyer by an ARU staff member. Coaches then contacted the primary researcher (K.L.B.) directly if they were interested in participating in the study. Inclusion criteria required participants to be coaching at an elite football club as their primary means of employment. Reflecting the current employment demographic within the two football leagues, all participating coaches were male. Procedures Overview. Data were collected initially through coaches wearing the Ambulatory Phonation Monitor (APM) (KayPENTAX Model 3200 - Lincoln Park, Montvale, NJ) during a training session. Coaches then participated in an interview and completed the Voice Capabilities Questionnaire (VCQ).23 Approximately 2 hours were required for each coach to complete their participation in this process. All activities occurred within club training facilities. Acoustic measurement – APM. The APM is a portable unobtrusive voice dosimeter. It consists of a small accelerometer, a microprocessor, and the APM computer software. The device measures vibrations of neck tissues that are created by the vocal folds during phonation. From this information, the APM software calculates the wearers’ phonation time, fundamental frequency (F0), and estimates of vocal intensity. Specifically, the software calculates the following characteristics of the wearer’s voice use: - Phonation time: the accumulated duration (minutes) of vocal folds vibration. - Percent phonation time: the percentage of time phonation occurred while the APM was worn. - Mean fundamental frequency (F0 mean): the estimated mean frequency of vocal fold vibration (hertz). - Fundamental frequency mode (F0 mode): the fundamental frequency value where most phonation occurred while the APM was worn. - Vocal intensity (dB SPL): The estimated mean amplitude value (amount of energy created with voice sound wave) during wear25 (Table 1). TABLE 1. Descriptive Statistics for APM Measurements Measure

Mean

SD

Range

Phonation time (min) % Phonation time Vocal intensity (dB SPL) F0 average (Hz) F0 mode (Hz)

13.40 19.25 83.67 150.00 124.72

6.50 4.90 10.25 30.50 20.15

4.24–23.34 11.35–26.88 65.92–103.62 114.97–200.43 104.00–176.00

Notes: F0 average, the mean fundamental frequency scores in hertz (as used by the APM software); F0 mode, the most commonly occurring fundamental frequency score within an individual’s data set in hertz (as used by the APM software).

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The APM was selected for use in this research based on maintenance of conversation confidentiality (conversations are not audio recorded),26 its portability,27 relative unobtrusiveness for long-term use in various activities, and lack of susceptibility to background noise.26 During the study, coaches wore the APM for a typical training session (nominated by each participant). Coaches defined ‘‘training’’ as any time they engaged with players to assist in the athletes’ football development. Data were collected in a variety of coaching environments, including meeting rooms, a sprung floor (similar to a basketball court), an outdoor oval, and a gymnasium. Four of the 12 coaches moved between training locations while wearing the APM (Table 2). The varied training sessions nominated by coaches also resulted in differing durations of APM wear (from approximately 30 minutes to 2 hours; Tables 1 and 2). Before APM data collection for each participant, the device was calibrated for sound pressure level (decibel) according to the manufacturer’s protocol. Successful calibration was achieved on the first attempt for nine coaches. Repetition of the process yielded successful calibration for two additional coaches. However, despite three attempts, calibration could not be achieved for one participant. Therefore, APM data were not obtained for this coach. Self-rating - VCQ. The VCQ is a self-rated inventory concerning vocal health at work. The version used in this study (Appendix A) was based on a similar questionnaire for teachers developed by Russell.28 Respondents rate how frequently they experience 16 voice symptoms, such as vocal fatigue, difficulties with projection, voice quality, pitch characteristics, loudness characteristics, and throat pain/discomfort. Each of the 16 items is presented on a five-point Likert-type scale (1 ¼ ‘‘never’’ to 5 ¼ ‘‘every time I use my voice’’). Total VCQ scores can range from 16 (all symptoms rated as ‘‘never’’) to 80 (all symptoms rated as ‘‘every time I use my voice’’). An additional item asks respondents to indicate if they believe they

have experienced a voice problem. If so, they then rate the severity of the problem on a five-point Likert-type scale (1 ¼ ‘‘slight’’ to 5 ¼ ‘‘severe’’). The VCQ was used given it measures vocal symptoms without implying that the respondent has a voice disorder per se. It was also used because it measures vocal symptoms rather than the broader aspects of voice-related quality of life. This is in contrast to other currently used voice self-rating tools such as the VHI,29 the Voice-Related Quality of Life30 questionnaire, and the Voice Activity and Participation Profile.31,32 In the present study, participants completed the paper-based VCQ twice in the same session. Initially, coaches considered each item for the current football season (‘‘current season’’). They then rated the same items over their entire coaching careers (‘‘overall coaching career’’). Internal consistencies were good for both versions of the VCQ used in this study33 (Cronbach alpha was .81 for items pertaining to ‘‘overall coaching career’’ and 0.90 for items pertaining to the ‘‘current season’’). Semistructured interviews. Each coach participated in a one-on-one semistructured interview with the primary researcher. This covered coaches’ perceptions and awareness of their occupational voice use, their vocal health experiences, and any methods they used to manage their voices. Example questions included ‘‘Have you found that certain practices help your voice function better at work?,’’ ‘‘What did you do to overcome any difficulties caused by your voice underperforming?,’’ and ‘‘Can you describe a time when you have noticed your voice was not performing as you needed it to for your work?’’ Interviews were conducted in an office or meeting room at each football club and ranged between 35–75 minutes (most lasting around 50 minutes). All interviews were audio recorded, using a Sony Clear Voice VOR Dictaphone (Analog voice recorder model TCM-200DV; Sony Corporation, Tokyo, Japan) and cassette tape.

TABLE 2. Descriptive Statistics for APM Measurements of Each Participant’s Fundamental Frequency Data Total Amplitude Examination Phonation % Phonation F0 Mode F0 Average Average Participant Duration Time Time (Hz) (Hz) (dB SPL) A B C D E F G H I J K

1:14:40 0:53:38 1:38:38 1:17:07 1:07:01 2:02:40 0:26:37 1:04:15 1:23:25 0:30:24 1:08:25

0:20:04 0:14:03 0:23:34 0:15:43 0:13:35 0:21:59 0:04:44 0:11:19 0:12:26 0:04:24 0:07:45

26.88 26.21 23.90 20.38 20.29 17.92 17.79 17.62 14.92 14.52 11.35

116 116 104 128 176 104 116 128 116 128 140

121.74 135.19 114.97 135.66 200.43 155.30 186.36 151.85 120.23 194.70 142.49

82.32 98.23 82.88 82.24 82.87 82.11 87.20 77.36 65.92 103.62 75.52

Coaching Environment/s Meeting room Outdoor training, meeting room Meeting room, playing oval Sprung floor, meeting room Gymnasium Playing oval Playing oval Playing oval Meeting room Sprung floor Meeting room

Notes: F0 average, the mean fundamental frequency scores in hertz (as used by the APM software); F0 mode, the most commonly occurring fundamental frequency score within an individual’s data set in hertz (as used by the APM software).

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Analyses All quantitative data were analyzed with descriptive statistics using the ‘‘Statistical Package for Social Sciences’’ (SPSS) version 17 (SPSS Inc., Chicago, IL, USA). For APM data, descriptive statistics were calculated for participants’ phonation times (accumulated duration and percent phonation time), fundamental frequency – F0 (hertz), and vocal intensity (dB SPL) (Table 1). For the VCQ data, descriptive statistics (mean, SD, and range) were calculated for both sets of data. Qualitative data that emerged from semistructured interviews were transcribed and then thematically analyzed using manual coding. Initially, the primary researcher transcribed all 12 interviews. These transcripts were then read line-byline and each idea was given a label (this process is referred to as open coding). Once all ideas were labeled, common ideas were grouped into categories (known as axial coding). These categories were then compared and contrasted to create themes.34 Open coding was validated through two processes. All participants were given the opportunity to read their respective coded transcript to ensure they agreed with the interpretation of each idea (known as member checking). Two coaches engaged in this process and no amendments to open codes were noted by the coaches. As a form of inter-researcher peer review, an additional member of the research team undertook open coding of a full interview transcript. The open codes were then compared with those of the primary researcher and the level of overlap was high. The researchers discussed any variations in coding interpretation and a consensus was reached. No themes required amendment from this process. In keeping with the traditions of qualitative research, anonymity was maintained by allocating each participant with a pseudonym for the purposes of data analysis.34 RESULTS Ambulatory Phonation Monitor Results revealed that the mean percent phonation time for all coaches was 19.25% (SD ¼ 4.9%) and mean vocal intensity was 83.67 dB SPL (SD ¼ 10.25 dB SPL). Across the participant group, the mean fundamental frequency was 150 Hz (SD ¼ 30.5 Hz). Table 1 summarizes descriptive data for phonation time (percent and accumulated duration), vocal intensity, and fundamental frequency across the participant group. Table 2 provides descriptive data for each participant, including each coach’s total examination time, overall and percent phonation time, vocal intensity, and fundamental frequency. Table 2 also notes the coaching environment/s where data were collected for each coach. Voice Capabilities Questionnaire (VCQ) When considering voice symptoms for coaches during the ‘‘current season,’’ the mean total score was 32.08 (SD ¼ 7.56). For the ‘‘overall coaching career’’ VCQ, the mean total score for voice symptoms was 35.83 (SD ¼ 10.26). Although no normative data are available for total VCQ scores, all coaches provided responses that indicated the presence of some symptoms. Specifically, no coach selected ‘‘1’’ (never) for all

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symptoms with respect to either the current season or their coaching careers. Any item with a mean of 2.5 or more was noted (to determine whether some voice symptoms were potentially more salient for coaches than others). This arbitrary cut off was used as it approximates the mid-way point of the frequency scale (1 ¼ ‘‘never’’ to 5 ¼ ‘‘every time I use my voice’’). For the ‘‘current season’’ VCQ, hoarseness (mean ¼ 2.58, SD ¼ 1.31) and vocal effort (mean ¼ 2.58, SD ¼ 0.79) were rated at or above this cut off. For the ‘‘overall coaching career’’ VCQ, vocal fatigue (mean ¼ 2.67, SD ¼ 0.98), dry throat (mean ¼ 2.50, SD ¼ 1.00), need to clear throat (mean ¼ 2.58, SD ¼ 1.08), and hoarseness (mean ¼ 2.83, SD ¼ 1.19) were rated at or above this cut off. Coaches’ responses to the VCQ also provided data on their perceived experiences of voice problems. Three of the 12 coaches (25%) indicated that they believed they had a voice problem during the ‘‘current season.’’ Four of the 12 coaches (33%) indicated experiencing a voice problem during their careers. The mean severity rating for the ‘‘current season’’ was 3 (SD ¼ 0.82) and for ‘‘overall coaching careers’’ was 2.33 (SD ¼ 1.15). Semistructured interviews The themes that emerged from analysis of interview transcripts are described in the following section. Awareness of voice use behaviors. Many coaches admitted that voice was not something they regularly contemplated. For example, one participant suggested that he did not typically consider how he used his voice at work: It is quite interesting that I’ve never really thought about it (voice) before. I never really thought about the different ways in which I use it (voice).

In discussing his own lack of consideration of his voice, another coach also noted that this was common in behavior of his colleagues: I don’t notice anyone doing anything with any purpose or with any logic to it at all. I just think it’s an untapped area. I think this is the first time that I’ve ever thought about it (voice). And it’s never been raised; it’s never been spoken about.

Experiencing voice symptoms and voice problems. Although they did not often discuss ‘‘vocal health’’ as a concept, all coaches spoke about situations when their voices did not feel ‘‘quite right.’’ Coaches often conceptualized sensations after heavy voice use as ‘‘fatigue’’ and also used terms such as ‘‘strained’’ and ‘‘run down in the throat.’’ Although coaches’ comments suggested they were aware of these voice experiences while coaching, symptoms were often dismissed as ‘‘just part of the gig.’’ Furthermore, some coaches admitted that, as players, they had considered experiencing voice symptoms as a positive reflection on their performance: I was always hoarse after the match and I was conscious of it. And actually I had players that I played with (that would) use that tool. The fact that it usually indicated we’d worked. Yeah, a bit of a badge of honour. I probably treated it like

480 that too. I was actually happy that I was working that hard on that part of the game (talking).

For some participants, considering voice symptoms in these ways had not appeared to alter when they became coaches. During the interviews, coaches were asked about any neck trauma they had experienced (as a player or as a coach). Three coaches reported neck trauma as players, with only one acknowledging that it had affected his voice. No coaches reported consulting health care professionals, such as general practitioners, otolaryngologists, or speech pathologists for specific issues related to their voices. Identifying and addressing risk factors for vocal ill health. Coaches identified that both indoor and outdoor environments impacted on their voices. When speaking during training, coaches noted that they required increased effort to overcome distance from players. They also experienced increased vocal effort when communicating over high levels of background noise, high sound reverberation, and adverse elements of the weather (eg, wind and rain). Coaches also suggested that the structure of the working week, workplace tasks, and vocal demands impacted on their voices. Coaches reported experiencing overall fatigue and voice symptoms on more vocally demanding days. These were typically during ‘‘game days’’ (requiring intense, frequent, short bursts of speaking) and ‘‘game review days’’ (requiring lengthy vocal communication with players). Despite coaches often suggesting that they were unaware of how to support their vocal health, coaches discussed how drinking fluids, vocal rest, and use of a whistle assisted their voices at work. Coaches noted that resting their voices and drinking fluids seemed to alleviate throat discomfort and improve voice quality after heavy or lengthy voice use. Most coaches suggested that use of a whistle was helpful for outdoor training. However, many felt that using a whistle did not completely replace the need to yell. Coaches felt that these behaviors (hydration, vocal rest, and use of instrumental support) benefited their voices. However, they noted that habit or job tasks often dictated when these behaviors occurred. For example, a whistle would be used because it gained players’ attention quickly not because it reduced the need for coaches to yell. DISCUSSION The current research findings provide preliminary insights into coaches’ occupational vocal health, their voice use patterns at work, and the nature of their working environments. Each of these is considered in the following section within the broader context of occupational vocal health literature. Voice use patterns and demands Data from this study indicate that coaches may experience heavy vocal loads during coaching activities. Coaches’ phonation times, estimated vocal intensity, and fundamental frequency data suggest that training players may be a vocally demanding task. Sustained vocal effort, accompanied by prolonged vocal loading, is assumed to increase the risk of voice problems in occupational voice users.35

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Percent phonation time. The percent phonation times demonstrated in the present study (19%) are comparable with those reported for occupations considered ‘‘moderate’’ voice users. Previously reported percent phonation times considered ‘‘moderate’’ have included those of preschool teachers (17%)36 and call center workers (15%).25 However, caution is required when comparing the current findings with those of previous studies of other occupational voice users. This study only recorded APM measures for a single training session (albeit a vocally demanding aspect of coaching). It was beyond the scope of this pilot study to collect data on coaches’ voice use over one or multiple days of work. Other studies using dosimeters have measured occupational voice use over durations spanning a full work day13,25 to more than a week.35,37–39 Therefore, it would be informative for future research into sports coaches to collect vocal use data over extended periods of time. The range of individual percent phonation times for the current participant group varied from 11.35–26.88%. This variation may be explained by personal factors, variation in coaching environments (Table 2), and the varied nature of voice demands undertaken by coaches while wearing the device. Substantial variability in percent phonation times has also been found in research on call center workers conducted by Cantarella et al.25 However, it seems that the vocal demands of coaches in the present study were not as high as some other occupational voice users such as teachers who have been reported to have daily percent phonation times at almost 30%.40 Given the reported variability in this study, future studies should examine diversities in coaching tasks, personal factors, and coaching environments. Fundamental frequency and vocal intensity. The fundamental frequency data (mode and average) for coaches in the present study appear unremarkable. However, the literature does suggest that prolonged use of elevated fundamental frequency may increase the likelihood of vocal overload41 and phonotrauma.38 This may be a consideration for sports coaches, as the APM data indicated the use of average fundamental frequencies at the upper range of normal (mean ¼ 150 Hz, SD ¼ 30.5 Hz). Similarly, coaches’ average vocal intensities across training environments (mean ¼ 83.67 dB SPL) appeared to exceed safe levels. Participants’ data were similar to those reported from other studies using the APM to estimate vocal intensity in teachers38 and opera singers39 (occupations characterized by high vocal loads). Vilkman suggests that output levels greater than 65 dB at 2 m are a potential risk factor for vocal health.41 Again, this conclusion must remain speculative given that only estimated vocal intensity can be derived from the APM. Furthermore, specific vocal dose measures, such as distance dose, were not made in this study. Coaches’ experiences of voice symptoms and voice problems VCQ and interview data revealed that all coaches experienced voice symptoms at least some of the time while coaching. No participants rated all items as 1 (never) within their responses to the VCQ. Furthermore, all participants discussed situations

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where their voices did not ‘‘feel right’’ and most went on to contextualize these experiences within work tasks. Hoarseness and vocal fatigue were the most frequently reported symptoms in both quantitative and qualitative data. Both of these symptoms are commonly reported among teachers.11,12 Within the present study, the rates of reported voice problems for both the ‘‘current season’’ and ‘‘overall coaching career’’ (25– 33%) also fall within12,23 or just slightly below reported rates for teachers.43 This suggests that, like teachers, coaches often experience voice symptoms while at work. However, although coaches recognized their occupational reliance on voice, they infrequently spoke about vocal health. No coaches had sought help from health care professionals regarding experiences of voice symptoms or voice problems. This appears common to the experiences of schooteachers,23,28 potentially reflecting a lack of awareness regarding vocal health. Thomas et al3 found that teachers who did not perceive voice in terms of vocal health were unlikely to seek health treatment for voice symptoms or voice problems. Gilman et al44 also highlighted this phenomenon in their research into health attitudes in performing artists. Coaches’ lack of vocal health awareness may mean that participants in the present research underestimated rates of voice problems as their ability to recognize and manage voice problems may be limited. Furthermore, coaches often considered experiencing voice symptoms as just ‘‘part of the gig’’ or their voices having ‘‘a good workout.’’ These views are alarming given the negative impact voice symptoms may have on overall vocal health.

environmental adaptations (eg, alterations to acoustic environments and use of personal amplification devices) may also support coaches’ vocal health.38,42 Some coaches did suggest that drinking fluids and vocal rest helped their voices. However, they did not appear to recognize the importance of these behaviors for normal biomechanical functioning of their voices. Nor did they appreciate the importance of these strategies for the normal repair of vocal fold tissues after demanding voice use.46 This lack of awareness may limit the success of workplace vocal health intervention programs with coaches. Active awareness of vocal health may empower individuals to avoid harmful vocal habits.1 When considering how health awareness impacts on health behaviors, Rosenstock47 proposed the ‘‘Health Belief Model.’’ In line with this model, if coaches are not aware of why vocal health-related actions are successful, these actions are unlikely to be implemented.47 Furthermore, lack of vocal health awareness may mean that coaches are unlikely to hold strong beliefs about the benefits of interventions. However, Rosenstock47 purports that a person will take health-related action if they become actively aware of required actions and believe benefits will stem from healthy behaviors. Furthermore, these healthy behaviors will be undertaken if the consequences of health issues are serious enough to avoid.47 Increasing coaches’ awareness of vocal health (both related to voice use practices and environmental factors) may increase positive occupational health actions.

Vocal demands, environmental risk factors, and management Research suggests several commonly occurring risk factors that impact on the vocal health of occupational voice users. These factors include lengthy duration of voice use; yelling over distances; room acoustics; background noise; irritants; lack of health awareness; stress; and workload demands.12,16,17 During the present study, coaches discussed several physical risk factors that are commonly experienced by other occupational voice users. Participants noted that distance from other coaches and their players, background noise, adverse elements of weather, and reverberation seemed to require increased vocal effort. Previous research also suggests that distance, background noise, and acoustic reverberation may impact on the vocal health of occupational voice users such as call center workers,6 performers,1 and school teachers.38 Specifically, physical education (PE) teachers are considered to be at risk of vocal health problems. PE teaching includes job tasks similar to coaching, such as needing to overcome distance and background noise while yelling instructions to others.1,11,45 Characteristics of physical environments and workplace organizations may negatively influence the vocal demands of coaches. Heavy vocal demands, increased vocal effort, and lack of vocal rest may increase coaches’ likelihood of experiencing voice problems. Occupational voice literature asserts the importance of considering workplace context when investigating vocal health.5,10 Suggestions made for other occupations, such as the inclusion of voice care strategies and

CONCLUSIONS This research is one of a limited number of studies to address the vocal health of elite sports coaches. It is also among a very small number of studies that have used a holistic mixedmethods approach to explore voice use at work. During this study, participants acknowledged that voice use is critical for coaching success. Despite this critical reliance, coaches infrequently considered their voice use or vocal health. All participants reported experiencing voice symptoms at least some of the time. Furthermore, 25% indicated experiencing a voice problem during the ‘‘current season’’ and 33% during their ‘‘overall coaching careers.’’ However, coaches rarely implemented strategies intended to support their vocal functioning or vocal health at work. Like many pilot studies, this research is associated with several limitations. Measuring voice use across different job tasks for each participant could strengthen the study. This would provide a more comprehensive data set on coaches’ voice use across a greater range of work tasks. Furthermore, analysis of habitual speech samples to better identify potential changes in acoustic characteristics between everyday voice use and that required when coaching would be valuable. Finally, when generalizing findings, it is important to consider that the present results were based on a small sample of male coaches from two types of football. Wearing of the APM by coaches over an entire working week would be desirable in future research to provide a more complete representation of voice use in coaches. Future research could also focus on both male and female coaches from a

482 variety of sports. Investigation of larger and more representative samples of coaches will also be necessary to provide more robust prevalence data on coaches’ voice disorders and symptoms. Inclusion of control groups (of nonoccupational voice users) and comparison groups of other occupational voice users would allow researchers to delineate any unique features of the vocal demands and vocal health of sports coaches. Given the paucity of voice research with this occupational group, further research is needed to build the evidence base pertaining to the voice use and vocal health demands of sports coaches. Such an evidence base may better inform the design of programs to facilitate effective and safe voice use in sports coaches. REFERENCES 1. Timmermans B, De Bodt MS, Wuyts FL, et al. Poor voice quality in future elite vocal performers and professional voice users. J Voice. 2002;16:372–382. 2. Williams NR. Occupational voice disorders due to workplace exposure to irritants – a review of the literature. Occup Med. 2002;52:99–101. 3. Thomas G, de Jong FI, Kooijman PG, Donders AR, Cremers CW. Voice complaints, risk factors for voice problems and history or voice problems in relation to puberty in female student teachers. Folia Phoniatr Logop. 2006;58:305–322. 4. Phyland DJ, Oates J, Greenwood KM. Self-reported voice problems among three groups of professional singers. J Voice. 1999;13:602–611. 5. Vilkman E. Occupational risk factors and voice disorders. Logoped Phoniatr Vocol. 1996;2:137–141. 6. Lehto L, Rantala L, Vilkman E, Alku P, B€ackstr€om T. Experiences of short vocal training course for call-centre customer service advisors. Folia Phoniatr Logop. 2003;55:163–176.  7. Nix J, Svec JG, Laukkanen AM, Titze IR. Protocol challenges for on-thejob voice dosimetry of teachings in the United States and Finland. J Voice. 2007;21:385–396. 8. Titze IR, Lemke J, Montequin D. Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report. J Voice. 1997;11:254–259. 9. Wingate JM, Brown WS, Shrivastav R, Davenport P, Sapienza CM. Treatment outcomes for professional voice users. J Voice. 2007;21:433–449. 10. Williams NR. Occupational groups at risk of voice disorders: a review of the literature. Occup Med. 2003;53:456–460. 11. Smith E, Lemke J, Taylor M, Kirchner HL, Hoffman H. Frequency of voice problems among teachers and other occupations. J Voice. 1998;12:480–488. 12. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med. 2008;58:74–76. 13. Lehto L, Laaksonen L, Vilkman E, Alku P. Changes in objective acoustic measurements and subjective voice complaints in call center customer-service advisors during one working day. J Voice. 2008;22:164–177. 14. Middleton RL, Hinton VA. A preliminary investigation of the vocal behaviors and characteristics of female pastors. J Voice. 2009;23:594–602. 15. Long J, Williford HN, Olson MS, Wolfe V. Vocal problems and risk factors among aerobics instructors. J Voice. 1998;12:197–207. 16. Kooijman PG, de Jong FI, Thomas G, Huinck W, Donders R, Graamans K, Schutte HK. Risk factors for voice problems in teachers. Folia Phoniatr Logop. 2006;58:159–174.  17. Niebudek-Bogusz E, Koty1o P, Politanski P, Sliwi nska-Kowalska M. Acoustic analysis with vocal loading test in occupational voice disorders: outcomes before and after voice therapy. Int J Occup Med Environ Health. 2008;21:301–308. 18. O’Neill J, McMenamin R. Voice use in professional soccer management. Logoped Phoniatr Vocol. 2014;39:169–178. 19. Fletcher D, Scott M. Psychological stress in sports coaches: a review of concepts, research, and practice. J Sports Sci. 2010;28:127–137. 20. Gould D, Guinan D, Greenleaf C, Chung Y. A survey of U.S. Olympic coaches: variables perceived to have influenced athlete performances and coach effectiveness. Sports Psychol. 2002;16:229–250.

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Vocal Health of Elite Sports Coaches

APPENDIX A Voice capabilities questionnaire 1. Indicate the extent to which the following statements apply currently to you as a coach/during your coaching career:

Never My voice has tired or fatigued My voice has been hoarse, croaky, husky etc My voice has been crackly or had breaks My voice has been lower in pitch than usual My voice has been higher in pitch than usual I have had difficulty making my voice as loud as I have needed I felt that using my voice was effortful My voice has not projected as well as needed I have had difficulty with breath control (eg, running out of breath, gasping) My throat has felt dry I have felt scratchiness or tickling in my throat I have felt as if I have had a lump in my throat My throat has ached or felt sore I have felt pain in my throat I have had a burning sensation in my throat I have needed to clear my throat or cough

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2a. Do you believe that you are currently experiencing a voice problem?

Always 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Yes

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

No

2b. If you believe that you had a voice problem, how severe is the problem? Slight 1

2

3

4

Severe 5