Workplace Productivity and Voice Disorders: A Cognitive Interviewing Study on Presenteeism in Individuals With Spasmodic Dysphonia *Derek Isetti and †Tanya Meyer, *ySeattle, Washington Summary: Objective. The objective of this study was to obtain initial reactions and suggested modifications to two existing presenteeism scales: the Stanford Presenteeism Scale 6 (SPS-6) and the Work Productivity and Activity Impairment Questionnaire-Specific Health Problem (WPAI-SHP) among a cohort of employed individuals with a focal laryngeal dystonia, spasmodic dysphonia (SD). Study design. The study design is a qualitative study. Methods. Nine speakers with SD underwent cognitive interviews, during which they were asked to evaluate the relevance of statements and clarity of wording on the SPS-6, the WPAI-SHP, and an additional set of voice-related statements designed by the researchers. Participants were asked to complete the scales, rank order statements in terms of perceived importance, and suggest additional statements of relevance. Results. Although all participants noted that their SD did have an effect on their jobs, there were suggestions for modifying both the WPAI-SHP and the SPS-6. Participants regarded specific voice-related statements that were generated by the researchers to be of greater importance than the majority of the statements on the SPS-6. Minor changes in the wording of the instructions on the WPAI-SHP were recommended. Conclusions. Presenteeism is an important construct to measure in individuals with a chronic voice disorder such as SD. However, existing presenteeism scales might best be administered in conjunction with additional statements that are more voice related so that clinicians can be made aware of specific difficulties encountered in the workplace. Key Words: Spasmodic dysphonia–Presenteeism–Workplace productivity.

INTRODUCTION Effective communication skills have become critical determinants of employability in the modern era. In the United States, 25–30% of the population considers the voice to be a primary tool of the trade.1 It stands to reason, therefore, that an individual with a voice disorder may encounter not only social but also vocational barriers because of an impairment to the vocal mechanism. Absenteeism is the most common method of measuring a loss in workplace productivity. This is because the number of hours or days missed as a result of a particular health condition is relatively easy to quantify. However, a newer term known as presenteeism is gaining ground in the occupational health literature. Presenteeism refers to a decrease in the quantity or quality of a person’s work as a result of attending work while ill.2 Workers may physically be present at their jobs, but they may function in a diminished capacity because of the symptoms of their illness. Presenteeism may be especially salient for chronic health conditions and is thought to account for more net productivity loss over time than absenteeism in conditions such as back pain, migraines, and depression.3 An individual with a voice disorder might be fully capable of holding a job, yet the quality of the voice and/or the effort Accepted for publication March 21, 2014. Portions of this article were presented in an oral presentation at the American SpeechLanguage-Hearing Association Convention, November 2013, Chicago, IL. From the *Department of Speech and Hearing Sciences, University of Washington, Seattle, Washington; and the yDepartment of Otolaryngology—Head and Neck Surgery, University of Washington, Seattle, Washington. Address correspondence and reprint requests to Derek Isetti, Department of Speech and Hearing Sciences, University of Washington, 1417 NE 42nd Street, Seattle, WA 98105. E-mail: [email protected] Journal of Voice, Vol. 28, No. 6, pp. 700-710 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.03.017

required to speak may adversely affect job performance. Although there is some literature detailing that voice quality has an impact on employment,4–6 the exact mechanisms of this effect on job performance or work productivity have not been well studied to date. Individuals with spasmodic dysphonia (SD), a chronic neurologic voice disorder, may be a useful population in which to study the impact of disordered voice on work productivity.5 SD has a defined neurologic etiology and a specific medical treatment (cyclical injections of botulinum toxin [BOTOX]). These traits distinguish SD from other types of voice disorders that might be caused by overuse or misuse of the vocal mechanism. Individuals with SD are not asked to modify or reduce their current level of speaking as a means of treatment. If this were the case, it would be difficult to differentiate if reduced workplace productivity was because of the presence of the voice disorder itself or whether productivity was compromised because patients were asked to modify their speaking as part of the therapeutic process. Therefore, the discrete medical intervention with no restrictions on voice use makes SD an ideal population to use when examining the impact of a voice disorder on work. The primary complaint of patients with SD is an effortful speaking voice, and qualitative studies have documented that patients with SD report limitations in professional and occupational roles.7 However, further elucidation and quantification of the impact of SD on work productivity is needed. Presenteeism scales Although there are a number of existing self-report scales that have been created to measure presenteeism, some are disease specific and designed to measure how particular chronic

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conditions such as asthma or gastroesophageal reflux might affect workplace productivity.8,9 Two existing measures, however, are generic self-report scales designed to be used with any health condition. Both the Work Productivity and Activity Impairment Questionnaire-Specific Health Problem (WPAI-SHP)10 and the Stanford Presenteeism Scale 6 (SPS-6)11 were designed such that a specific diagnosis can be substituted for ‘‘problem’’ or ‘‘health problem’’ on those scales. Although both scales have demonstrated good psychometric properties in terms of reliability and validity,10–12 neither is norm referenced. In the general population, individuals may not be productive at work for any number of reasons (eg, highly distractible, unmotivated, bored). However, the aforementioned scales were designed to assess the degree to which a specific health condition might cause a presenteeism effect. Therefore, in theory, an individual completing either of the scales who does not have the disorder in question would report zero loss in productivity because of that specific disorder. Because of their supposed utility in measuring presenteeism across any health condition, both the WPAISHP and the SPS-6 might be useful in studying presenteeism in those with a voice disorder such as SD. However, it should be noted that the two scales vary dramatically in terms of their presentation. The SPS-6 is composed of a series of six statements (three positive and three negative), in which respondents are asked to rate the degree to which they agree with those items. The five response options are as follows: 1, I strongly disagree with the statement; 2, I somewhat disagree with the statement; 3, I am uncertain about my agreement with the statement; 4, I somewhat agree with the statement; and 5, I strongly agree with the statement. The items from the SPS-6 are listed in the Appendix. Scoring for the SPS-6 is rather unique, in that the higher the total score, the lesser the impact a health condition has on workplace productivity. The SPS-6 was created by Koopman et al when the concept of presenteeism had a positive rather than a negative connotation according to those authors (ie, the opposite of absenteeism). Today, however, the common consensus is that presenteeism is not a positive quality and that if an individual exhibits a high degree of presenteeism, then the quantity or quality of that person’s work is being adversely affected because of working while ill.2 Half of the statements on the SPS-6 are negative in nature (items 1, 3, and 4), whereas the others are positive (items 2, 5, and 6). The three negative items are reversed scored such that a higher total score yields a more positive result (ie, the health condition has less of an impact on workplace productivity). Scores can range from 6 (severe impact on workplace productivity) to 30 (no impact on workplace productivity). The WPAI-SHP also has six questions, but the first four questions are designed to specifically address absenteeism or the total number of hours missed over the past 7 days because of a health condition. Question 5 is designed to assess how a health problem affects workplace productivity (presenteeism), and question 6 asks about how a health problem affects daily activities other than work. Questions 5 and 6 are completed using a 0–10 scale, with 0 ¼ problem had no

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effect on my work and 10 ¼ problem completely prevented me from working. See Appendix for the complete WPAISHP protocol. On the WPAI-SHP, a percentage can be obtained indicating the net self-reported productivity loss because of the health problem. For example, a score of 2 of 10 on question 5 is converted to a 20% self-reported loss of productivity because of the specific health problem. Furthermore, the WPAI-SHP has an option to combine the absenteeism score with the presenteeism score to arrive at an overall work impairment score. An expert panel convened by the American College of Occupational and Environmental Medicine (ACOEM) stressed that all presenteeism scales should include elements that address how a health condition affects four core components at work: time, quality, quantity, and personal factors (social, mental, physical, and emotional).13 Unfortunately, these recommendations made by the ACOEM panel were suggested after the SPS-6 and the WPAI-SHP were already in existence. Additionally, none of the existing presenteeism scales were designed specifically to address the work-related concerns of individuals with voice disorders. Disease-generic presenteeism scales designed before the ACOEM guidelines may not be the most appropriate or sensitive instruments to capture the concerns of individuals with voice disorders. Perhaps more specific statements involving voice use at work would be more appropriate in discovering the specific ways in which a disordered voice affects workplace productivity. Purpose of the study The present study used qualitative methodology involving cognitive interviews on a cohort of individuals with a confirmed diagnosis of SD. All the study participants were currently employed. The aim of the study was to 1. Determine if productivity loss because of working while ill (presenteeism) is a construct that is deemed important in the lives of individuals with a chronic voice disorder such as SD. 2. Ascertain if two existing work productivity measurement tools, the WPAI-SHP and the SPS-6, are regarded by patients as adequate in assessing how the quality and quantity of a person’s work is affected by SD. 3. Determine if an additional set of researcher generated voice-related statements (VRS) are viewed as valuable by individuals with SD in capturing the specific ways in which a chronic voice disorder affects workplace productivity. This research is important because a better understanding of how a patient’s voice impacts his/her job status is a critical but poorly studied quality-of-life domain. It is essential for the health-care worker to understand the specific ways in which a voice disorder affects the quality and quantity of an individual’s work so that potential accommodations can be made. Additionally, a tool that adequately captures this impairment could be used as an outcome measure to gauge the effectiveness of voice treatment over time.

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METHODS Participants Participants included a sample of nine adults aged 18 years and older with a diagnosis of SD, who were receiving BOTOX (BTX-A) injections from the University of Washington Medical Center Department of Otolaryngology. Participants had received a diagnosis of SD based on an assessment by a board-certified laryngologist and two experienced speechlanguage pathologists. Diagnoses were made via a thorough case history, videolaryngostroboscopy, auditory-perceptual assessment, and fine-wire laryngeal electromyography. All participants were receiving BOTOX injections for SD, reported a reduction in their symptoms with injections, and had been living with their diagnoses for at least 1 year before study participation. Participants needed to be currently working to meet eligibility criteria and have no other neurologic conditions other than SD. Informed consent documents approved by the Institutional Review Board at the University of Washington were signed by all interviewees before study involvement. Participant demographics are presented in Table 1. Questionnaires Participants were presented with paper-based questionnaires, which included the SPS-6 and the WPAI-SHP. Because the SPS-6 and WPAI-SHP were not validated on individuals with voice disorders, it was important to include additional statements in the current investigation that specifically involved voice use. Therefore, participants were also presented with a set of researcher-generated VRS. The VRS were crafted using the newer presenteeism guidelines set forth by the ACOEM as a template and included statements to address the recommended domains of time, quality, quantity, and personal factors.13 Sample statements addressing the time component were created based on length of time to accomplish work-related tasks and length of time spent in conversations at work. The statements addressing the quantity and quality domains were selected by the authors primarily on the basis of their face validity (eg, the quality of the work I do is diminished because of my voice). Many of the additional VRS, especially those designed to address the personal factors domain suggested by the ACOEM, were derived from an existing quality-of-life measure known as

the Voice Handicap Index (VHI).14 In many cases, items from the VHI were adapted for the current investigation by simply changing the wording to make them more specific to the workplace (eg, I put off making or answering phone calls at work). Finally, some statements were designed based on what speakers with SD have reported in a previous qualitative study.7 Baylor et al. interviewed individuals with SD about their experiences living with this chronic voice disorder, and various subthemes were reported. Commonalities among participants in that study included the subthemes of ‘‘talking requires physical effort’’ and ‘‘SD has deprived me of certain roles.’’ It was deemed important to address some of the physiological, social, and personal factors that have been shown to affect quality of life among speakers with this chronic voice disorder. An Appendix has been provided which not only summarizes the VRS but also delineates the statements that were derived from their respective sources. The instructions on the WPAI-SHP ask that statements be evaluated based on work-related functioning during the past 7 days, whereas the SPS-6 asks for a recall period of 1 month. Because all participants were being interviewed at the time of their next BOTOX injection, when their voices were arguably at or near their worst, participants were asked to use the more conservative 7-day recall period when responding to statements on all questionnaires. Having individuals with SD fill out questionnaires at the time of their next injection (as opposed to the height of effectiveness after a BOTOX injection) was thought to give the most accurate representation of how a chronic voice disorder might impact workplace productivity when the voice problem is at its worst. Interviews Before the administration of the paper-based questionnaires and accompanying interviews, participants were asked to fill out a demographic form that included their age, gender, current job, level of voice use, and date of diagnosis of SD. All interviews were audio recorded in a private office at the University of Washington Medical Center and lasted between 45 and 60 minutes. In addition to the audio recordings, notes were taken by the research team in real time to ensure accuracy of responses. Participants were encouraged to read all

TABLE 1. Participant Characteristics of Individuals With Spasmodic Dysphonia Participant

Age/Gender

1 2 3 4 5 6 7 8 9

28 (F) 54 (F) 37 (F) 49 (M) 55 (M) 62 (F) 59 (F) 44 (F) 71 (M)

Occupation

Years Since dx

Nurse Teacher Pharmacy tech Nurse anesthetist Data manager Clerical Bookkeeper Legal assistant Consultant

6 20 10 2 3 23 8 1 5

Abbreviations: F, female; M, male; dx, adductor spasmodic dysphonia.

Level of Voice Use High High High High Low Moderate Moderate High High

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instructions and statements aloud, explaining their thought process in responding to each statement. This ‘‘think aloud’’ protocol is a common technique used during cognitive interviews. The use of cognitive interviews as a methodological approach is typically used by researchers when attempting to test the appropriateness and clarity of candidate survey items before mass distribution15 or in the preliminary phase of scale construction.16 A small number of the targeted population is selected for these in-depth interviews. In the current investigation, cognitive interviews were used not necessarily as a step in the construction of a new scale but rather to gauge participant responses to existing scales that have not yet been validated on this specific patient population. Throughout the interview, participants were encouraged to discuss each statement aloud using prompts typically used during cognitive interviews.17 Prompts included such questions as:  Can you say in your own words what you think the questions are asking?  Did this statement address your voice concerns regarding this topic?  Is the wording of this statement clear?  Do you think this could be stated in a better way?  Do you have the information you need to rate the statement?  Is there anything additional you think should be added to these statements? Through this think aloud protocol, the research team was able to note any wording that was unclear, not applicable, or in need of modification. Participants were also instructed that they were free to suggest additional statements that were not included on any scale. The cognitive interview process is iterative in nature. The suggestions for improvement made by each participant were noted by the researchers and offered as potential options to subsequent participants. Ranking task On completion of the SPS-6 and VRS, participants were told to examine the statements from both scales simultaneously and place an asterisk next to the eight statements from either of those two scales that were most applicable to how SD affected their work. Participants were instructed to look back at those eight marked items and rank order those specific items in terms of perceived importance (1, most important, to 8, least important). Rather than have participants rank order all 20 statements (6 from the SPS-6 and 14 from the VRS), the rationale behind the selection of the top eight items was that this would reduce the cognitive load involved in such a ranking task. The WPAI-SHP was not included for the ranking task as the format of the WPAI-SHP calls for the participant to make a general global measure of productivity loss on a 0–10 scale and does not involve the use of specific statements. Analysis Paper-based questionnaires were scored, and audio recordings were analyzed to ensure that they accurately matched the

researcher notes taken during the interviews. Researchers took note of items that were considered confusing or in need of modification. Items that were rank ordered by each participant according to importance were given a numerical point value based on frequency of selection. For example, items that were ranked first were given 8 points, second were given 7 points, third were given 6 points, and so on down to items that were ranked eighth that were given 1 point. If an item was not ranked in the top eight for a particular participant, that item received 0 points. Once point values were tabulated for each individual participant, these values were then summed across all participants to yield a total point value for each statement. The higher the total point value for a particular statement, the more important that statement was deemed in the eyes of the participants. RESULTS It was hypothesized that participants would report adverse consequences in workplace productivity because of their SD, but it was unknown whether existing scales such as the WPAI-SHP and the SPS-6 would be regarded as adequate or appropriate for use by individuals with a chronic voice disorder. Scores on various scales Results from the participants on the three measures are listed in Table 2. There are no normative cutoff values established for either the WPAI-SHP or the SPS-6 as to what scores would be indicative of a significant versus minimal impact on productivity. However, in interpreting the scores, a score of 30 on the SPS-6 and a score of 0% on the WPAI-SHP would indicate that the voice disorder was regarded to have no impact at all on workplace productivity. Any departure from those two values on the respective scales (lower than 30 on the SPS-6 or higher than 0% on the WPAI-SHP) indicates that there is some effect of presenteeism due specifically to the presence of SD. On the VRS added by the research team, any score above 14 indicates that SD was perceived to have some effect on work-related TABLE 2. Participant Scores on the Various Scales Participant 1 2 3 4 5 6 7 8 9

SPS-6

WPAI-SHP (Presenteeism %)

VRS

28 18 21 23 22 22 23 21 13

40 60 60 0 10 50 40 40 60

25 39 38 36 48 54 61 50 56

Note: SPS-6 scores can range from 6 to 30, with higher scores being more positive (ie, less of an impact of the health condition on productivity). Percentages from the WPAI-SHP indicate how much the voice problem affected work productivity, with higher percentages indicating a more negative impact on productivity. The VRS range is 14–70, with higher scores indicating a more negative impact on productivity.

704 functioning. All participants noted some degree of presenteeism on all the measures, with the only exception being participant 4. This particular participant noted a presenteeism effect on both the SPS-6 and the VRS but not on the WPAI-SHP. In filling out the measures, he explained that his SD caused no loss in productivity (ie, number of patients seen) for his job as a nurse anesthetist. Because he interpreted question 5 on the WPAI-SHP as dealing solely with productivity loss, he reported zero on that particular measure. When the statements became more specific on the other measures (eg, I do not speak up as often as I would like at work, I do not volunteer for certain tasks at work because of my voice), he reported that he agreed with those specific statements. Participant preferences On completion of all questionnaires, participants were asked to select statements from both the SPS-6 and the VRS that were the most important to them. Incorporating statements from both scales, each participant was asked to rank order the top eight statements in terms of perceived importance. Statements that received the greatest number of points summed across all participants are listed in Table 3. Suggested modifications On the SPS-6, all participants took issue with the word ‘‘hopeless’’ in the statement ‘‘I felt hopeless about finishing certain work tasks due to my voice.’’ The main complaint was that the choice of that particular word seemed too desperate when evaluating how SD impacts work-related functioning. Common suggestions included substituting the terms ‘‘frustrated’’ or ‘‘challenged’’ for ‘‘hopeless.’’ Four participants noted that although they liked the statement on the VRS ‘‘I do not volun-

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teer for certain tasks because of my voice,’’ they would have taken it a step further to say that they actually go out of their way to ‘‘avoid’’ certain tasks when their voices are problematic. Avoidance of certain tasks is supported by other qualitative work in this population.7 A summary of other suggested modifications is presented in Table 4. Clarity of instructions On the whole, participants had no difficulty understanding the instructions on any of the measures. However, on the WPAISHP, every participant felt that the instructions specifically for question 6 (regarding the effect of SD on regular activities other than work) should be reworded for individuals with voice disorders. The instructions state ‘‘By regular activities, we mean the usual activities you do, such as work around the house, shopping, childcare, exercising, studying, etc.’’ It was pointed out that many of the activities mentioned would not require voice use of any kind. Suggestions for more appropriate examples included ‘‘speaking, communicating, going to restaurants, talking on the phone, going to parties, and social activities.’’ It should be noted that these particular instructions on the WPAI-SHP were used to answer question 6 only, and this question was not designed to factor into the presenteeism composite score. In other words, the fact that the participants had difficulty with the types of activities listed in the instructions for question 6 alone should technically not affect the scoring of the other questions on the WPAI-SHP that were designed to measure absenteeism and presenteeism at work (questions 1–5). Additional statement suggestions Eight of the 10 participants felt that no other statements would need to be added beyond those already present on the

TABLE 3. Participant Rank Ordering of Items on the VRS and SPS-6 in Terms of Perceived Importance Statement 1. I put off making or answering phone calls at work 2. I do not speak up as often as I would like at work 3. The amount of speaking that I do at work is diminished 4. I experience fatigue at work because of the extra effort that it takes to talk 5. I do not volunteer for certain tasks at work because of my voice 6. My conversations at my job are shorter than I would like 7. I feel that others at my job are distracted by how I sound 8. I felt hopeless about finishing certain work tasks due to my voice* 9. I have been excluded or bypassed from opportunities at work due to my voice 10. Because of my voice the stresses of my job were much harder to handle* 11. My voice distracted me from taking pleasure in my work* 12. It takes me longer to accomplish tasks at work because of my voice 13. I have difficulty concentrating on my work because of my voice 14. I do not function at my typical performance level because of my voice 15. I experience discomfort or pain due to my voice which affects my work 16. The amount of work that I produce is diminished because of my voice 17. The quality of the work that I do is diminished because of my voice 18. Despite my voice, I was able to finish hard tasks in my work* 19. At work, I was able to focus on achieving my goals despite my voice* 20. Despite my voice, I felt energetic enough to complete all my work* * Items from the SPS-6. All the other items in this list were from the VRS created by the researchers.

Point Value 54 53 33 29 28 27 20 17 16 12 11 6 4 4 4 3 2 0 0 0

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TABLE 4. Suggested Modifications Original Statement ‘‘I do not volunteer for certain tasks at work because of my voice.’’ (VRS) ‘‘I felt hopeless about finishing certain work tasks due to my voice.’’ (SPS-6) ‘‘Despite my voice, I felt energetic enough to complete all my work.’’ (SPS-6)

WPAI-SHP, SPS-6, or VRS. However, one participant in particular believed that a statement focusing on the anxiety that results from having SD at work would be helpful. No statement on any of the scales used in the present investigation addressed the particular issue of anxiety. Because the expert panel from the ACOEM has suggested that all presenteeism scales should incorporate elements that refer to the mental and emotional impacts of a chronic health condition on workplace functioning, the issue of anxiety because of the presence of a voice disorder deserves further exploration. One participant elaborated on the VRS statement, ‘‘I feel that others at my job are distracted by how I sound.’’ This person suggested that, ‘‘I feel that others stop listening to me because of how I sound’’ might also be added. Although ‘‘My conversations at my job are shorter than I would like’’ was a statement on the VRS that was deemed important to many participants, it was noted by two individuals that it was specifically conversations with ‘‘groups of people’’ or conversations in ‘‘noisy environments’’ that were particularly problematic. It was also not simply how short the conversations were, but rather how difficult it was to hold the conversations that should also be emphasized. Additional statement suggestions are summarized in Table 5. Timing-related concerns As was stated earlier, a recall period of 1 week was used for all measures in the current investigation because this was the specified time frame intended to be used when completing the WPAI-SHP. When responding to the statement on the VRS ‘‘I have been excluded or bypassed from opportunities at work because of my voice,’’ many participants noted that this was a difficult question to answer when restricted to a time frame of the past 7 days. Participants remarked about being demoted within their companies, having their jobs restructured, or being denied employment because of their SD. Specifically, one individual remarked that her SD prevented her from joining the army because she could not be guaranteed

Suggestion ‘‘I avoid certain tasks at work because of my voice.’’ ‘‘I felt frustrated about finishing certain work tasks due to my voice.’’ ‘‘It took more energy to talk at work because of my voice.’’

medical access for her BOTOX treatments depending on where she might be deployed around the globe. This type of missed ‘‘opportunity’’ would not have been captured if a respondent was asked to think back only 1 week in answering. Additionally, although presenteeism refers to how a health condition interferes with a current job, three respondents in particular commented that the phrase ‘‘excluded from opportunities’’ brought up the inherent barriers they faced in securing work in the first place. These individuals noted the difficulties SD posed when interviewing for jobs, citing long periods of unemployment that often occurred before gaining employment. Two individuals remarked specifically that over-the-phone job interviews were especially problematic. Another timing-related concern dealt with the cyclical nature of the injection cycle and its effects on ratings. SD tends to respond well to BOTOX injections into the intrinsic laryngeal muscles.18,19 However, the improvement in voice quality is temporary, lasting only a few months until the process must be repeated. Each participant surveyed in the present study was interviewed just before the next injection, on returning to the clinic because the effectiveness of the injection had worn off. Therefore, the 7-day recall period used on the WPAI-SHP can only capture a small window of how SD affects workrelated functioning. In fact, every single participant noted that had they been able to fill out all the measures just a few weeks earlier when their symptoms were more manageable with BOTOX, this would have had a profound effect on their ratings. To illustrate this point, each participant was informally asked to answer question 5 on the WPAI-SHP in two different ways. The first question was asked as written, ‘‘During the past 7 days, how much did your voice affect your productivity while you were working?’’, whereas the second informal question was asked in the following way, ‘‘During your ‘best’ voicing week since your last injection, how much did your voice affect your productivity while you were working?’’ When asked the question in the second manner, all participants noted an improvement in work-related functioning. More specifically,

TABLE 5. Additional Statement Suggestions Suggested Statements ‘‘When my voice is bad, it increases my overall level of anxiety at work.’’ ‘‘I feel that others stop listening to me because of the way I sound at work.’’ ‘‘Conversations in noisy environments at work are more difficult than I would like.’’

706 participants 5 and 7 reported that during their best voicing week since their last injection, they experienced only a 10% loss in productivity. Even more notable, seven of the nine participants said that they would have reported no loss in productivity whatsoever (0%) if they had simply been able to fill out question 5 on the WPAI-SHP just a few weeks earlier. This suggests that unlike other chronic conditions that are relatively stable, there may be dramatic fluctuations in terms of workplace productivity based on the cyclical nature and timing of the BOTOX treatment cycle. These preliminary results suggest that when BOTOX treatment is at the height of effectiveness, selfreported productivity loss can be greatly minimized and in some cases is no longer a concern at all.

DISCUSSION Presenteeism, or a decrease in the quality or quantity of a person’s work because of a health condition, is a concept that has been steadily gaining ground in the occupational health literature. The present study examined the construct of presenteeism in patients with a chronic voice disorder known as SD. This study was exploratory in nature, being the first of its kind to garner participant feedback on whether presenteeism scales might be appropriate for use in individuals with voice disorders. Two existing presenteeism scales (the WPAI-SHP and the SPS-6) along with supplemental VRS created by the research team were presented to a small cohort of working individuals with SD. Cognitive interviews were conducted as a means of obtaining feedback on these measures. One finding from the current investigation dealt with issues related to timing. Because the WPAI-SHP and SPS-6 have recall periods of 1 week and 1 month, respectively, they were designed to capture and measure presenteeism experienced either currently or in the very recent past. On one hand, this might be an asset in terms of administration. All participants noted that there could be drastic short-term fluctuations in reported presenteeism, depending on where in the BOTOX cycle an individual with SD happens to be. A shorter recall period would theoretically allow individuals with SD to track their productivity on a weekly (WPAI-SHP) or monthly (SPS-6) basis. However, if a clinician during an evaluation aims to capture the history of a patient’s work-related difficulties (many of which were reported by participants in the current investigation), then an additional line of questioning may be needed. For example, the VRS statement added into the current investigation ‘‘I have been excluded or bypassed from opportunities at work due to my voice’’ allowed participants the opportunity to share demotions or job restructuring that would not otherwise have been able to be captured using the shorter time frames on the WPAI-SHP or the SPS-6. Additionally, despite its supposed utility for any health condition, participants did have suggestions for improving the instructions on the WPAI-SHP for one section in particular. Many of the activities that were provided as examples in those instructions (ie, exercising, studying, working around the house) did not necessarily involve voice use. Participants noted that it was difficult to imagine those particular activities being

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compromised as a function of their SD. However, the instructions that were problematic only involved a single question designed to measure nonwork activities (question 6). For this reason, the other questions on the WPAI-SHP, specifically questions 1–5 that were designed to measure absenteeism and presenteeism, may still have clinical utility for individuals with voice disorders. The fact that participants suggested alternative activities for the one question designed to measure the impact of voice on areas outside of work should not negate the potential utility of the WPAI-SHP in measuring work-related functioning. Currently, there are existing scales designed to measure both the psychosocial impact of living with a voice disorder and communicative participation.14,20,21 If the aim of the clinician is to measure how a voice disorder might restrict activities and participation more globally outside of the workplace, then the use of these other scales would be more appropriate. Finally, participants rank ordered items that were specifically voice related (VRS) higher in terms of perceived importance compared with the more general presenteeism statements on the SPS-6. This makes intuitive sense, because the SPS-6 was designed to be used for any number of health conditions, whereas the researcher-generated statements on the VRS were specifically created with voice patients in mind. Another potential reason for the preference of the VRS over statements on the SPS-6 was that the VRS attempted to address the newer guidelines set forth by the ACOEM. These newer guidelines created in 2009 stress that all presenteeism scales should include items that address the domains of time, quality, quantity, and personal factors. These guidelines, however, were not in place at the time that either the WPAI-SHP or the SPS6 was created. The fact that participants ranked the newly created VRS to be of greater importance can be addressed in two potential ways. The first solution might be to quantify absenteeism and presenteeism with the WPAI-SHP, yet also have clinicians verbally inquire about the specific VRS that were deemed most important to individuals with SD. Although the WPAISHP can yield a discrete score for hours of absenteeism and the percentage of self-reported productivity loss because of a voice disorder, it cannot reveal the specific reasons why the person is struggling at work. Using some of the VRS used in the current investigation in conjunction with the WPAI-SHP may enable clinicians to identify more precisely what struggles are being encountered in the workplace at an individual level. Using some of the additional statements suggested by patients (ie, those dealing with anxiety or noisy environments) during this inquiry might also be helpful. This ultimately has counseling implications in this population because clinicians who are made aware of specific difficulties encountered by their voice patients can troubleshoot and provide potential accommodation suggestions at work. A second solution may involve the creation of an entirely new scale designed to measure the impact of disordered voice on a person’s job. There has been some concern in the literature that of the more than 14 scales currently designed to measure presenteeism, many may not be measuring the same construct.22 This concern may have been illustrated in the

Derek Isetti and Tanya Meyer

Presenteeism in Individuals With SD

present study through the responses of participant 4. Had participant 4 only filled out the WPAI-SHP, no problems would have been reported. He claimed that there was no direct loss in productivity because of his SD. However, when probed further and statements became more specific on the VRS, he did reveal that the quality of his workplace environment was affected because of his SD. More specifically, he reported that his SD prevented him from speaking as much as he would like to and from volunteering for certain activities that he would enjoy (ie, committee work, interviewing potential hires at restaurants). This implies that although productivity (ie, the quantity of work produced) might not be affected directly, there may still be more subtle ways in which a voice disorder affects workplace functioning. Perhaps, the creation of a new scale that more sensitively captures these changes in functioning may be in order. Knowing in what ways the presence of a voice disorder might affect not just the quantity but also the quality of a person’s work can help clinicians provide better care. However, the cognitive interviews conducted in the current investigation are merely one small step in the process of developing a psychometrically sound measurement tool. If the VRS were ever to be crafted into a formal scale for use with individuals across various voice disorders, more cognitive interviews would be required using larger samples in other voice patient populations. Construct validity would need to be established, and more advanced statistical procedures such as a factor analysis would need to be performed to ensure the appropriateness of the subcategories. Future directions Presenteeism scales have the potential to be used as outcome measures in gauging the effectiveness of voice treatment on work-related functioning. Rather than relying on a clinician’s perceptual judgment that vocal quality has improved after treatment, self-report presenteeism scales could allow voice patients themselves to reflect on how a change in voice symptoms directly affects them at their place of work. Future studies might track workplace productivity longitudinally in individuals with voice disorders. Having individuals with SD fill out a scale such as the WPAI-SHP before the initial BOTOX injection, and then again at subsequent intervals, could track the effects of the injection on presenteeism over time. Participants in the present study completed all measures on returning to the clinic, when the effects of the BOTOX had begun to wear off and their voices were arguably at their worst. However, participants stressed that they would have reported improved productivity had they been able to complete these same questionnaires just a few weeks prior during the optimal period of the BOTOX cycle. If this finding was to be borne out in future studies, it would serve to demonstrate that BOTOX not only results in improvements in voice quality but also that the injections can have a measurable effect on self-reported workplace productivity as well. Because this study was interview based, many participants mentioned not only the barriers encountered while working but they also spoke about the difficulty that the symptoms of SD posed when attempting to secure employment. Measuring

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workplace functioning is obviously important. However, perhaps just as fundamental is discovering the ways that a person’s voice disorder might be a hurdle to obtaining employment in the first place. After all, measuring presenteeism is contingent on a person’s ability to secure a job. Many individuals spoke about how their voices caused them to be perceived negatively by employers during the hiring process, with telephone interviews being especially problematic. Long periods of unemployment were mentioned by multiple participants. Therefore, an additional line of research exploring how individuals with SD are perceived by employers during the interview process is currently underway. Finally, future studies might also examine the concept of presenteeism among other types of voice disorders beyond SD. It may be discovered that other populations (ie, unilateral vocal fold paralysis) also experience very similar presenteeism effects despite their differing etiologies. CONCLUSIONS 1. Presenteeism is a concept worthy of exploration among working adults with SD. Individuals with this condition reported that their voice disorder had a negative impact on the quantity and quality of their work. 2. The timing of BOTOX injections may play an important role in determining the degree to which the symptoms of SD affect a person’s job performance. 3. Existing presenteeism scales have short recall periods but may not be specific enough in addressing key concerns about how a voice disorder affects job performance. 4. A presenteeism scale such as the WPAI-SHP can yield discrete percentages for self-reported absenteeism and reduced productivity, but clinicians will need to probe further as to the specific reasons why a person with a voice disorder might be struggling at work. 5. To address the precise ways in which a voice disorder affects the quantity and quality of a person’s work, the creation of a new scale may be warranted.

REFERENCES 1. 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. 2. Johns G. Presenteeism in the workplace: a review and research agenda. J Organizational Behav. 2010;31:519–542. http://dx.doi.org/10.1002/ job.630. 3. Schultz AB, Chen CY, Edington DW. The cost and impact of health conditions on presenteeism to employers. Pharmacoeconomics. 2009;27: 365–378. http://dx.doi.org/10.2165/00019053-200927050-00002. 4. Izdebski K, Dedo HH, Boles L. Spastic dysphonia: a patient profile of 200 cases. Am J Otolaryngol. 1984;5:7–14. http://dx.doi.org/10.1016/ S01960709(84)80015-0. 5. Meyer TK, Hu A, Hillel AD. Voice disorders in the workplace: productivity in spasmodic dysphonia and the impact of botulinum toxin. The Laryngoscope. 2013;123:S1–S14. http://dx.doi.org/10.1002/lary.24292. 6. Smith E, Taylor M, Mendoza M, Barkmeier J, Lemke J, Hoffman H. Spasmodic dysphonia and vocal fold paralysis: outcomes of voice problems on work-related functioning. J Voice. 1998;12:223–232. http://dx.doi.org/10. 1016/S0892-1997(98)80042-8.

708 7. Baylor CR, Yorkston KM, Eadie TL. The consequences of spasmodic dysphonia on communication-related quality of life: a qualitative study of the insider’s experiences. J Commun Disord. 2005;38:395–419. http:// dx.doi.org/10.1016/j.jcomdis.2005.03.003. 8. Chen H, Blanc PD, Hayden ML, Bleecker ER, Chawla A, Lee JH, TENOR Study Group. Assessing productivity loss and activity impairment in severe or difficult-to-treat asthma. Value Health. 2008;11:231–239. http://dx.doi. org/10.1111/j.1524-4733.2007.00229.x. 9. Wahlqvist P, Guyatt GH, Armstrong D, et al. The work productivity and activity impairment questionnaire for patients with gastroesophageal reflux disease (WPAI- GERD): responsiveness to change and English language validation. Pharmacoeconomics. 2007;25:385–396. 10. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoconomics. 1993;4:353–365. 11. Koopman C, Pelletier KR, Murray JF, et al. Stanford presenteeism scale: health status and employee productivity. J Occup Environ Med. 2002;44: 14–20. 12. Tang K, Beaton DE, Boonen A, Gignac MAM, Bombardier C. Measures of work disability and productivity: Rheumatoid Arthritis Specific Work Productivity Survey (WPS-RA), Workplace Activity Limitations Scale (WALS), Work Instability Scale for Rheumatoid Arthritis (RA-WIS), Work Limitations Questionnaire (WLQ), and Work Productivity and Activity Impairment Questionnaire (WPAI). Arthritis Care Res. 2011;63: S337–S349. http://dx.doi.org/10.1002/acr.20633. 13. Loeppke R, Hymel PA, Lofland JH, et al. Health-related workplace productivity measurement: general and migraine-specific recommendations from the ACOEM expert panel. J Occup Environ Med. 2003;45:349–359.

Journal of Voice, Vol. 28, No. 6, 2014 14. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, Newman CW. The voice handicap index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:66–70. 15. Willis GB. Cognitive interviewing: A tool for improving questionnaire design. Thousand Oaks, CA: Sage Publications, Inc.; 2005. 16. Yorkston KM, Baylor CR, Dietz J, Dudgeon BJ, Eadie T, Miller RM, Amtmann D. Developing a scale of communicative participation: a cognitive interviewing study. Disabil Rehabil. 2008;30:425–433. http://dx.doi. org/10.1080/09638280701625328. 17. Fowler FJ. Survey research methods. Thousand Oaks, CA: Sage Publications Inc.; 2009. 18. Blitzer A, Brin MF, Stewart CF. Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients. The Laryngoscope. 1998;108:1435–1441. http://dx.doi.org/ 10.1097/00005537-199810000-00003. 19. Ludlow CL. Treatment for spasmodic dysphonia: limitations of current approaches. Curr Opin Otolaryngol Head Neck Surg. 2009;17:160–165. http://dx.doi.org/10.1097/MOO.0b013e32832aef6f. 20. Baylor C, Yorkston K, Eadie T, Kim J, Chung H, Amtmann D. The communicative participation item bank (CPIB): item bank calibration and development of a disorder-generic short form. J Speech, Lang Hearing Res. 2013;56:1190–1208. http://dx.doi.org/10.1044/1092-4388(2012/120140). 21. Hogikyan ND, Sethuraman G. Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice. 1999;13:557–569. 22. Brooks A, Hagen SE, Sathyanarayanan S, Schultz AB, Edington DW. Presenteeism: critical issues. J Occup Environ Med. 2010;52:1055–1067. http://dx.doi.org/10.1097/JOM.0b013e3181f475cc.

Derek Isetti and Tanya Meyer

Presenteeism in Individuals With SD

APPENDIX

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4. During the past seven days, how many hours did you actually work?

Items on the Stanford Presenteeism Scale 6 _____HOURS (If ‘‘0,’’ skip to question 6.) 1. Because of my (health problem), the stresses of my job were much harder to handle. 2. Despite having my (health problem), I was able to finish hard tasks in my work. 3. My (health problem) distracted me from taking pleasure in my work. 4. I felt hopeless about finishing certain work tasks because of my (health problem). 5. At work, I was able to focus on achieving my goals, despite my (health problem) 6. Despite having my (health problem), I felt energetic enough to complete all my work.

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5. During the past seven days, how much did your PROBLEM affect your productivity while you were working? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

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Notes: The five response options are as follows: 1, I strongly disagree with the statement; 2, I somewhat disagree with the statement; 3, I am uncertain about my agreement with the statement; 4, I somewhat agree with the statement; and 5, I strongly agree with the statement.

Work Productivity and Activity Impairment Questionnaire: Specific Health Problem V2.0 (WPAI:SHP) The following questions ask about the effect of your PROBLEM on your ability to work and perform regular activities. Please fill in the blanks or circle a number, as indicated. 1. Are you currently employed (working for pay)? _____ NO ___ YES If NO, check ‘‘NO’’ and skip to question 6. The next questions are about the past seven days, not including today. 2. During the past seven days, how many hours did you miss from work because of problems associated with your PROBLEM? Include hours you missed on sick days, times you went in late, left early, etc., because of your PROBLEM. Do not include time you missed to participate in this study. _____ HOURS

Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual. If PROBLEM affected your work only a little, choose a low number. Choose a high number if PROBLEM affected your work a great deal. Consider only how much your PROBLEM affected productivity while you were working.

PROBLEM PROBLEM had no effect on 0 1 2 3 4 5 6 7 8 9 10 completely prevented me my work from working

CIRCLE A NUMBER. 6. During the past seven days, how much did your PROBLEM affect your ability to do your regular daily activities, other than work at a job? By regular activities, we mean the usual activities you do, such as work around the house, shopping, childcare, exercising, studying, etc. Think about times you were limited in the amount or kind of activities you could do and times you accomplished less than you would like. If your PROBLEM affected your activities only a little, choose a low number. Choose a high number if your PROBLEM affected your activities a great deal. Consider only how much your PROBLEM affected your ability to do your regular daily activities, other than work at a job. PROBLEM PROBLEM had no effect on 0 1 2 3 4 5 6 7 8 9 10 completely prevented me my daily from doing my activities daily activities

3. During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study? _____HOURS

CIRCLE A NUMBER. WPAI:SHP V2.0 (US English)

710 Voice-Related Statements Added by Researchers Time 1. It takes me longer to accomplish tasks at work because of my voice 2. My conversations at my job are shorter than I would like* 3. I put off making or answering phone calls at worky Quality 4. I do not function at my typical performance level at work because of my voice 5. The quality of the work that I do is diminished because of my voice Quantity 6. The amount of work that I produce is diminished because of my voice 7. The amount of speaking that I do at work is diminished* Personal factors (social, mental, physical, and emotional) 8. I feel that others at my job are distracted by how I sound*y 9. I have difficulty concentrating on my work because of my voice 10. I experience fatigue at work because of the extra effort that it takes to talk*y 11. I experience discomfort or pain due to my voice which affects my work* 12. I do not speak up as often as I would like at worky 13. I do not volunteer for certain tasks at work because of my voice* 14. I have been excluded or bypassed from opportunities at work due to my voice*

Journal of Voice, Vol. 28, No. 6, 2014

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Notes: The five response options used were as follows: 1, I strongly disagree with the statement; 2, I somewhat disagree with the statement; 3, I am uncertain about my agreement with the statement; 4, I somewhat agree with the statement; and 5, I strongly agree with the statement. *A statement based on qualitative data obtained from the study by Baylor et al (2005). yA statement derived from the Voice Handicap Index but modified for work.

Workplace productivity and voice disorders: a cognitive interviewing study on presenteeism in individuals with spasmodic dysphonia.

The objective of this study was to obtain initial reactions and suggested modifications to two existing presenteeism scales: the Stanford Presenteeism...
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