{"id":6746,"date":"2019-12-13T14:42:00","date_gmt":"2019-12-13T20:42:00","guid":{"rendered":"http:\/\/thesportjournal.org\/?p=6746"},"modified":"2019-11-27T08:36:50","modified_gmt":"2019-11-27T14:36:50","slug":"voice-health-in-pre-service-physical-education-majors-a-pilot-study","status":"publish","type":"post","link":"https:\/\/thesportjournal.org\/article\/voice-health-in-pre-service-physical-education-majors-a-pilot-study\/","title":{"rendered":"Voice Health in Pre-Service Physical Education Majors: A Pilot Study"},"content":{"rendered":"\n

Authors:<\/strong> Marty Marra, Ed. D., Kellyn Hall, Ph. D., and Fred J. Cromartie, Ed. D.<\/p>\n\n\n\n

Corresponding Author: <\/strong>
Dr. Marty Marra
Longwood University
201 High Street
Farmville, VA 23909
marraml@longwood.edu<\/a>
434-395-2935<\/p>\n\n\n\n

Dr. Marty Marra is an Assistant\nProfessor of Health and Physical Education at Longwood University in Farmville,\nVA. Dr. Marra has been involved in education for 33 years and continues to\nresearch and study in the areas of pedagogy, professionalism, current trends\nand gender equity issues in health, physical education and athletics.<\/p>\n\n\n\n

Kellyn Hall, Ph.D. CCC\/SLP is a clinician, researcher, teacher, and author with over 30 years\u2019 experience working in a variety of medical settings.\u00a0 She is currently an Associate Professor in the Communication Sciences and Disorders program at North Carolina Central University where she teaches medical speech-language pathology courses. Her clinical interests are in adult and pediatric voice disorders.<\/p>\n\n\n\n

Dr. Fred J.\nCromartie, is the Director of Doctoral Studies at the United States Sports\nAcademy. <\/p>\n\n\n\n

Voice Health in Pre-Service Physical Education Majors: A Pilot Study<\/h3>\n\n\n\n

ABSTRACT<\/strong><\/p>\n\n\n\n

Teachers are at a higher risk for\nphono-traumatic voice disorders due to increased vocal demands of their\nprofession. Previous studies suggest that training modules may be effective in\neducating practicing teachers about vocal hygiene and vocally abusive\nbehaviors.<\/p>\n\n\n\n

The purpose of this study was to\npilot an online training module targeting student teachers before they entered\ntheir teaching professions. The goals were to provide instruction about vocal\nhygiene, strategies for optimal voice production, and determine the\neffectiveness of the training in their vocal practices in their future careers.\nIt was hypothesized that an online educational module will increase\nundergraduate students\u2019 knowledge of vocal hygiene, thereby reducing their risk\nof developing voice disorders in the future.<\/p>\n\n\n\n\n\n\n\n

Key words:  <\/strong>vocal hygiene, pre-service teachers, physical education teachers, voice health, Phono-traumatic voice disorders, vocal abusive behaviors<\/p>\n\n\n\n

INTRODUCTION<\/strong><\/p>\n\n\n\n

The prevalence of\nvoice disorders is high among professions where vocal use is demanding\n(14).  Teachers are professional voice\nusers; they depend on a consistent and effective voice quality for their work.\nIf voice problems develop, then the ability to perform their job is threatened\n(13, 15). Vocal\ndysfunction may lead to periods of sick leave and the need for vocal\nrehabilitation involving great financial costs (17, 18). The\netiology of the voice problems in teachers is linked not only to the high\ndemands for vocal use, but also for the environment in which the voice (19).\nTeachers, especially physical education teachers, need to speak loudly for\nprolonged periods of time often against competing background noise such as in\nthe gymnasium or an outside space.  It is\nnot surprising that the incidence of voice disorders among teachers and student\nteachers is estimated to be as high as 38% with more than half of teachers\nreporting that they have experienced voice problems during their careers (14).\nThese problems range from mild throat discomfort, vocal fatigue, hoarseness, to\nthe complete loss of voice (10).  Voice\nproblems ultimately can affect the ability to work. More than 40% of teachers\nreport that they reduce or alter their teaching activities and were absent from\nwork for at least one day in the previous year due to their voice problem (13).<\/p>\n\n\n\n

The consequences of voice problems for teachers vary\ndepending on the etiology, severity, and frequency of the voice problems\n(10).  For example, teachers who suffer\nvocal inflammation due to repeated vocal trauma associated with loud talking\n(e.g. phono-trauma), may recover after a period of vocal rest. However,\nrepeated phono-trauma can lead to lasting vocal cord tissue changes resulting\nin persistent hoarseness, vocal weakness, and reduced loudness (7). One common\ntype of vocal tissue change is vocal nodules or \u201csinger\u2019s nodes\u201d. These are benign growths, similar\nto callouses, that develop on the vocal cords as a result of vocal abuse,\nmisuse, and overuse (12). Chronic or fibrotic vocal nodules often require\nsurgical removal and thus threaten the professional voice users\u2019 livelihood.\nThe impact of voice disorders is most often seen in professional singers. For\nexample, Julie Andrews, who is world famous for vocal performances in movies\nand theatre, lost her singing voice after surgery on her vocal cords to remove\nnodules. Following surgery in 1997, Andrews was no longer able to perform and\nher professional career as a singer was over (12).  In the same vain, a teacher who has chronic\nvoice problems will eventually suffer a loss in the ability to effectively\nperform his\/her job and may need to consider leaving the field (8). This was\ntrue for the first author, who chronically battled vocal hoarseness and periods\nof aphonia (complete loss of voice) throughout her career as a physical\neducation teacher in the schools. <\/p>\n\n\n\n

Given that not all teachers suffer voice problems,\nindividual factors associated with the development of voice disorders have been\nresearched to help determine who is at greatest risk (5).   Poor \u2018vocal hygiene\u2019 habits\nare etiologically linked with voice disorders (3).  Specifically, reduced water consumption\n(hydration), lack of sleep, over use of caffeine, exposure to vocal irritants\n(i.e. smoking, inhaling chemicals etc.), and engaging in other vocally\ntraumatic behaviors (i.e. excessive throat clearing and coughing) have also\nbeen found to contribute to voice problems in teachers (7). Gender differences\nexist as well. Female teachers are more likely than men to suffer voice\nproblems (5). The gender differences are believed to be related to hormonal and\nanatomical differences in the underlying vocal cord tissue in males compared to\nfemales (4, 5). Other variables associated with voice problems are age, and\nyears of work in the field. Roy and colleagues (13) found that female teachers\nbetween 40-59 years of age who had been teaching 16 or more years were at risk\nfor developing voice problems. <\/p>\n\n\n\n

In light of these findings, and given the vocal demands of physical education teachers, it is not surprising female physical education teachers tend to have voice changes sooner than classroom teacher (11). Roy and colleagues found an increase in voice issues among female physical education teacher after teaching for as few as five years (13). Voice changes included difficulty reaching high and low notes when singing, lower voice tones in general conversation and a tendency to speak loudly in other, non-teaching environments. Many females who have taught more than 16 years tended to have male characteristics in their voice tones because of excessive use, overuse, or improper use of their voices due to teaching (14).<\/p>\n\n\n\n

Teaching may be viewed as an occupational hazard for\nthe development of voice disorders, particularly in female physical education\nmajors.  Simberg et al. (16) stated that\nvoice disorders in teachers are preventable and advocated for vocal disorder prevention\nprograms need to be developed. Unfortunately, training in vocal hygiene and\ntechniques for voice use are often missing from teacher training (16). Physical\neducation teachers report limited exposure to proper vocal hygiene training or\nspecific instruction on how to prevent voice problems (2). Previous research\nsuggests that vocal hygiene training has a positive effect in high risk\npopulations such as teachers (20). However, Roy et al. (13) found that teachers\nare reluctant to take time off work for medical appointments and they also show\nconcern that doctors may advise them to reduce voice use at work, switch\noccupations, or stop teaching altogether. Vilkman (19) interpreted these\nfindings to mean that teachers accept voice disorders as an occupational hazard\nand may be unaware of available resources to treat or eliminate them. Aiken and\nRumbach (2) found that when physical education instructors were exposed to\nvocal training, it was often described as brief, uninteresting, and irrelevant\nto their specialized profession. Much of the lack of vocal education was\nattributed to apathetic attitudes toward voice use and vocal hygiene from\nmanagement staff. As a result, physical education instructors often felt\npressured to work despite vocal problems because vocal hygiene practices were\nnot prioritized in the industry (2).<\/p>\n\n\n\n

With adequate training and instruction, it is possible\nfor voice problems in teachers, especially physical education teachers, to be\navoided. Voice therapy programs typically target individual and group therapy\nof current teachers (20). Voice disorders prevention training geared toward the\nstudent physical education teacher population may help future teachers avoid\nvoice problems prior to the start of their careers. It would be difficult,\nhowever, to provide weekly individual and\/or group face-to-face training for\nstudent teachers who are scattered among different placement sites. An online\ntraining program may be an efficient and effective way to achieve the same\ngoals. The training program would need to be geared toward teachers\u2019 interests,\neasy to access, brief, and interesting. A multifaceted controlled study is\nneeded to determine the effectiveness of online education\/training in voice\ndisorders prevention and the long-term effects of the training on voice\ndisorders prevention.<\/p>\n\n\n\n

The purpose of this pilot study was to determine the effectiveness of an online vocal hygiene training module for physical education majors at high risk for developing voice disorders. The goals were to provide instruction about vocal hygiene, strategies for optimal voice production, and determine the effectiveness of the training in promoting healthy vocal practices. This study is part of a longitudinal investigation of an online vocal training program for the prevention of voice disorders in physical education teachers who are at high risk for developing voice problems. Results may lend support to the need and benefit of early voice education and training in the physical education major curriculum.<\/p>\n\n\n\n

METHODS<\/strong><\/strong><\/p>\n\n\n\n

Participants<\/strong><\/strong><\/p>\n\n\n\n

Undergraduate physical education majors were invited to participate in this study through announcements made in classes and a mass email sent to all physical education student teachers at Longwood University.  Five participants met the following inclusion criteria: held senior status, enrolled in intern teaching experience (HPEP 482), reported no history of smoking, respiratory allergies or asthma, reported voice problems in the past, and provided informed consent. The participants consisted of 3 male students and 2 female students. The participants mean age was 23.5 (range: 22 \u2013 25 years of age). <\/p>\n\n\n\n

Materials\/Measurements:<\/strong><\/strong><\/p>\n\n\n\n

Perceptual and\ninstrumental measures of voice quality were obtained.  The perceptual evaluation was performed using\nthe Consensus Auditory-Perceptual Evaluation of Voice (6). The CAPE-V uses a visual\nanalog scale (VAS) for ratings of\noverall voice disorder from 0 (normal) to 100 (severe).  Acoustic measurements of\nvoice were made using OperaVox\u00ae<\/sup>, a software system used to analyze\nfrequency, jitter, shimmer, and noise-to-harmonics ratio (NHR) by an iPad’s internal microphone with sampling\nrate of 45 kHz. Frequency is the number of times the\nvocal cords vibrate each second measured in Hertz (Hz). Shimmer (measured in\ndecibels or dB%) and jitter (measured in dB%) are vocal perturbation measures\nof the cycle-to-cycle variability in amplitude (shimmer) the acoustic waveform.\nHigh perturbation measures (greater than 1%) are correlated with vocal\nhoarseness (9). A 5 second voice sample was recorded of each participation\nsustaining a mid-vowel \/\u0251\/ as in the word \u2018hot\u2019.  Recordings were made in a sound-reduced booth\nwith the microphone-to-mouth distance held constant at 30 cm.  The middle 1-second of each sample was selected\nfor acoustic analysis.  <\/p>\n\n\n\n

A \u201cVocal Hygiene Training\u201d module was embedded into the\nlearning management system (Canvas) of the course HPEP 482. Within the module,\nwritten material and a 15-minute instructional video created for this study\nusing PowToons\u00ae<\/sup> were embedded. The written material addressed\ngeneral knowledge about voice disorders in teachers and coaches as well as\nvoice therapy\/prevention strategies. The video provided general education on\nvoice production, vocal hygiene strategies, and voice therapy and prevention\nstrategies. Vocal hygiene and consequences of poor vocal health (i.e. smoking,\nvocal abuses, dehydration, alcohol, and caffeine effects on the voice) and\nenvironmental factors specific to physical educators (i.e. talking against\nbackground noise and\/or in reverberating environments) were emphasized.  Vocal training education included breath\nsupport, reduced vocal tension, vocal warm up, and vocal projection strategies.\nPre-training and post-training tests were also embedded in the module. The 15\nitem pre-training test assessed the prior knowledge regarding topics covered\nwritten material and the video. This test was repeated at the conclusion of the\nstudy (i.e. post-training test) as an estimate of post-training learning of the\nmaterial presented in the module. Finally, pre- and post-training\nquestionnaires surveyed participants daily vocal habits, vocal abuses,\nperceived changes in voice quality, use of vocal hygiene, and application of\nvocal techniques\/vocal hygiene strategies. <\/p>\n\n\n\n

Procedures<\/strong><\/strong><\/p>\n\n\n\n

All participants were seen individually at the Longwood University Speech and Hearing clinic one week prior to the start of their spring semester student internship. After obtaining informed consent, the pre-training questionnaire and voice recordings were taken. Next, students accessed the online training module in Canvas during their first week of internship. The participants completed the pre-training test and then proceeded to view the modules materials and video. The first author made follow-up weekly contact with the students through announcements and email to encourage them to implement the strategies they learned in the vocal hygiene training module. After 10 weeks, participants returned to the clinic for the post-training voice recordings, CAPE-V, and to complete the post-training questionnaire. At this time they also completed the online post-training test. This study is ongoing; therefore statistical analysis of group data were not performed due to the low sample size. Descriptive statistics were used to provide a preliminary snapshot of the feasibility of using an online training module embedded in students\u2019 internship course as an easy and effective method of improving vocal health of student teachers of physical education.<\/p>\n\n\n\n

RESULTS AND DISCUSSION<\/strong><\/strong><\/p>\n\n\n\n

The results of the pre- and post-training tests are\npresented in Table 1. Overall there was a 36% increase in identification of\nfactors that negatively affect voice after participating the online training\nmodule (pre-test = 36%; post-test=100%). Knowledge of factors that negatively\naffect the voice increased 34% (pre-test=32%, post-test=92%). Awareness of\nstrategies to improve the voice increased from 8% to 80%.  At the post training, the overall test score\naverage improved from 10\/15 (66%) to 14\/15 (93%). These data show that\nparticipants\u2019 knowledge regarding voice issues improved as a result of the training\nmodule suggesting that participants learned and retained the information.<\/p>\n\n\n\nTable 1:<\/strong> Percentage of Pre- and Post- Test Scores for Three Content Areas\n\n\n \n \n \n \n \n
 <\/td>\n Pre-Training<\/td>\n Post-Training<\/td>\n <\/tr>\n
Knowledge of Vocal Hygiene (5 items)<\/td>\n 36 %<\/td>\n 100%<\/td>\n <\/tr>\n
Knowledge of Factors Negatively Affecting Voice (5 items)<\/td>\n 32%<\/td>\n 92%<\/td>\n <\/tr>\n
Vocal Strategies (5 items)<\/td>\n 8%<\/td>\n 80%<\/td>\n <\/tr>\n
Total Test Score<\/td>\n 53%<\/td>\n 80%<\/td>\n <\/tr>\n<\/tbody>\n<\/table>\n\n\n\n

The results of the pre- and post-training acoustic\nmeasures are presented in Table 2. For all of the acoustic measures, the values\ndecreased suggesting a positive trend in voice quality. At the pre-training\ntesting, participants\u2019 voices were ratings on the CAPE-V ranged from mildly to\nmoderately dysphonic (scores between 10\/100 \u2013 30\/100). Following the training\nand at the end of their student teaching experience, these ratings decreased to\nthe normal to mild range (0\/10 to 10\/100). \n<\/p>\n\n\n\nTable 2:<\/strong> Acoustic Measures for Fundamental Frequency (Fo), Jitter, Shimmer, and CAPE-V Ratings for Pre- and Post-Training\n\n\n \n \n \n \n \n \n \n
Participant<\/td>\n Fo Hz<\/td>\n Jitter %<\/td>\n Shimmer %<\/td>\n Cape-V Rating<\/td>\n <\/tr>\n
1<\/td>\n Pre-
\n Post-<\/td>\n 		212
\n 218<\/td>\n 		1.40
\n 0.89<\/td>\n 		8.18
\n 4.19<\/td>\n 		27\/100
\n 10\/100<\/td>\n <\/tr>\n
2<\/td>\n Pre-
\n Post-<\/td>\n 		195
\n 210<\/td>\n 		2.49
\n 0.78<\/td>\n 		8.59
\n 4.44<\/td>\n 		15\/100
\n 10\/100<\/td>\n <\/tr>\n
3<\/td>\n Pre-
\n Post-<\/td>\n 		222
\n 225<\/td>\n 		1.59
\n .089<\/td>\n 		8.12
\n 5.63<\/td>\n 		30\/100
\n 8\/100<\/td>\n <\/tr>\n
4<\/td>\n Pre-
\n Post-<\/td>\n 		200
\n 230<\/td>\n 		0.63
\n 0.77<\/td>\n 		5.37
\n 3.88<\/td>\n 		10\/100
\n 10\/100<\/td>\n <\/tr>\n
5*<\/td>\n Pre-
\n Post-<\/td>\n 		126
\n 130<\/td>\n 		2.01
\n 1.74<\/td>\n 		8.52
\n 3.88<\/td>\n 		10\/100
\n 10\/100<\/td>\n <\/tr>\n
Note: * denotes male participant.<\/td>\n <\/tr>\n<\/tbody>\n<\/table>\n\n\n\n

Date from the pre-and post-test questionnaire suggest that at the time of the pre-test, 17.4% did not recognize teachers as being at risk for vocal problems and 78.2% of participants felt that they had less than average knowledge of vocal hygiene. However, at the time of the post-test, 100% of participants reported awareness of voice issues related to teaching and strategies to avoid these problems. Furthermore, the participants reported that they considered vocal hygiene factors more often when they were preparing for teaching in the gymnasium or outside.  Participants were asked to rate the likelihood of implementing the vocal hygiene strategies in the future on a 5 point scale (0 = not likely; 5 = extremely likely). The average rating was 3.7 which is \u201cvery likely\u201d. <\/p>\n\n\n\n

Anecdotally the participants commented on their experiences in voice changes that they have had since entering their intern teaching experiences. Participants initially experienced voice-related symptoms such as hoarseness of voice, sore throats, vocal fatigue, and frequent throat clearing during their intern teaching experiences. Four of the five participants described their intentional behavioral changes during their teaching such as decreasing or altering communication during classes, using non-verbal physical cues, altering their pitch, and less \u201cthroat\u201d projection and more \u201cdiaphragm\u201d projection. The participants reported that previously they had experienced voice changes that impacted their performance in the gymnasium which they were now intentionally monitoring. <\/p>\n\n\n\n

CONCLUSION<\/strong><\/strong><\/p>\n\n\n\n

Overall, the participants were more cognizant of their own personal voice health and therefore, made intentional choices to execute the information learned in the methods classes as well as the module shared prior to their vocal testing. These findings suggest that physical educators should advocate for services that address the specific needs and requirements of those entering the teaching profession. Using a microphone necklace in the gymnasium and a megaphone when outside, may help to preserve vocal health. However, when not available, correct vocal techniques and recognition of early vocal strain and ways to avoid are also a necessary part of the physical education curriculum. Clear directives for the content and delivery of proper intervention strategies tailored to this specific population and their vocal health should be explored. <\/p>\n\n\n\n

APPLICATION\nIN SPORT<\/strong><\/strong><\/p>\n\n\n\n

In the future, teaching prospective Physical Educators\nhow to project their voices in a proper manner is imperative in the methods courses\nof all universities. Teaching how to blow the whistle appropriately and using\nthe diaphragm to project when speaking are as important as learning how to\nteach skills properly to PK\u201312 students. Every methods course should include\nvoice health practices and management techniques, including non-verbal actions.\nMethods courses must also teach future Physical Educators to utilize whistles,\nmusic, and other modes of management signals in an appropriate and effective\nway instead of only their voices. This profession is considered high risk for\nvoice-related disorders. By increasing awareness about healthy voice behavior\nin the teaching profession, teachers will improve their quality of work and\nminimize any permanent impairments and\/or disabilities to their voice which\nultimately may impact their livelihood.<\/p>\n\n\n\n

ACKNOWLEDGMENTS<\/strong><\/p>\n\n\n\n

The authors would like to thank the following Longwood University Communication Disorders graduate students in their assistance in this research project: Stephanie Fields, Lauren McGonagle, Anna Powers, Hunter Reese, Seraphina Chabinec, Leah Horton, and Jayln Taylor.<\/p>\n\n\n\n

REFERENCES<\/strong> <\/p>\n\n\n\n

  1. \u00c5hlander, V. L., Rydell, R., & L\u00f6fqvist, A. (2011). Speaker’s comfort in teaching environments: Voice problems in Swedish teaching staff. Journal of Voice<\/em>, 25<\/em>(4), 430-440.<\/li>
  2. Aiken, P. J. & Rumback A.F.  (2018). Keeping the voice fit in the group fitness industry: A qualitative study to determine what instructors want in a voice education program. Journal of Voice, 32<\/em>(2), 256-267. https:\/\/doi.org\/10.1016\/j.jvoice.2017.04.014<\/a><\/li>
  3. de Medeiros, A. M., Barreto, S. M., & Assun\u00e7\u00e3o, A. \u00c1. (2008). Voice disorders (dysphonia) in public school female teachers working in Belo Horizonte: Prevalence and associated factors. Journal of Voice<\/em>, 22<\/em>(6), 676-687.  <\/li>
  4. Gray, S. D., & Thibeault, S. L. (2002). Diversity in voice characteristics\u2014Interaction between genes and environment, use of microarray analysis. Journal of Communication Disorders<\/em>, 35<\/em>(4), 347-354.  <\/li>
  5. Hunter, E. J., Smith, M. E., & Tanner, K. (2011). Gender differences affecting vocal health of women in vocally demanding careers. Logoped Phoniatr Vocol<\/em>. Online publication. doi:10.3109\/14015439.2011.587447 <\/li>
  6. Kempster, G. B., Gerratt, B. R., Verdolini-Abbott, K., Barkmeier-Kraemer, J., & Hillman, R. E. (2009). Consensus auditory-perceptual evaluation of voice: Development of a standardized clinical protocol. American Journal of Speech-Language Pathology, 18,<\/em> 124-132.<\/li>
  7. Kooijman, P. G., De Jong, F. I. C. R. S., Thomas, G., Huinck, W., Donders, R., Graamans, K., & Schutte, H. K. (2006). Risk factors for voice problems in teachers. Folia Phoniatrica et Logopaedica<\/em>, 58<\/em>(3), 159-174. <\/li>
  8. Lee, S. Y. Y., Lao, X. Q., & Yu, I. T. S. (2010). A cross-sectional survey of voice disorders among primary school teachers in Hong Kong. Journal of Occupational Health<\/em>, 52<\/em>, 344\u2013352.  <\/li>
  9. Martin, D., Fitch, J., & Wolfe, V. (1995). Pathologic voice type and the acoustic prediction of severity. Journal of Speech and Hearing Research, 38<\/em>(4):765\u2013771.<\/li>
  10. Martins, R. H., Pereia, E. R., Hidalgo, C., & Tavares, E. (2014). Voice disorders in teachers. A review. Journal of Voice, 28<\/em>(6), 716-724.<\/li>
  11. Morton, V. & Watson, D. (2001). Voice in the classroom: A re-evaluation in P.H. Dejonckere Occupational voice: care and cure. Kluger Publications: The Netherlands. P. 53-69.  <\/li>
  12. Moyer, J. W. (2015). How Julie Andrews\u2019s voice was stolen by a medical disaster. The Washington Post<\/em>. Retrieved September 12, 2018, from https:\/\/www.washingtonpost.com\/<\/a>news\/morning-mix\/wp\/2015\/03\/19\/how-julie-andrewss-voice-was-stolen-by-a-medical-disaster\/?noredirect=on&utm_term=.b134d9a92c66 <\/li>
  13. Roy, N., Merrill, R. M., Thibeault, S., Gray, S. D., & Smith, E. M. (2004). Voice disorders in teachers and the general population: Effects on work performance, attendance, and future career choices. Journal of Speech, Language, and Hearing Research, 47<\/em>(3), 542\u2013551. doi:10.1044\/1092-4388(2004\/042) <\/li>
  14. Roy, N., Merrill, R. M., Thibeault, S., Parsa, R. A., Gray, S. D., & Smith, E. M. (2004). Prevalence of voice disorders in teachers and the general population. Journal of Speech, Language, and Hearing Research, 47<\/em>(2), 281\u2013293. doi:10.1044\/1092-4388(2004\/023) <\/li>
  15. Sala, E., Laine, A., Simberg, S., Pentti, J., & Suonp\u00e4\u00e4, J. (2001). The prevalence of voice disorders among day care center teachers compared with nurses: A questionnaire and clinical study. Journal of Voice<\/em>, 15<\/em>(3), 413-423. <\/li>
  16. Simberg, S., & Ronnema, S. (2000). Prevalence of voice disorders among future teachers. Journal of Voice, 14<\/em>, 231-235.<\/li>
  17. Van Houtte, E., Claeys, S., Wuyts, F. & Van Lierde, K. (2011). The impact of voice disorders among teachers: Vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-related absenteeism. Journal of Voice<\/em>, 25, 570-575. https:\/\/doi.org\/10.1016\/j.jvoice.2010.04.008<\/a> <\/li>
  18. Vilkman, E. (1996). Occupational risk factors and voice disorders. Logopedics Phoniatrics Vocology<\/em>, 21<\/em>(3-4), 137-141. https:\/\/doi.org\/10.3109\/14015439609098881<\/a> <\/li>
  19. Vilkman, E. (2004). Occupational safety and health aspects of voice and speech professions. Folia Phoniatrica et Logopaedica<\/em>, 56<\/em>(4), 220-253. <\/li>
  20. Ziegler, Gillespie, & Verdonlini Abbott, K. (2010). Behavioral treatment of voice disorders in teachers. Folia Phoniatrica et Logopaedica, 62<\/em>, 9-23. https:\/\/doi-org.libproxy.uncg.edu\/10.1159\/000239059<\/a><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

    Authors: Marty Marra, Ed. D., Kellyn Hall, Ph. D., and […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"jetpack_publicize_message":"","jetpack_is_tweetstorm":false,"jetpack_publicize_feature_enabled":true,"jetpack_social_options":[]},"categories":[580],"tags":[1531,1535,1534,1536,1532,1533],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p4btio-1KO","jetpack-related-posts":[{"id":5225,"url":"https:\/\/thesportjournal.org\/article\/the-perceptions-of-male-and-female-athletic-administrators-towards-genderequity-in-faith-based-institutions\/","url_meta":{"origin":6746,"position":0},"title":"The Perceptions of Male and Female Athletic Administrators Towards Gender\\Equity in Faith-Based Institutions","date":"August 24, 2017","format":false,"excerpt":"Authors: Martha Marra, Ed. D. Corresponding Author: DR. MARTY MARRA LONGWOOD UNIVERSITY 201 HIGH STREET FARMVILLE, VA 23909 marraml@longwood.edu 434-395-2935 Dr. Marty Marra is an Assistant Professor of Health and Physical Education at Longwood University in Farmville, VA. Dr. Marra has been involved in education for 30 years and continues\u2026","rel":"","context":"In "Commentary"","img":{"alt_text":"Table 3","src":"https:\/\/i0.wp.com\/thesportjournal.org\/wp-content\/uploads\/2017\/08\/Table3.jpg?resize=350%2C200","width":350,"height":200},"classes":[]},{"id":4004,"url":"https:\/\/thesportjournal.org\/article\/a-comparison-study-of-the-perceptions-of-athletic-administrators-towards-gender-equity-in-the-cccu-and-ncccu-schools\/","url_meta":{"origin":6746,"position":1},"title":"A Comparison Study of the Perceptions of Athletic Administrators towards Gender Equity in the CCCU and NCCCU Schools","date":"September 29, 2016","format":false,"excerpt":"Authors: Martha L. Marra Affiliations: Cornerstone University Corresponding Author: Martha L. Marra Cornerstone University 4627 Ramswood Dr. NE. Grand Rapids, MI 49525 martym7302@att.net 616-560-8653 Dr. Marty Marra is an Associate Professor of Kinesiology at Cornerstone University in Grand Rapids, MI. Dr. Marra has been involved in education for nearly 30\u2026","rel":"","context":"In "Sports Management"","img":{"alt_text":"Gender Equity - Table 3","src":"https:\/\/i0.wp.com\/thesportjournal.org\/wp-content\/uploads\/2016\/09\/GenderEquity-Table3.jpg?resize=350%2C200","width":350,"height":200},"classes":[]},{"id":2322,"url":"https:\/\/thesportjournal.org\/article\/teaching-coaching-the-challenges-and-conflicts-of-dual-roles\/","url_meta":{"origin":6746,"position":2},"title":"Teaching & Coaching: The Challenges and Conflicts of Dual Roles","date":"March 10, 2015","format":false,"excerpt":"Submitted by Dr. Christopher Saffici* 1* Department of Education, Florida Memorial University, Miami Gardens, Florida 33054 Dr. Saffici is an Associate Professor at Florida Memorial University in the field of Education, with a specialization in Physical Education. He serves as President Elect of the Faculty Senate. He has served as\u2026","rel":"","context":"In "Sport Education"","img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":66,"url":"https:\/\/thesportjournal.org\/article\/results-and-recommendations-of-the-world-summit-on-physical-education\/","url_meta":{"origin":6746,"position":3},"title":"Results and Recommendations of the World Summit on Physical Education","date":"February 13, 2008","format":false,"excerpt":"Document presented on behalf of the World Summit on Physical Education by the International Council of Sport Science and Physical Education for MINEPS III Introduction Over 250 delegates from 80 countries, representing governments, inter-governmental and non-governmental organizations (NGO), and academic institutions attended the World Summit on Physical Education (Berlin, November\u2026","rel":"","context":"In "Contemporary Sports Issues"","img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":8423,"url":"https:\/\/thesportjournal.org\/article\/understanding-high-school-females-perceptions-of-physical-education-through-attitude-theory\/","url_meta":{"origin":6746,"position":4},"title":"Understanding High School Females\u2019 Perceptions of Physical Education Through Attitude Theory","date":"December 9, 2022","format":false,"excerpt":"Authors: Heidi Miller Crone University of North Carolina Wilmington Corresponding Author: Heidi Miller Crone, Ed.D.6518 Trammel Dr.Dallas, TX, 75214croneheidi@gmail.com972-977-9990 Dr. Heidi Miller Crone is a physical education teacher and coach at the Hockaday School in Dallas, TX. Understanding High School Females\u2019 Perceptions of Physical Education Through Attitude Theory ABSTRACT Purpose:\u2026","rel":"","context":"In "Research"","img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":223,"url":"https:\/\/thesportjournal.org\/article\/are-physical-education-and-sports-teachers-in-turkey-trained-appropriately-a-study-of-basic-education-institutions\/","url_meta":{"origin":6746,"position":5},"title":"Are Physical Education and Sports Teachers in Turkey Trained Appropriately? : A Study of Basic Education Institutions","date":"January 5, 2006","format":false,"excerpt":"Submitted by: Hakan Sunay, Ph.D. and Surhat Muniroglu, Ph.D. Abstract Teaching physical education and sports activities are among the indispensable occupations of our time. Sports, apart from being an occupation of entertainment and free time, have also a function that develop health and contributes joy and happiness to the participants\u2019\u2026","rel":"","context":"In "Contemporary Sports Issues"","img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]}],"_links":{"self":[{"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/posts\/6746"}],"collection":[{"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/comments?post=6746"}],"version-history":[{"count":6,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/posts\/6746\/revisions"}],"predecessor-version":[{"id":6754,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/posts\/6746\/revisions\/6754"}],"wp:attachment":[{"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/media?parent=6746"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/categories?post=6746"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/thesportjournal.org\/wp-json\/wp\/v2\/tags?post=6746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}