Journal of Psychosomatic Research 68 (2010) 379–384

Biopsychosocial impact of the voice in relation to the psychologicalfeatures in female student teachers

Leo F.P. Meulenbroeka,⁎, George Thomasb, Piet G.C. Kooijmanb, Felix I.C.R.S. de Jongc

aInstitute for Primary Teacher Education, Vocational University of Arnhem, Nijmegen, The NetherlandsbDepartment of ORL, Radboud University Medical Centre Nijmegen, The Netherlands

cUZ Leuven, Department of Oto, Rhino, Laryngology, Head and Neck, Leuven, Belgium

Received 20 June 2009; received in revised form 24 September 2009; accepted 1 October 2009

Abstract

Objective: The aim of the study was to assess biopsychosocialimpact of the voice in relation to the psychological features infemale student teachers. Methods: This research was a cross-sectional study in 755 student teachers using general question-naires, the Voice Handicap Inventory (VHI), Type D Scale-16,Symptom Check List (SCL-90), and Utrecht Coping List (UCL).Student teachers with a relative high score on the VHI (N75thpercentile) and students with a relative low score (b25thpercentile) were compared. Results: Type D student teachershad a 4× greater risk of a high VHI-score (OR 4.23) than the non-type-D group. The student teachers with relative high VHI scoresscored significantly higher (Pb.001) on the SCL-90 total and allsubscales, compared to the student teachers with relative low VHIscores. Furthermore, the students with a relative high VHI score

⁎ Corresponding author. PABO Arnhem, Hogeschool van Arnhem,Nijmegen, Ruitenberglaan 27, 6826 CC Arnhem. Tel.: +31 26 3691653.

E-mail addresses: L.Meulenbroek@12move.nl,Leo.Meulenbroek@han.nl (L.F.P. Meulenbroek).

0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.jpsychores.2009.10.002

had significant high scores on the subscales passive attitude(Pb.001), palliative reactions (Pb.001), avoidance and a waitingattitude (Pb.001), and expression of emotions (P=.003) of theUCL. Conclusion: This study showed that a relative highbiopsychosocial impact of the voice is related to the personalitytrait Type D, psychosomatic well-being and coping strategies infemale student teachers. These features should be implemented inscreening and training programs for students for a voicedemanding profession. The students have to be prepared to copewith psychological, physical and vocal demands of the teachingprofession. The speech therapist (of the vocational university) hasto be aware of an important role in coaching the students into amore active coping attitude.© 2010 Elsevier Inc. All rights reserved.

Keywords: Biopsychosocial impact of the voice; Coping; Psychological aspects; Psychosomatic well-being; Student teachers; Type D

Introduction

Various studies showed that teachers are more at risk forvoice problems than other voice professionals, e.g., singers,social workers, lawyers, and clergymen [1–4]. Absenteeismin teachers due to voice problems was found to be abouttwice as often compared to other vocally demandingprofessions [5–7]. Female teachers had significantly more,acute, and chronic voice problems compared to their malecounterpart [3,5,8]. Voice disorders in general and occupa-

tional voice disorders in particular had been observed tooccur more frequently and to a larger degree in women thanin men [3,5,6].

Simberg et al. [9] indicated that the size of the class, noisyor misbehaving pupils could explain the increase of stress,vocal symptoms and voice disorders among teachers. Voiceproblems among teachers apparently had an influence onsick-leave, psychological distress, and the quality of life[1,5,10–14]. The voice problems were found to affect job-performance and daily and social communication and isrelated to the quality of life [11,13].

Personal, emotional, and economical consequences ofvoice problems were also seen to have a negative impact onthe effectiveness of the teacher itself [7,8]. Effect ofdysphonic teachers' voice on children's speech processing

380 L.F.P. Meulenbroek et al. / Journal of Psychosomatic Research 68 (2010) 379–384

has been shown by Rogerson et al. [15] and Morton et al.[16]: the children recalled words poorly in response tofemale teacher with a dysphonic voice compared to teacherswith a normal voice. The voice problems depended merelyon the individual perception, reactions and adjustments tothe voice problem [13]. Limitation of activity and therestriction in participation were observed to be influenced byenvironmental and personal factors [12] and also bypersonality traits and psychological factors: the voice reflectsthe emotional status of the speaker. [5,10,17–24]. Vanhoudtet al. [25] showed that teachers with a high biopsychosocialimpact of the voice had a greater relative risk of a high scoreon the total SCL-90 and all the subscales, measuringpsychosomatic well-being.

Kooijman et al. [17] showed that more voice complaintsare reported earlier during the teaching career. More than12% of the teachers had experienced voice problems duringtheir education and they reported more voice complaintsand absence of work during their professional career [5].The prevalence of voice problems during education cantherefore been seen as a risk for getting voice problemsduring the career. Simberg et al. showed that universitystudents in general, report frequently occurring vocalsymptoms [26], but 20% of the students studying tobecome teachers in comprehensive schools reported moreand severe vocal symptoms and 19% had organic voicelesions [14]. This is an indication that student teachers aremore at risk for developing vocal symptoms later in theprofessional career. The pertinent study, part of a largerstudy on the causes and consequences of voice problems instudent teachers, aims to assess the biopsychosocial impactof the voice in students teachers.

In a recent study Thomas et al. [27] reported that 17% ofthe student-teachers who did not report a voice complainthad a relative high Voice Handicap Index (VHI) score. Thismight indicate that they are not fully aware of their vocalsituation in daily situations. Furthermore, Kooijman et al.[17] found that student teachers tended to underestimate thevoice demands of the future profession.

The aim of this study was to investigate psychologicalaspects personality traits, psychosomatic well-being andcoping behaviour in relation to the biopsychosocial impact ofthe voice in female student teachers.

This study is part of a project on the cause andconsequences of voice problems in student teachers, at theVocational University of Arnhem/Nijmegen.

Methods

Among all starting student teachers of the VocationalUniversities of Arnhem (n=778) and Deventer (n=181) inthe Netherlands 959 questionnaires were distributed in theperiod 2005–2007. The aim and the background of thestudy was explained to the students. The students (17.72%male and 82.28% female) filled out a mandatory question-

naire in the classrooms in the presence of an universityteacher. The questionnaires were individually returned.

The male students (n=170) were excluded in this studybecause they may respond differently to voice problems thanfemales [5]. Thirty-four questionnaires were not filled incompletely and therefore were not suitable for analysis. Intotal, 755 questionnaires were useful for analysis.

The questionnaires contained a general questionnaire withenclosed questions about many aspects of voice and voiceproblems in relation to vocal load, physical, environmentaland psychological aspects. Furthermore, the VHI, Type DScale-16 (DS16), Symptom Check List (SCL-90) and theUtrecht Coping List (UCL) were part of the questionnaire.

The Dutch version of the VHI according to Jacobson et al.[28] was used for rating the subjective biopsychosocialconsequences caused by voice problems [29]. It consists of30 questions in total. The questions regard emotional, physicaland functional subscales. The questions were rated accordingto a five-point scale: never (0), almost never (1), sometimes (2),almost always (3) and always (4). The total score is between 0and 120.

The Type D scale-16 (DS16) is a scale to measureNegative Affectivity (the tendency to experience negativeemotions) and Social Inhibition (the tendency to inhibit self-expression in social interaction) [30]. The list is a brief self-report measure an eight item negative affectivity and aneight item social inhibition scale. The subjects describedhow they felt and there were no right or wrong answers. Theresponse was on a five-point scale [false (0), rather false (1),neutral (2) rather true (3) to true (4)]. Using this data a TypeD classification was made. The students with a high scoreon both negative affectivity and social inhibition, asdetermined by a median split, were classified as the TypeD-group. The type-D scale-16 is a practical and sound,reliable, and valid, tool to assess and identify type-Dpersonalities [18,30–32].

The Utrechtse Coping List (UCL). A questionnairemeasuring the coping behaviour at problems and accidents[33]. There are seven subscales: active attitude (ACT),palliative reactions (PAL), avoidance and a waiting attitude(AV-W), social contact (SOC), passive attitude (PAS),expression of emotions (EXP), reassuring thoughts (REAS).

The SCL-90 helps to evaluate a broad range ofpsychological problems and symptoms of psychopathology[34,35]. The subjects are investigated to measure psychoso-matic well-being with nine dimensions: anxiety (ANX),phobic anxiety (AGO), depression (DEP), somatization(SOM), insufficiency of thinking and acting (IN), interper-sonal sensitivity (SEN), hostility (HOS) and sleepingproblems (SLE). Some items are not to be arranged inprevious subscales and are therefore arranged in miscella-neous items (MISC). The subject indicates whether an itemfits the person in a five-point scale: not all (0), a little bit (1),moderately (2), quite a bit (3), and extremely (4).

From the total population two groups of student teacherswere selected: with a relative high and low biopsychosocial

Table 1The voice handicap; median scores and the inter quartile range on the VHItotal compared to Type D

Median scoreVHI total

Interquartile range(minimum-maximum)

PPearsonChi-square

Non–Type D(n=551)

5 8 (0-49) b.001

Type D(n=192)

9 12 (0-78)

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impact of the voice, i.e., a group (n=186) with a relative highscore at the VHI (N75th percentile) and a group (n=167) withal relative low score (b25th percentile).

Statistical Analysis

The data was analyzed using the statistical program SPSS16.0. For discrete outcome variables Chi-square tests wereused. One-sample, two-tailed Kolmogorov-Smirnov tests (K-S) were applied in order to determine if continuous outcomevariables were normally distributed. For continuous outcomevariables that were not normally distributed, Mann-WhitneyU (M-W U) tests were used. The significance level was set atPb.05. Odds ratios (OR) were used to quantify thedependency in 2×2 tables.

Results

Subjects and selection of the groups

The total group consisted of 755 female students with amean age of 18.8 years (range 16-29 years).

The scores of the VHI (K-S: Pb.001), the SCL-90 (K-S:Pb.001), and the Utrecht Coping List (UCL) (K-S: Pb.05)were not normally distributed in the total population.

The median of the total VHI scores was 6 (lowest quartilescore was 2 and the upper quartile score was 12). The group ofstudent teachers with the relative highest voice handicap wasdetermined as having a VHI score N75th percentile, [i.e.,24.6% of the total population (n=186)]. Vice versa, the groupwith a relative low VHI score (b25th percentile) consisted of167 persons (22.1%).

The students with a high score on both negativeaffectivity and social inhibition, as determined by a mediansplit (5 and 11, respectively), were classified as the Type D-group. The group consisted of 554 non–type D (74.1 %) and194 Type D (25,9%).

Biopsychosocial impact of the voice in relation totype-D personality

The type-D students have a significant higher medianscore on the VHI total compared to the non-Type D group(Pb.001). See Table 1.

Significantly more students of the Type D group (76.5%,75/98) had a high VHI score (N75th pc), versus 23.5% (23/98) of the type-D group with a relative low VHI score (chisquare Pb.001). Type D student teachers had 4× greater riskto a high VHI-score (OR 4.23) than the group non Type Dstudent teachers. See Table 2.

Biopsychosocial impact of voice in relation to psychosomaticwell-being

The group students with a relative high VHI score(n=185) showed significant higher scores at the SCL-90 total

(Pb.001) and all subscales (Pb.001), compared to thestudents with a relative low VHI score (Table 3).

Biopsychosocial impact of voice in relation tocoping behaviour

The students with a high impact of voice (VHI N75thpercentile) showed higher scores on PAS (Passive Coping)(Pb.001), PAL (Pb.001) and VER (Avoidance and awaiting attitude) (Pb.001) at the Utrecht Coping List,compared to the group with a relative low biopsychosocialimpact of the voice (Table 4). Students with a relative highVHI score showed significant higher scores on EXP(P=.003). Although the median and IQR scores were thesame, the significance is supplied by the mean ranks. Thegroup with a relative low voice handicap showed a meanrank of 160 versus 191 by the students with a relative highimpact of the voice.

Discussion

Although the participants were very young (18.8 years),the impact of age in the VHI scores does not seem to berelevant since the VHI is an instrument that has proved to bereliable in identifying the degree of vocal handicapregardless age, gender or disease type [36–38]. Althoughthe results were in line with studies on professional teachersand standardized tests were used, the fact that participationwas mandatory might have influenced the results. Thestudents were aware that the test results would be used tocoach the student in the following periods. There might havebeen a danger that the participants tried to project what thespeech pathologist wanted to hear and what could result in apositive image of themselves.

Personality trait: Type D

Previous studies [30,31,39,40] showed personality sub-type Type D was associated with poor prognosis in healthstudies: coronary heart disease, post-traumatic stress syn-drome, depression, vital exhaustion, etc. There is a tendencyto see type-D as a significant predictor in health problems.Some studies showed [18,19] that Type D personalitiestended to underestimate or deny the consequences of theirvoice problem and tended to seek less voice care. Thomas

Table 2Cross-tabulation: relative risk of a higher VHI total score and a Type Dclassification

Voice HandicapIndex total

Type DPPearsonChi-square

OddsRatio (CI)

NoIn % (n)

YesIn % (n)

VHI pcN75 No 56.5%144/255

23.5%23/98

b.001 4.23(2.49-7.17)

Yes 43.5%111/255

76.5%75/98

95% confidence intervals (CI) are presented with the Odds Ratios.

Table 4The median (interquartile range) of student teachers with a relative highpsychosocial impact of voice (pcN75), versus students with a relative lowimpact of the voice (pcb25), on coping behaviour (UCL)

SubtestUCL

VHI, pcb25n=166

VHI, pcN75n=185

PM-W U

Median(IQR)

Median(IQR)

ACT 17 (7-25) 17 (7-27) .144PAL 16 (8-24) 17 (10-25) b.001AV-W 15 (8-24) 16 (11-26) b.001SOC 15 (6-23) 15 (7-24) .630PAS 9 (7-20) 11 (7-21) b.001EXP 6 (3-11) 6 (3-11) .003REAS 11 (5-19) 12 (5-20) .106

IQR, interquartile range.

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et al. [18] showed in female student teachers and femaleteachers for primary education, that the Type D group,despite having a relative high VHI score, did not alwaysreport voice complaints and were reluctant to seek voicecare. This pertinent study revealed that a significantly higherpercentage of student teachers (76.5%) of the type-D grouphad a relative higher VHI score (N75th pc) than the non-type-D group (23.5%). The difference is also reflected by theOdds Ratio (OR=4.23). A similar outcome was found byThomas et al. [18], although they mentioned a smallerpercentage (32.4%).

Psychosomatic well-being

Multidimensional factors, including the relationshipbetween mental and physical aspects, have been shown toplay an important role in human functioning. In Engel'sbiopsychosocial model psychosocial factors have beenproposed to cause indirectly a biological effect by predis-posing the patient to risk factors [41]. In the pertinent studyfemale student teachers with a relative high VHI score, showsignificantly high scores on the SCL-90 total and allsubscales compared to the group with relative low VHIscores. This is in accordance with findings of Vanhoudt et al.[25], Simberg et al. [9] and Mattiske et al. [42] who show

Table 3The median (inter quartile range, IQR) scores of the total SCL-90 and allsubscales of student teachers with a relative high bio psychosocial impact ofvoice (pc N75) (n=185), versus students with a relative low impact (pc b25)(n=166)

VHI pcN25median (IQR)

VHI pcb75median (IQR)

P-valuesMann-Whitney U.

ANX 11 (10-23) 14 (10-32) b.001AGO 7 (7-17) 8 (7-20) b.001DEP 18 (16-56) 22 (16-69) b.001SOM 15 (12-32) 19 (12-38) b.001IN 11 (9-24) 14 (9-35) b.001SEN 20 (18-55) 26 (18-59) b.001HOS 6 (6-16) 7 (6-22) b.001SLE 3 (3-13) 4 (3-14) b.001MISC 9 (9-27) 11 (9-26) b.001TOTAL 103 (90-219) 128 (92-302) b.001

TOTAL, total SCL score.

that biopsychosocial factors are involved with voiceproblems. Sapir et al. [43] also described that a significantnumber of teachers reported that their symptoms adverselyaffected their ability to teach effectively and that their voicewas a chronic source of stress or frustration.

As in this pertinent study the students were confrontedfor the first time with questions concerning their voice, thepossible awareness of voice problems may have been new.In this perspective the larger fear (ANX), but also gloomand DEP in the student teacher with a high VHI could beexplained in the consciousness to stand at the beginning ofa career as a “professional voice user”, where therestriction of the potentialities caused by a handicappedvoice, increases the stress. This seems to be in line withthe statement of Jacobson et al. [28] that young studentteachers are more unaware of the degree of severity oftheir voice problem until they completed the VHI. Anotherexplanation could be found in the relative high percentageof students belonging to the type-D group (40%) withinthe total group of students that score relative high at theVHI. De Fruijt et al. [32] showed that type-D subjectsreported more distress, anxiety and depression than non-type-D subjects.

Coping behaviour

This study is in line with previous studies amongteachers [44,45]. In the pertinent study the student teacherswith relative high VHI scores showed higher scores on allsubscales related to a passive coping style: a PAS, moreAV-W, more PAL and REAS. It was interesting to observesignificant higher scores by students with a relative highVHI score on the subscale EXP, that could be seen as anactive attitude.

Vice versa: It was to be expected that students with a lowVHI score (pcb25) showed a more active coping style. Theyshowed higher scores on active attitude which could be seenas a more active coping style. This can be important sincethey try harder to adjust personal disabilities (e.g., a voice

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problem) and restore competence. This might explain thelow scores on voice handicap.

Conclusions

This study indicated a relation between voice handicapand coping, psychosomatic well-being and Type D person-ality. The group with personality trait Type D showed higherscores on the VHI. Furthermore, a relative high voicehandicap in student teachers showed on the one hand passivecoping behavior and on the other hand more concerns inpsychosomatic well-being. This relation is in accordancewith other studies demonstrating psycho-emotional factorsto be one of the most important risk factors in developingvoice problems early in their career [46–48] and may beimportant in diagnosis, treatment and prevention of voiceproblems at the start of the Vocational University.

These findings support the need to change the vocalattitude of the students during the education period, in order toprepare them for a vocally demanding profession. Thestudents have to be prepared to cope with stress, workpressure and the physical and vocal demands of the teachingprofession. The speech therapist (of the vocational university)has to be aware of an important role in coaching the studentsinto a more active coping attitude and should make use of theexpertise of a psychologist. A multidisciplinary approach canbe important to coach and stimulate the student to talk abouthis voice handicap with professionals, fellow students,teachers and friends and to set a series of voice traininggoals for future trainee periods, during the education period.

This might help to implement a new vocal attitude into adeveloping occupational teaching style. Voice care shouldalso be combined with attention to psychological featureswith regard to personality traits. The speech therapist of theUniversity has to realize that the use of suitable tests andquestionnaires (VHI, DS16, SCL-90, and UCL) could bevaluable in multidimensional coaching and supervisingstudent teachers.

Future directions: suggestions for coaching programs(adequate coping, supervision in trainee settings andpsychological treatment) should be made, in order to assessand coach the starting student teachers properly and preparethem for an intensive future profession.

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