Performer’s Attitudes Toward Seeking Health Care for
Voice Issues: Understanding the Barriers
*Marina Gilman, †Albert L. Merati, *Adam M. Klein, *Edie R. Hapner, and *Michael M. Johns, * Atlanta, Georgia and
ySeattle, Washington
Summary: Contemporary commercial music (CCM) performers rely heavily on their voice, yet may not be aware of
the importance of proactive voice care. This investigation intends to identify perceptions and barriers to seeking voice
care among CCM artists. This cross-sectional observational study used a 10-item Likert-based response questionnaire to
assess current perceptions regarding voice care in a population of randomly selected participants of professional CCM
conference. Subjects (n ¼ 78) were queried regarding their likelihood to seek medical care for minor medical problems
and specifically problems with their voice. Additional questions investigated anxiety about seeking voice care from
a physician specialist, speech language pathologist, or voice coach; apprehension regarding findings of laryngeal examination, laryngeal imaging procedures; and the effect of medical insurance on the likelihood of seeking medical care.
Eighty-two percent of subjects reported that their voice was a critical part of their profession; 41% stated that they were
not likely to seek medical care for problems with their voice; and only 19% were reluctant to seek care for general medical problems (P < 0.001). Anxiety about seeking a clinician regarding their voice was not a deterrent. Most importantly,
39% of subjects do not seek medical attention for their voice problems due to medical insurance coverage. The CCM
artists are less likely to seek medical care for voice problems compared with general medical problems. Availability of
medical insurance may be a factor. Availability of affordable voice care and education about the importance of voice
care is needed in this population of vocal performers.
Key Words: Medical care-seeking behaviors–Voice disorders–Contemporary commercial music–Singers–Medical
coverage–Access to health care–Voice–Singing.
INTRODUCTION
Contemporary commercial music (CCM) is the largest, and
possibly the most popular genre of music in the United States
at this time. Vocalists performing this genre of music are generally less likely to have formal voice training or an understanding of voice production mechanics than classically trained
singers. It has been the authors’ observation that CCM singers
(particularly those in the early stages of their career) are also
less likely to seek medical care for problems with their voice
than classically trained singers. The reasons for this are diverse
and may include lack of awareness, financial constraints, anxiety over seeing a voice expert, apprehension regarding laryngeal endoscopy, and fear of what may be found (ie, nodules).
The purpose of this study was to determine predictive factors
for treatment seeking regarding voice disorders in this population. The investigators were interested in determining whether
individuals involved in the CCM scene, particularly singers,
sought help for voice problems from coaches, singing voice
teachers, or medical professionals. In addition, they were interested in determining the barriers to seeking appropriate help for
voice problems.
The theoretical framework for understanding and predicting
treatment seeking was based on work by Azjen and Fishbein.1
Their model suggests that treatment seeking for health probAccepted for publication August 14, 2007.
From the *The Emory Voice Center, Emory University, Department of Otolaryngology,
Atlanta, Georgia; and the yDivision of Laryngology and Professional Voice, Department of
Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine,
Seattle, Washington.
Address correspondence and reprint requests to Michael M. Johns, Emory Voice Center,
Emory University, Department of Otolaryngology, 550 Peachtree Street NE, 9th Floor,
Suite 4400, Atlanta, GA 30308. E-mail: michael.johns2@emory.edu
Journal of Voice, Vol. 23, No. 2, pp. 225-228
0892-1997/$36.00
Ó 2009 The Voice Foundation
doi:10.1016/j.jvoice.2007.08.003
lems is based on one’s own attitude about treatment (estimated
from one’s personal feeling about seeking treatment or ‘‘self’’
factor); and social norms relative to treatment (estimated
from others’ opinions about treatment, in one’s own social
group or ‘‘other’’ factor). To further elucidate these factors in
CCM vocalists, a questionnaire-based study was designed and
administered to performers attending a regional CCM conference in Atlanta, GA.
METHODS
A cross-sectional observational study design using a self-administered questionnaire was used for this investigation. The
questionnaire consisted of 10 questions, each with a five-point
Likert-based response format. The survey was administered to
participants at a professional commercial music conference in
Atlanta, GA in 2006. Attendees included singers, instrumentalists, producers, and agents. The survey was offered to random
attendees, not just singers, at the conference with voluntary participation. No information regarding the nature of the questions
or the purpose of the study was given. Individuals were simply
asked to complete a questionnaire about their profession.
The short questionnaire (Table 1) was designed to determine
some of the barriers to seeking treatment for voice disorders in
the general contemporary commercial musical culture and
among singers. Questions included the likelihood of seeking
medical care in general and specifically for voice disorders; apprehension about seeking voice care from a physician specialist, voice coach, or speech language pathologist; fear about
what might be found on examination; uncertainty about the
trans-oral or trans-nasal laryngeal examination; and the effect
of medical insurance on their decision to seek medical care.
Participation was completely voluntary, anonymous, and
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Journal of Voice, Vol. 23, No. 2, 2009
TABLE 1.
Performer’s Attitudes Questionnaire
The following questions were administered with a five-point Likert.
1. I am likely to see a doctor for general medical check ups and/or minor illness.
2. I am likely to see a doctor when I am having problems with my voice.
3. I have anxiety/fear about going to a voice coach/singing teacher for problems with my voice.
4. I have anxiety/fear about going to a voice therapist/speech therapist for problems with my voice.
5. I have anxiety/fear about going to a specialist for problems with my voice.
6. I may not seek health care for my voice problem due to medical coverage.
7. I do not see a specialist when I have voice problems because I’m afraid of what may be found.
8. I do not see a specialist when I have voice problems because I don’t want to get a scope through my nose.
9. I do not see a specialist when I have voice problems because I don’t want to get a scope through my mouth.
10. My voice is an important part of my profession.
Age: __________________________ Gender: M/F
confidential. The study was exempt from Institutional Review
Board (IRB) review at Emory University.
Descriptive and statistical analysis of the data was performed. A two-tailed t test (Microsoft Excel 2003; Microsoft
Corporation, Redmond, WA) was used to test for significant differences among responses. Data were also further stratified by
age group and gender for analysis.
RESULTS
Seventy-eight individuals voluntarily participated. All surveys
that were distributed were returned completed. Age of subjects
ranged from 19 to 59 years with a mean age of 28.06 years. Of
participants, 34 were females and 44 males. Responses are summarized in Figure 1.
Eighty-two percent of the respondents reported that voice
was very important to their professional identity (Figure 2).
Questions 1 and 2 questioned participants’ likelihood to seek
medical attention for minor general medical problems versus
seeking medical attention for vocal problems. Subjects were
less likely to seek medical help for voice problems than for general medical problems. When asked if they were likely to see
a doctor for general medical problems 65% (36% somewhat
agreed; 29% strongly agreed) indicated they were likely to
see a doctor for general medical problems, 15% indicated
they were neutral, and 19% disagreed (9% strongly disagreed;
10% somewhat disagree). When asked their likelihood to
seek medical attention for their voice, 43% (18% somewhat
agreed; 25% strongly agreed) indicated they would seek medi-
cal attention for a voice problem, 16% were neutral, but 41%
(16% strongly disagreed; 25% somewhat disagreed) indicated
they disagreed. The differences were statistically significant
(P < 0.006) (Figure 3A and B).
In response to questions asked about anxiety regarding seeking help from a voice coach (question 3), speech language pathologist (question 4), or specialist (question 5), a large
percentage of participants indicated that anxiety about seeing
a vocal coach, voice therapist, or voice specialist does not prevent them from seeking help (42%, 32%, and 40%, respectively,
strongly disagree; only 1%, 1%, and 4%, respectively, strongly
agree). Similarly, in response to question 7, participants reported a low degree regarding fear of findings (ie, vocal pathology) (44% strongly disagree; only 3% strongly agree). The
questions regarding the procedures for laryngeal imaging
(questions 8 and 9) also indicated that this was not a deterrent
to seeking care (37% and 44%, respectively, strongly disagree;
only 10% and 8%, respectively, strongly agree).
In response to question 6: I may not seek health care for my
voice problem due to medical coverage, a significant, 39%
(18% somewhat agree; 21% strongly agree) indicated that
lack of medical coverage was a barrier with 15% neutral and
46% (19% strongly disagree; 27% somewhat disagree) indicating that health coverage was not a barrier to seeking help (Figure 4).
Respondents were stratified by age to determine if perceptions about seeking treatment change over time. There were
no statistically significant differences between responses to
My voice is very important to my profession
DATA by Percent
80%
By
%
Strongly
disagree
Somewhat
disagree
Neutral
Somewhat
agree
Strongly
agree
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q10
9%
16%
42%
32%
40%
19%
44%
37%
44%
3%
10%
25%
15%
18%
22%
27%
24%
13%
10%
8%
15%
16%
29%
32%
22%
15%
21%
24%
22%
8%
36%
18%
12%
17%
13%
18%
9%
15%
17%
15%
29%
25%
1%
1%
4%
21%
3%
10%
8%
67%
FIGURE 1. Data summary.
70%
67%
Q 10
60%
50%
40%
30%
15%
20%
10%
8%
8%
Somewhat
disagree
Neutral
3%
0%
Strongly
disagree
Somewhat
agree
FIGURE 2. Question 10 results.
Strongly
agree
Marina Gilman, et al
Performer’s Attitudes Toward Voice Issues
A
By %
Strongly
disagree
Somewhat
disagree
Neutral
Somewhat
agree
Strongly
agree
Q1
Q2
9%
16%
10%
25%
15%
16%
36%
18%
29%
25%
B
70%
60%
50%
65%
General Health Problem
Voice Problem
43%
41%
40%
30%
20%
19%
15% 16%
10%
0%
Disagree
Neutral
Agree
FIGURE 3. Questions 1 and 2: (A) Likelihood to see a doctor for
general health (Q1) versus likelihood to see a doctor for a voice problem (Q2). (B) Combined agree and disagree.
the questions by age (older than 35 years vs those younger than
35 years). Additionally, data were analyzed by gender to see if
this is a factor in treatment-seeking behaviors. Indeed, there
were statistically significant findings when the results were analyzed by gender. Men were less likely than women to see a doctor when they are having trouble with their voice (P < 0.03);
have greater anxiety about seeking help from a coach or singing
teacher (P < 0.019) or a speech language pathologist or medical
specialist (P < 0.002); and do not see a specialist when they
have a voice problem due to fear of what may be found
(P < 0.007). This study did not investigate how these findings
correlate to gender differences in seeking health care in the general population.
DISCUSSION
It has been assumed that professional singers (whether full time
or part time) are at risk for voice problems, resulting in vocal
A
By %
Strongly
disagree
Somewhat
disagree
Neutral
Somewhat
agree
Strongly
agree
Q6
19%
27%
15%
18%
21%
B
50%
46%
39%
40%
30%
20%
15%
10%
0%
Disagree
Neutral
Agree
FIGURE 4. Question 6: (A) I may not seek health care for my voice
problem due to medical coverage. (B) Combined agree and disagree.
227
pathologies or voice disorders. Much has been written about
voice treatment for singers and other premier vocal athletes.
It is therefore surprising that there are very few studies documenting the prevalence of voice disorders in singers. Phyland
et al2 surveyed 167 professional singers and 86 nonsingers
about vocal behaviors and vocal health over the previous 12
months. The survey queried them in terms of vocal impairment,
disability, and handicap as defined by the World Health Organization. The professional singers were classical operatic, musical theater, and contemporary commercial. Of the singers,
69.2% reported voice problems as compared to 41.5% of the
nonsingers. Reported diagnosed vocal disorders were higher
in singers (44%) than nonsingers (21%). Tepe et al3 surveyed
129 choral singers younger than 25 years with questions that related to vocal hygiene and general voice use. Of the respondents, 55.8% reported having had vocal difficulties
(hoarseness, vocal fatigue, volume disturbance, breathiness,
prolonged warm-up, and change in voice). Older singers reported higher incidence than younger singers. Vocal difficulties
were all self reported. Sapir et al4 surveyed 159 females—70
singers (mostly classically trained voice majors) and 89 nonsingers (mostly students in speech/language communication
disorders programs)—enrolled at three universities in the
United States. The mean age in both groups was 21.8 years.
There was no difference in the groups in reported hoarseness,
pitch or voice breaks, and pain in the throat. However, 34%
of the singers versus 17% of the nonsingers had seen an otolaryngologist in the past 3 years for voice-related problems. All
the singers were classically trained. In general, the conservatory
student is assumed to be more in tune with the importance of
vocal health and aware of specialty care for voice problems
than the general population.
These studies provide some preliminary information regarding the incidence of voice disorders among singers. However,
with the exception of the Sapir et al4 study of college students,
these studies do not address the question of whether or not this
population actually seeks treatment; from whom they seek
treatment—medical professional, coach, agent, or other nonmedical professional; and lastly if they do not seek treatment,
then what are the factors at play in their decision making. Phyland et al2 reported that although 69.2% of the singers reported
voice problems, only 44% reported diagnosed voice problems;
among nonsingers, 41.5% of those queried reported voice problems but only 21% reported diagnosed vocal problems. There
are no studies describing the health care-seeking behaviors of
singers in general or by vocal style (classical, musical theater,
commercial contemporary, etc) in particular.
Verdolini and Ramig5 in a review of occupational risks for
voice problems reports on a study of self-perceived voice problems in singing teachers. The questionnaire was sent to members of the National Association of Teachers of Singing.
Treatment-seeking patterns were among the questions investigated. Of this population, 56% with current history of voice
problems and 83% of those with past history of voice problems
had sought professional assistance for their voice problems.
Verdolini reports on another study conducted with members
of the National Convention of Gospel Choirs and Choruses
228
Association consisting of mostly African-American members
and the American Choral Directors Association, whose membership is mostly Caucasian. Some of the questions sought information on treatment-seeking behaviors. Results indicated
that 50% of the gospel singers reported current perceived
hoarseness, whereas only 35% of the classical singers reported
hoarseness. When asked about treatment seeking, those African
Americans with current hoarseness were neutral regarding the
likelihood of seeking treatment for their voice. On the basis
of survey responses, the Caucasian and mostly classical singers
were more likely to seek treatment for their vocal problems.
Most of the participants in the current study indicated that
their voice was very important to their profession, yet participants were slightly more likely to seek help for general health
issues than vocal problems. Health coverage was a factor,
with nearly 37% indicating that they do not seek help due to
the lack of adequate health coverage. It is commonly held
that awareness of health care options and availability improves
with education and socioeconomic status. Young aspiring musicians in a conservatory or university setting tend to be better
informed about health care options than singers and performers
who are either self-trained, or mentored by agents and producers. The classical and to a large extent musical theater singer
receives vocal training in an environment attuned to medical intervention for vocal problems. However, the self taught, intuitive singer does not have the support system in place to guide
them to seek help from coaches, singing teachers, or medical
professionals. In fact, CCM singers are often under the impression that singing teachers do not understand the vocal styles and
demands of a CCM singer, a reality that is slowly shifting. Economic factors play a huge role in whether singers seek help for
vocal problems. Professional singers often have limited means,
are often uninsured, and cannot afford expensive health care.
Many do not seek medical attention for complicated social, economic, and cultural reasons. As a result of some or all of these
factors, CCM singers either ignore vocal problems, attribute
them to a ‘‘cold,’’ ‘‘allergies,’’ or ‘‘temporary hoarseness.’’
Sadly, for many this can be a career stopper. They are not aware
that help is available for voice problems.
Interestingly, fear of nodules or other negative findings, fear
of laryngeal imaging procedures, and fear of consulting a voice
expert, coach, singing teacher, speech language pathologist, or
physician was not a factor. Rather, it appears as though lack of
Journal of Voice, Vol. 23, No. 2, 2009
awareness of the services provided by laryngologists and
speech pathologists is a potential factor in not seeking medical
care for voice disorders. During informal conversation with participants after they completed the survey, participants frequently expressed a lack of awareness of the very existence
of voice care professionals. The act of filling out the questionnaire itself increased the awareness by many of the participants
to other options for voice care.
CONCLUSIONS
Lack of health care coverage and lack of awareness about the
specialty voice care services available from laryngologists
and speech language pathologists among the commercial musicians are among major barriers to seeking care for voice problems. According to survey results, men were less likely to seek
help for voice problems than women, whether from a coach,
speech pathologist, or laryngologist. The Azjen and Fishbein1
model suggests that cultural and possibly gender factors may
play a role in health care-seeking behaviors.
Questions for further investigation include determining the
levels of awareness of voice specialty health care options
among various populations (Classical, CCM, Gospel, etc) of
professional singers. Investigations of whether the nature and
level of training, that is, classically trained or conservatory
trained versus self-trained influence awareness of specialty
health care or availability of coaches? How do cultural, ethnic,
and gender differences impact on health care-seeking behaviors
among singers? Finally, what can the medical profession do to
increase awareness and reduce the barriers to seeking appropriate treatment for voice problems?
REFERENCES
1. Azjen I, Fishbein M. Attitudinal and normative variables as predictors of specific behaviors. J Pers Soc Psychol. 1973;27:41-57.
2. Phyland DJ, Oates J, Greenwood KM. Self-reported voice problems among
three groups of professional singers. J Voice. 1999;13:602-611.
3. Tepe ES, Deutsch ES, Sampson Q, Lawless S, Reilly JS, Sataloff RT. A pilot
survey of vocal health in young singers. J Voice. 2002;16:244-250.
4. Sapir S, Mathers-Schmidt M, Larson GW. Singers’ and non-singers’ vocal
health, vocal behaviors, and attitudes toward voice and singing: indirect findings from a questionnaire. Eur J Disord Commun. 1996;31:193-209.
5. Verdolini K, Ramig LO. Review: occupational risks for voice problems.
Logoped Phoniatr Vocol. 2001;26:37-46.