Listening to the Voices Behind the Voice: Developing a Profession-Specific Patient-Reported Outcome Measure for...

Voice is central to identity and livelihood in vocally intensive professions. Vocally demanding occupations span four broad categories: performing voice users (singers, actors); instructional voice users (teachers); communication-intensive professionals (broadcasters, politicians, lawyers, telecommunication office workers); and clergy or ritual voice users. Even minor dysphonia can disrupt performance and professional stability. While advances in laryngoscopy and phonosurgery have refined structural outcomes, current outcome assessment in ENT practice remains anchored predominantly to anatomical and acoustic recovery, with profession-specific functionality, in our clinical experience, less consistently captured. Existing voice-related patient-reported outcome measures (PROMs), such as the Voice Handicap Index (VHI and its short form, VHI-10) or Singing Voice Handicap Index (SVHI and SVHI-10), may not fully capture the profession-specific concerns, vocal demands, and recovery expectations unique to diverse professional voice users.

To explore and compare the profession-specific concerns, vocal priorities, functional demands, and recovery thresholds of eight professional voice user groups and to design a new Profession-Specific Voice PROM (PS-PROM) that reflects occupation-specific concerns and considerations and can be integrated into ENT voice care as a complementary tool alongside the VHI/VHI-10 and SVHI/SVHI-10.

A qualitative interview study was conducted using semi-structured interviews with 40 participants drawn from eight professions (n=5 per profession), grouped into four occupational categories: performing voice users (singers and actors); instructional voice users (teachers); communication-intensive professionals - grouped into broadcast and high-visibility communication (media broadcasters, politicians) and sustained-communication endurance (lawyers, telecommunication office workers); and clergy/ritual voice users. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically using Braun and Clarke's six-step framework. Candidate PROM items were derived inductively from the interview data using a 0-10 Numerical Rating Scale (NRS) format. The proposed instrument comprises a short screening version for outpatient use and an expanded version for research and specialty clinics. The instrument has not yet undergone psychometric validation; this is the planned next phase.

Distinct vocal concerns and demands emerged across the four categories. Performing voice users (singers, actors) prioritized tonal finesse and expression. Instructional voice users (teachers) emphasized vocal stamina and end-of-day fatigue. Within communication-intensive professionals, broadcasters and politicians valued clarity, perceived vocal reliability, and rapid recovery in high-visibility settings, while lawyers and telecommunication office workers shared a common functional profile of sustained, high-quantity daily communication, though the nature of the demand differed: lawyers required vocal projection during unamplified courtroom delivery, whereas telecommunication office workers spoke at normal conversational intensity through a headset microphone, with the principal burden arising from call frequency, shift duration, and limited autonomy over rest and pacing rather than vocal loudness. Clergy identified a distinct dimension of sustained ritual and devotional voice use. Across all groups, dysphonia was perceived as a substantial threat to identity, livelihood, and confidence, with emotional distress consistently exceeding physical symptoms. These dimensions are not specifically assessed by existing PROMs.

This is the first qualitative interview study to propose a candidate Profession-Specific Voice PROM grounded in narratives from eight vocally demanding occupations across four neutral categories. The PS-PROM is designed to complement existing PROMs (VHI/VHI-10, SVHI/SVHI-10) by capturing profession-specific functional outcomes that may not be fully reflected by laryngeal examination findings or general voice handicap scores. Formal psychometric validation, including reliability, construct validity, responsiveness, and minimal clinically important difference (MCID) determination, will be conducted in a planned subsequent study.