|Year : 2013 | Volume
| Issue : 1 | Page : 3-9
The prevalence and impact of voice problems in call center operators
Usha Devadas, B Rajashekhar
Department of Speech and Hearing, MCOAHS, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||24-Sep-2013|
Department of Speech and Hearing, MCOAHS, Manipal University, Manipal - 576104, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Since the past 10 years, the call center industry has expanded rapidly in India. Effective and healthy voice is a primary need for these professionals. Voice problems may threaten both the working ability and occupational health and safety of call center operators (CCOs). Western literature reports higher prevalence of voice problems in CCOs: Yet such investigations are not reported in India. Hence, the present study was focused on investigating the prevalence of voice problems among CCOs and its impact on their working performance. Materials and Methods: A cross sectional survey study was conducted using self-reported questionnaires. Data for the present study were obtained through convenient sampling by distributing 2000 questionnaires in 11 voice-based call centers in Bengaluru, Karnataka, India. The results of the study are analyzed and discussed, based on 1093 eligible questionnaires. Results: The career and point prevalence of voice problems in CCOs were observed to be 59% and 27%, respectively, with no significant gender difference (P > 0.05). The impact of the voice problem in terms of missing work was found to be significantly greater in female CCOs as compared with their male counterparts. Conclusions: This study supports the findings in the literature that CCOs are at greater risk of developing voice problems and that voice problems affect their performance. Thus, there is a great need to identify the risk factors associated with these voice problems and educate the CCOs and employers/organizations about the consequences of voice problems for monitoring effective functioning of CCOs.
Keywords: Call center operators, impact, prevalence, voice problems
|How to cite this article:|
Devadas U, Rajashekhar B. The prevalence and impact of voice problems in call center operators. J Laryngol Voice 2013;3:3-9
| Introduction|| |
As the service sector continues to grow, more and more personnel depend on their voices for their livelihood. Call center operators (CCOs) are among the workers relying heavily on their voices to carry out their profession. In the late 1990s, with the rise in the number of call centers across the world, researchers began to investigate the factors specific to their working environment that could affect the workers' health. Studies conducted on a large group of CCOs in Europe revealed a higher relative risk of developing health-related problems, namely, musculoskeletal problems and psychological distress, ,, and organic voice problems. ,, Studies conducted in different parts of the world confirmed higher prevalence and greater impact of voice problems in CCOs. ,,,,
Although occupational health and safety issues are evincing increasing interest in India, there is still a lack of adequate research highlighting the prevalence of voice problems in this sector. A recent study conducted on 21 CCOs, using Voice Handicap Index and adapted version of vocal self-perception attitudinal questionnaire revealed that CCOs' vocal demands affected their quality of voice, with no self-awareness of this among most of the workers.  In another study, Shah and Sanghi,  reported that 40% of the international CCOs and 30% of the domestic CCOs are experiencing voice problems. However, these studies are quite preliminary due to the small number of participants.
The present study was conducted to investigate, prevalence of voice problems in CCOs, using self-reported questionnaires to highlight functional impact on CCOs performances, thus enhancing self-awareness both to identify risk factors and to prevent and reduce voice problems in these workers.
| Materials and Methods|| |
This cross sectional survey research was conducted by contacting human resource (HR) managers at 25 voice-based call centers in Bengaluru, a metropolis in southern India, using a self-reported questionnaire. The responses were forthcoming from 11 call centers: They accepted to participate in the survey once assured of confidentiality. Nonparticipation by other companies is attributed mainly to non-grant of permission from their management, organization and their company policies. The employees in these 11 companies ranged from 250 to 3000.
Description of the questionnaire
The self-reported questionnaire focused on CCOs answers on demographic data, vocal attrition symptoms, frequency and severity of the symptoms, and impact of these symptoms on their emotion, social interaction, job performance and voice-related absenteeism, and also if experiencing voice problems on that same day. The questionnaire data for the present study was obtained from 'voice survey' questionnaire developed by Jones et al.,  to study the prevalence and risk factors for voice problems in telemarketers with permission from the primary author. The questionnaire was accompanied by a covering letter, explaining the broad outline of the research topic, with assurance of confidentiality to each participant. The participants were required to sign a consent form included in the questionnaire for documentation and future reference purposes. Prior to data collection, the protocol was presented before the institutional ethical committee. On its approval, the study was conducted in accordance with the stipulated guidelines.
Two thousand questionnaires were distributed across 11 (7 inbound and 4 outbound) voice-based call centers. The questionnaires were handed over to HR managers of these call centers who distributed the questionnaires to the CCOs. The number of questionnaires distributed varied according to the number of employees. That is, the number of questionnaires distributed was around 100 and 250, respectively, in companies with less than and more than a thousand employees. The questionnaires filled from the CCOs were collected by HR managers and returned to the researcher. Follow up of non-responders by HR managers was restricted by their busy work schedule and inability to contact them individually.
SPSS software version 15 (Software Package for Social Sciences, South Asia, Bangalore) was used for the analysis. The prevalence (career and point) of voice problems was analyzed in terms of percentage. Mean and SD were used to summarize continuous variables. Pearson's Chi-square test was used to compare the differences in prevalence and impact of voice problems between two genders.
| Results|| |
A wholesome response rate of 60.95% was obtained with returning of 1219 completed questionnaires. The data were analyzed based on 1093 questionnaires excluding the 126 incomplete questionnaires. This was further categorized gender-wise as response rates of 58% (632) and 42% (461) for males and females, respectively. As literature quotes of significant gender differences in experiencing voice problems, the results were discussed gender-wise.
Demographic and vocational information
The demographic and vocational information of CCOs is given in [Table 1]. The gender groups presented no significant difference in age range and work experience. All of them were involved exclusively in answering customer calls (80-100 calls/shift) during the entire working day/shift with 50% of them serving inbound call centers. The average length of their working day/shift was 8.7 and 8.5 hours (range: 8-10 hours.) for male and female CCOs, respectively, including one 30 minutes and two 10 minutes breaks.
Career prevalence of voice problems
For the present study, to measure the career prevalence of voice problems, the CCOs were asked to indicate whether they experienced any of the vocal attrition symptoms listed in the questionnaire, since they began their profession as a CCO. No symptoms of vocal attrition were reported throughout their career by 446 (41%) composed of 42% male and 40% female CCOs. Higher number (n = 647; 59%) of the CCOs (58% male and 60% female) reported of one or more symptoms of vocal attrition, since they began their career as CCOs irrespective of the gender. Even though the percentage of female CCOs experiencing voice problems was slightly higher (60%) than their male counterparts (58%), it was not statistically significant (c2 = 0.406; P = 0.524). The prevalence of individual vocal symptoms reported by the CCOs, gender wise is shown in [Table 2].
|Table 2: The prevalence of individual vocal symptoms reported by the CCOs|
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As depicted in [Table 2], among the 14 vocal attrition symptoms listed, higher percentage of CCOs (both genders) indicated the symptoms of 'dry throat' and 'frequent need to clear throat'. Pearson's Chi-square test indicated no significant gender difference in reporting vocal attrition symptoms except significantly higher number of male CCOs experiencing hoarse voice. However, no significant relationship was found between age, work experience, education level of the CCOs and career or point prevalence of voice problems.
Out of the 369 male and 278 female CCOs reporting one or more symptoms, 92% of male and 93% of female CCOs reported frequent voice problems, indicating they had occurred for every 2-3 months or more frequently. The remaining 8% males and 7% of females reported experiencing vocal attrition symptoms infrequently, indicating that they had occurred once in every 6 or 9 months. Further, when the CCOs were asked to indicate the severity of these symptoms (very mild, mild, moderate, severe, very severe), 74% of them (76% of males and 73% of females) rated it as very mild or mild. The remaining 22% (21% males and 24% females) rated it as moderate and 3% (4% of males and 3% of females) as 'severe' or 'very severe'. However, there was no significant difference between reporting the frequency of vocal attrition symptoms (x 2 = 2.311; P = 0.252) or the severity rating (x 2 = 3.537, P = 0.171) and gender.
Point prevalence of the voice problems
The prevalence of the voice problems on the day of survey was reported by 292 (27%) composed of 161 (25%) male and 131 (28%) female CCOs. The relationship between point prevalence and gender was non-significant by Pearson's Chi-square analysis (x 2 = 1.311; P = 0.252). In response to the question of 'how severe is the problem with your voice', 70% of the CCOs rated their voice problems as of milder degree.
Impact of vocal symptoms
The CCOs were asked to describe whether the vocal attrition symptoms caused any stress or frustration, affected their productivity, interaction with family or friends, and whether they missed work.
Feelings about the vocal symptoms
The CCOs were asked to indicate their feelings about voice problems using the following statements: Does not affect me, rarely frustrates, occasionally frustrates, often frustrates, major source of stress, and frustration. It was found that 41% of male and 37% female CCOs did not get affected by the presence of vocal symptoms. For 51% of males and 52% of females, the vocal symptoms affected rarely or occasionally, whereas, 8% of the male and 12% of the female CCOs felt that the vocal symptoms was a major source of frustration for them. However, there was no significant gender difference (x 2 = 6.997, P = 0.136) in reporting their feeling about the vocal symptoms.
Impact of vocal symptoms on social interaction
Presence of vocal symptoms affected social interaction in only 57 (15%) male and 38 (17%) female CCOs, with no significant gender difference (x 2 = 0.400; P = 0.527).
Impact of vocal symptoms at work
Presence of vocal symptoms affected job performance in 288 (45%) of the CCOs and there was a significant relationship (x 2 = 9.466; P = 0.002) between work being affected and gender with significantly higher percentage of female CCOs (51%) reporting of work being affected than their male counterparts (39%). Those CCOs whose work was affected due to vocal symptoms, indicated the effect of vocal symptoms on their work using five statements as shown in [Table 3].
As evident from [Table 3], more than 50% of the CCOs (male and female) reported that they need to repeat information as well as need to force their voice in order to communicate effectively with their customers. At the same time, taking breaks away from phone was reported by higher percentage of male (30%) compared with female (18%) CCOs.
Missing work due to vocal symptoms
One effective way to understand the impact of voice problems is the number of days off work. This was investigated by asking them "during your career, how long have you missed work because of a problem with your voice?" (none, a few days, about a week, about 2 weeks, about 3 weeks, or more than 3 weeks). In 45% of the CCOs, presence of vocal attrition symptoms affected their job performance among whom only 28% (n = 182) (25% male and 33% female CCOs) missed work. Among the 182 employees reporting of missing work, for 22% of males and 26% of females, it was for few days, while for 2% of males and 6% of females it was for a week or more. Pearson's Chi-square test showed a significant association (x 2 = 12.770, P = 0.026) between missing work due to voice problems and gender with significantly higher percentage of females (33%) reporting of missing work than their male (25%) counterparts.
Physician/speech language pathologist (SLP) consultation
This was investigated using two questions "since beginning this type of work, have you ever seen a doctor for problems with your voice?" and "since beginning this type of work, have you ever seen a speech therapist for problems with your voice?" If yes, "how frequently did you visit the physician or SLP?" (once in 9 months, once in 6 months, once every 2-3 months, monthly, fortnightly, weekly). Despite 647 CCOs reporting of experiencing one or more vocal symptoms, only 85 (13%) consulted the Physician (11% males and 16% females), while only 18 (3%), visited SLP (4% males and 2% females), with majority, 562 (87%), reporting of not consulting either of them. Among the CCOs who visited the Physician, 60 (9%) reported that their work was affected due to the vocal attrition symptoms and only 12 (2%) sought advice from SLPs. There was no significant relationship observed between consulting Physician/SLP and gender ((c2 = 3.090, P = 0.079). In spite of 182 CCOs (90 male and 92 female) missing work ranging from few days to 1 or 2 weeks, very few of them (10% male and 12% female) sought help from physicians or SLPs for their problem.
Instructions for voice care
The CCOs who participated in the study were asked whether they had received any instructions on the care of their voice. Out of 1093, only 158 (14%), that is, 97 (15%) males and 61 (13%) females reported of receiving some instructions, while 935 (86%) never got any. Of those who received the instructions, only 4 (4%) male CCOs received SLPs instructions, 106 (67%) reported of having received instructions from either the present or the previous employer, 14 (8%) got them from singing teachers and the remaining 34 (22%) from friends and family physician. The results indicated higher percentage of male (15%) CCOs receiving instructions about voice care as compared with their female counterparts (13%). Among the 158 CCOs who received instructions about their voice care, 47 (30%) reported that they did not experience any vocal symptoms, while the remaining 111 (70%) reported of one or more symptoms, with majority reporting of multiple symptoms (n = 87; 55%). When the 935 CCOs who had not received any instructions on their voice care were asked whether they would like to receive instructions regarding their voice care, 668 (71%) (374 males and 294 females) answered they will, while 267 (29%) (161 males and 106 females) did not show any interest in receiving voice care instructions.
| Discussion|| |
The present study is probably the first to provide data on prevalence of voice problems in Indian CCOs, based on a large sample size. The results of the current study support the findings in the literature that CCOs are at greater risk of developing voice disorders, irrespective of experiencing one or more vocal symptoms. The findings also indicate that these voice problems have or could have adverse effects on their job performance.
Higher career (59%) and point (27%) prevalence of voice problems, observed in the present study with non-significant gender difference, is consistent with reports of other studies in the literature. ,,],, The consistently higher prevalence of voice problems in CCOs from different studies proves that vocal problems are universal among CCOs owing to the occupational vocal demands. In CCOs, the vocal performance is not limited to physiological aspects; rather, it includes occupation demands, coordination of vocal, emotional, and cognitive settings for interaction with customers. It has been reported that continuous use of voice for 2 hours is the maximum allowable time and exceeding that would cause a person's vocal tract to be strained and tensed. , Apart from this, most of the CCOs were younger (20-30 years) with lack of experience and coping skills to deal with vocal demands and more vulnerable for vocal strain.  Thus, in these professionals, younger age, attending to higher number of calls (80-100 calls/shift) with few breaks, excessive stress and certain ergonomic conditions could lead to permanent damage of vocal fold mucosa not amenable for day to day recovery enhancing prevalence of voice problems threatening the effective functioning.  In general, women have higher prevalence of voice problems due to some peculiarities, such as higher fundamental frequency. , hormonal influence on the vocal fold,  and lower levels of hyaluronic acid in the vocal folds.  However, this was not reflected for the CCOs in the present study as both genders reported higher prevalence of voice problems. Studies in the literature suggest that, the CCOs need to speak with a voice that is symbolically feminine with wider pitch range and intonation that are unnatural and difficult for male CCOs; such subtle paralinguistic vocal changes could unconsciously affect them as well as their customer negatively. , This unnatural speaking style along with other influencing factors (smoking) would have led to higher prevalence of vocal symptoms in male CCOs.
The vocal symptoms such as hoarseness, tiring of voice and extra effort to talk, throat irritation or throat pain during speech are signs of voice abuse or overuse in inappropriate working conditions, characterizing an occupational disease. Generally, these symptoms develop sporadic to permanent with the appearance of organic lesions (vocal nodules).  Both genders in the present study reported experiencing multiple symptoms [Table 2]. Among the 14 vocal symptoms, "dryness of the throat" and the "need to clear the throat" were the most prevalent in both genders. Higher prevalence of these symptoms among this group has been reported and attributed to relatively low ambient humidity in call center offices. ,, The greater frequency of occurrence of multiple vocal symptoms affected their work productivity, as they needed to repeat the information and to force their voices to be understood. This indicates that CCOs experienced vocal fatigue related to heavy vocal loading resulting in functional voice disturbances and are at greater risk of developing vocal pathology. , In contrast, significantly less percentage of female CCOs reporting of taking breaks away from phone comparatively, could be due to the fear to disclose their real problems for job security in spite of anonymous questionnaires.
The impact of voice problems on an individual does not depend merely on impairment or disability but on the handicap degree.  This was evident in the present study where CCOs of both genders reported vocal symptoms with similar degree of severity and frequency of occurrence, with female CCOs finding their work being affected significantly more than males. In contrast, women in general, are more likely to recognize bodily changes as symptoms of illness and more concerned with their health than males. ,, It is felt that this factor among the female CCOs would have resulted in greater impact on their work performance and taking more time off from work. Unfortunately, neither these CCOs nor their employers recognize voice problems as work-related risks and CCOs with increasing difficulty in working due to their voice problems may consider transition to less vocally demanding jobs. This supports the literature findings that there is both a low level of knowledge related to occupational voice problems among professional voice users and a lack of easily available help to reduce or eliminate these problems. ,, This is even more relevant in the Indian context, where SLPs are less known as voice care professionals. However, the concern expressed by the CCOs about their voice care shows that, if made aware of available services, they will be most motivated to act on their voice. Hence, the initiative to teach the CCOs that, voice as their occupational tool and the need for occupational health safety can be regarded as an important step toward greater understanding of voice disorders and its prevention.
Hence, the current study projects and reiterates the need to educate CCOs on early identification and management of vocal symptoms, as the majority never received any instructions on voice care. It was also evident that these professional voice users were highly interested in receiving voice care education, thus sending a clarion call to the practicing SLPs on the dire need for periodical assessment and monitoring to develop specific preventive voice care techniques for this group to get their best output. In addition, it is necessary to convince both employers and organizations about the consequences of voice problems on the performance with its impact on customer care productivity and organizational growth.
Though this study included a large sample size, non-willingness of some call centers to participate and non-availability of exact statistics on CCOs in India restricted the researchers in obtaining random samples. However, the absolute number of useful responses obtained (n = 1093) could be considered as adequate to provide information on self-experienced voice problems among the CCOs. It was also felt that a proportion of these voice problems may be related to health, lifestyle, personality, and work environment-related factors not considered in the present study. Further work is required to understand the risk factors contributing to voice problems, which are under progress by the present authors.
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[Table 1], [Table 2], [Table 3]