Voiceguard: Using mHealth Technology for Vocal Health Promotion
Christina Cesar Praça Brasil
1
, José Eurico de Vasconcelos Filho
2
, Daniele de Araújo Oliveira Carlos
1
,
Thiago de Oliveira Magalhães
2
and Raimunda Magalhães da Silva
1
1
Pós-Graduação em Saúde Coletiva, Universidade de Fortaleza, Fortaleza-CE, Brazil
2
Laboratório de Inovação Tecnológica - NATI, Universidade de Fortaleza, Fortaleza-CE, Brazil
Keywords: Voice, Mobile Technology, mHealth, Evaluation Studies, Content Analysis.
Abstract: This study aims to describe the development of an app for mobile devices to assist voice professionals in the
management of vocal health. The research was held in two phases, from November 2014 to December 2015:
1) literature review and app stores search and 2) laboratory design, development and usability test. The
multimedia feature was chosen for the app design and development, since it favours a motivating and dynamic
environment. Teachers, when participating in the usability test, handled the tool for a few hours and issued
their opinions. Data were analysed based on content analysis in the thematic mode. The results show the
feasibility of the tool development to support and assist professionals in the care of their voice and open new
perspectives to show that, in health promotion, technology can create new alternatives for health education
and care, empowering the users.
1 INTRODUCTION
The use of m-Health technologies to promote vocal
health is an issue that deserves attention in the current
scenario, in view of the potential and vascularity of
these technologies and the importance of voice for
humans. The voice is a hallmark of the human being,
is widely used in interpersonal, social and
professional relationships. Characteristics such as
sex, age, emotional state and personality are
expressed through the vocal quality (Behlau et al.,
2009). Moreover, the voice enriches the transmission
of the word or message, both socially and
professionally (Fabricio et al., 2010).
Among the professionals who use their voices as
a working tool, there are the teachers, which
intensively require this function and undergo several
changes or even problems, due to lack of care and
protective measures (Brazil, 2015). Vocal disorders
in teachers represent a serious health problem, since
it undermines the quality of life, work performance
and compromises the quality of education (Fabricio
et al., 2010).
Researches that investigated the vocal changes in
teachers from different levels of education concluded
that such prevalence is high, ranging from 21% to
80% (Roy et al., 2004; Strong et al., 2007, Brazil,
2015). Other studies that have captured information
from teachers, showed a percentage of complaints
related to voice that ranged from 54% to 79%
(Gonçalves; Penteado; Silverio, 2005). These data
reveal that there is a high incidence of voice problems
among teachers, demonstrating that this profession
can be demanding more attention from public policies
to vocal health.
In this context, the technology brings new
possibilities and resources that can make life easier
for people and professionals to develop the health
care, an example of this, are the mHealth technologies
(Sarno et al., 2014).
In recent years, mobile health (mHealth), a branch
of electronic health (eHealth), defined as "the use of
computer technology and mobile communications in
health care and public health" has been constantly
expanding (Free et al., 2010). Thus, applications for
mobile devices in health can cater to a heterogeneous
audience (Free et al., 2010) and a wide variety of
purposes (Riley et al., 2011).
The biggest advantages of using mobile
applications in health consist in the fact that the
devices are personal; that, nowadays, they have large
processing capacity, several sensors (camera,
microphone, accelerometer, gyroscope), internet
connection; and are portable (Whittaker, 2012).
Therefore, they can be used everywhere, even in
everyday life and during hospitalization or
rehabilitation. They can also meet the health care
348
Cesar PraÃ
˘
ga Brasil C., de Vasconcelos Filho J., de AraÞjo Oliveira Carlos D., de Oliveira MagalhÃ
ˇ
ces T. and MagalhÃ
ˇ
ces da Silva R.
Voiceguard: Using mHealth Technology for Vocal Health Promotion.
DOI: 10.5220/0006170103480353
In Proceedings of the 10th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2017), pages 348-353
ISBN: 978-989-758-213-4
Copyright
c
2017 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
providers during routine visits or emergency
procedures. In addition, the technology has been
widely used by health professionals in health
promotion strategies.
The high frequency of voice disorders in teachers
and the lack of public policies for the vocal health of
these professionals (Brazil, 2015), show that the
creation of technologies that empower the teacher to
take care of the voice can contribute to health
promotion, improving quality of life and occupational
conditions of this population.
Given the above, it was thought in a technological
feature that allows the teachers and professionals who
intensively use the voice, to monitor vocal health
(even in real time), creating an interface between the
users and the environment. This way, the aim of this
study was to develop a technology for mobile devices
as a tool for promoting the teacher's vocal health.
2 METODOLOGY
A study of exploratory and experimental type was
conducted, from November 2014 to December 2015
in the Application Center for Information Technology
of University of Fortaleza - UNIFOR in the state of
Ceará - Brazil.
The project, is still in development with two
concluded phases – 1) literature review and app stores
search and 2) laboratory design, development and
usability test.
In the first phase, after listening to the difficulties
faced by the voice professionals (future users of the
app) due to the needs to take care of their voices, it
was carried out a literature review on the subject and
context proposed, allowing the research team a better
understanding of concepts, methodologies and tools
of the involved areas. The review included a survey
of the existing applications dedicated to vocal health.
The team investigated the existing vocal health
technologies through a survey conducted in the app
stores on the web, on the Android (Google Play) and
iOS platforms, using the following terms: vocal
health, voice management and voice (in Portuguese
and English). As a result, we identified, among
others, four applications directed to vocal health,
which approached the purpose of this study; besides
VoxMetria tool, that is a specific software for voice
analysis and voice quality.
The second phase, held in laboratory,
contemplated the development of the application,
with the participation of a multidisciplinary team of
speech pathologists, computer engineers and graphic
designers.
For the development of the tool, it was adopted a
methodology in Human Computer Interaction area,
the participatory interaction design (Preece et al.,
2013), which was chosen because it focuses on the
user´s needs and in its continued participation during
the process. The interaction design is divided into
four activities (Figure 1): identify user´s needs and
establish requirements (for the system), conceive the
solution design and (when necessary) the redesign,
build an interactive version (working prototype) and
evaluate the version produced with users.
Once established the requirements and based on
them, the activity of design began. At this moment,
drawings of system interfaces were built, in order to
achieve the requirements, as well as usability and
aesthetics. These drawings were understood by all the
members of the staff, allowing reviews with the
participation of potential users of the proposal.
Finalized the revisions (design and redesign) of
the artefact, it was started the construction phase of
the interactive version. In this phase, the
programming/coding of technological artefact was
made. For this activity, the team used the best
practices and tools of the areas of Human-Computer
Interaction and Software Engineering. The platform
chosen for the application was Android, since it
dominates more than 80% of the Brazilian market for
mobile devices.
The last activity of the laboratory process
corresponded to application usability evaluation
(Barbosa and Silva, 2010). This evaluation aims to
determine whether the application is understandable,
easy to use and generates a good user experience.
This assessment, however, does not evaluate the
content or if the artifact produced, reaches the
proposed objectives, leaving this evaluation to the
next stage of the methodology. In this activity, 6
female teachers, from Yolanda Queiroz Elementary
School participated. They received smartphones with
the app installed a script of activities to be performed
in the app, the activities were associated with the
main system functions: register in the system, make a
vocal analysis and check the result, set the "water
time" function and get tips on vocal health. In
addition to the script, a form (answered individually
by each participant) so that impressions and opinions
on the user experience could be registered.
As result of the usability evaluation, positive
evidence was obtained, since the teachers considered
the application easy to handle, they used it in the
proper way and had a good user experience, despite
some minor changes that have been suggested.
Voiceguard: Using mHealth Technology for Vocal Health Promotion
349
Figure 1: Interaction Design (Preece et al., 2013).
3 RESULTS
A first result of the project, from the literature review
and the meetings with voice professionals (users) is
the identification of the features/functions to be
developed. A second result was the evaluation of the
applications identified in the app stores based on the
selected criteria. With this analysis, it was observed
that the identified applications addressed the subject
by focusing on specific points and did not offer
features for managing, monitoring or a full self-care
of vocal health, as can be seen in Table 1.
Based on the requirements and in the fact that
there is no tool that would meet all these
requirements, emerged VoiceGuard, a tool for mobile
devices to the individualized support of the use of
voice. The application is composed of 16 interfaces,
each of them with a specific function. Table 2 shows
the most relevant.
4 DISCUSSION
Throughout the research process, it was identified the
lack of applications dedicated to vocal health. Thus,
the VoiceGuard application brings new possibilities
and helps professionals in the healthy use of this
important tool that is the voice.
It is clear that technological advances have
allowed the improvement of the media and bring to
people the communicative interaction. Currently, the
world has experienced the era of communication and
health is one of the areas benefiting from the
integration of these resources in the daily life of the
population.
The VoiceGuard application fills a gap in the
context of care to vocal health, giving users
monitoring and self-management of vocal health
through information, testing and alarm, setting an
interface with the user. The application consists of a
main menu covering six areas - voice analysis, sound
level meter, time of water, results, tips and vocal
heating - which unfolds in 16 interfaces, as outlined
in Figure 1.
Each application area will be presented in detail in
the following subsections:
Table 1: Evaluation summary of the applications studied based on the proposed requirements.
FEATURES / SYSTEMS
Vocal
WarmUp
Saúde Vocal Vocal Ease
Warm me up
for singers
VoxMetria
Vocal warm-up X - X X X
Ambient sound measurement - - - - X
Vocal health analysis - - - - X
Care history - - - - X
Vocal health tips X - - - X
Water intake reminder - - - - -
Level of vocal protection - - - - -
Legend: Symbol "X" mark the existence of the function in the application.
HEALTHINF 2017 - 10th International Conference on Health Informatics
350
Table 2: Voice Guard interfaces
.
1. Login 2. Register 3. User classification 4. Vocal risk classification
5. System menu 6. Test of Maximum time
of phonation
7. Measurement of
sound/noise
8. Water time function
4.1 Register and Access Functions
There are seven interfaces that correspond to the
functions for: the presentation of the application,
login in the application (Table 2-1), user registration
(Table 2-2), user classification (Table 2-3), data
sharing, predisposition classification to vocal risk
(Table 2-4) and main menu (Table 2-5).
Other system functionalities and associated
interfaces are explained below.
4.2 Vocal Analysis
The first interface to support Vocal Analysis, presents
an explanatory text on the operation of functionality.
This explanation has its origin from users questions,
recorded during testing, and shows to user the
operation that occurs on the interface that executes
the test used to check the maximum phonation time -
TMF (Table 2-6) and that presents the result of the
test with explanation.
Regarding the voice analysis, we used the test to
measure the Maximum Phonation Time (TMF). TMF
is widely used to verify the voice quality, using,
among others, the fricative phonemes / s / and / z /
(Behlau et al., 2001).
The test is performed as follows: the user, by
issuing the phoneme /s/ in a sustained manner after a
single exhalation, have the time of issue timed by the
application. After finalize the issue of the first
phoneme, other phoneme (/z/) should be required.
The use of phonemes /s/ and /z/ establish the link
that checks the condition of glottal closure. Thus, the
test based on parameters validated by experts
Voiceguard: Using mHealth Technology for Vocal Health Promotion
351
(Miglioranzi; Cielo; Smith, 2012), provides data on
the dynamics of vocalization, being quite reliable in
the evaluation of glottal efficiency. It is noteworthy
that the normal range of s / z ratio is estimated at
approximately 1 second (Gelfer; Pazera, 2006).
If the result of this test is less than 0.8, it indicates
excessive coaptation of the vocal folds, which harms
the vocal health of teachers, because it is perceived
excessive effort to speak. Results from 0.8 to 1.2 is
indicative of normality, suggesting that there is a
normal operation of the vocal folds. Finally, the result
of more than 1.2, indicates soprosity, i.e., there is an
air leak between the vocal folds during phonation
(Christmann et al., 2012).
The presented feature enables check and provide
an overview of the glottal operation of each user,
helping them in self-monitoring of vocal glottal
efficiency. These results may alert about the signs of
possible changes in the glottal closure, serving as a
warning to seek expert help. The application also
allows sharing the results in real time, with the speech
therapist and/or physician, who are accompanying the
teacher.
Another function is that, after the indication of the
result of this test, the application presents the
individual explanations of the identified condition,
the interface results. With this, the user can access the
tips interface where he/she will learn about the
preservation of vocal health. It is clear that
technology can influence and change the way of
living and acting of people, even when these issues
go through the care and health promotion context.
Thus, it confirms the importance of incorporating
advanced technologies in scenarios of assistance to
vocal health as it implies a redefinition of self-care
(Silva; Ferreira, 2009)
4.3 Decibelimeter
Another important function of VoiceGuard is the
decibelimeter, which captures and shows the level of
environmental noise. Moreover, it is possible to
identify the noise spikes that exceed the acceptable
intensity for the preservation of vocal health. For this
purpose, the application presents three interfaces:
explanations of the functions on the Main Menu,
noise/sound measurement (Table 2-6) and the results
of the noise measurement.
Studies show that noise is considered one of the
most important risk factors for voice disorders in
teachers. When the teacher is in the classroom and
under the influence of noise, trying to be heard, he/she
normally exceeds the voice intensity. Without
realizing it, the teacher becomes vulnerable to the
appearance of vocal disorders (Baring & Murgel,
2005; Brazil, 2015).
A study of Guidini et al. (2012) shows that,
according to NBR 10,152, the acceptable noise level
in the classroom must remain 40dB to 50dB (A).
Thus, the application presents the following
parameters to alert the user to the level of
environmental noise: audible alarm - generates
acoustic signals when the noise exceeds 50dB,
conditioning students to reduce the parallel
conversation or remain silent during the class; and
visual alarm - reinforces the idea of the loud noise
through the issuance of lights and aids in listeners
behavior conditioning.
4.4 Water Time
The "water time" is another application function that
helps professionals to condition themselves to drink
water during vocal use. For this, the interfaces of
"water time" (e.g. Table 2-8) are available.
The device enables the user to program the times
for water intake over the work shifts. The application
signals through visual and audible alarms the time for
water intake, reminding the professional this as an
important action for continued hydration and
maintenance of vocal health. It is also possible that
the user reports how many glasses of water he/she
drank during the working day (Table 2-8).
Hydration is recommended in both the prevention
and treatment of voice disorders. It is known that the
benefits of hydration are many, such as: reducing the
viscosity of mucus in the larynx and facilitating
mucus-wave motion. Thus, a more hydrated mucosa
provides greater flexibility to the vibration of the
vocal folds, increasing vocal resistance and reducing
the sensations related to vocal effort (Medaglia et al.,
2008).
4.5 History Log
The interface of “History Log” provides access to the
application user history and gives access to tips of
voice heating and cool-down.
The interface that corresponds to the "results" is
simple. It is possible to see the results of all tests, and
enable visualization of comparative graphs. It also
allows data sharing with the health professional who
takes care of the app user. The VoiceGuard keeps in
chronological sequence the results of the tests
performed by the users and of other tests they want to
register (reports or images).
Finally, the "heating and cool-down" is a tool that
is still in the test phase for improvement. In this
HEALTHINF 2017 - 10th International Conference on Health Informatics
352
interface, the user can perform simple exercises of
voice heating and cool-down, before and after voice
use, respectively.
5 CONCLUSION
The VoiceGuard application was designed in order to
facilitate the improvement of the management of
vocal health, aiming the adoption of habits and
behaviors able to maintain healthy voice, which is
consistent with the health promotion strategies.
As the mobile technology is present in everyday
society, use it as a resource in health care can be a
quick, easy and inexpensive strategy to achieve a
considerable number of people. Therefore, we believe
that the mobile application as a tool for vocal health
promotion is a necessary resource and a new
possibility for professional voice in the current
context.
The usability testing gives us a positive and
preliminary indication of acceptance and positive
impact of the tool. All invited users were able to meet
the proposed activities in an average time considered
good, without doubts about the interaction with the
tool and with some good suggestions (embraced by
the staff) to change some terminologies and the
location of information in the interfaces.
A third phase will be conducted after the
development of the VoiceGuard, in which it will be
validated with experts in voice and a larger number of
elementary school teachers, in order to be available
for free in the app stores.
REFERENCES
Fabricio, Mariana Zerbetto; Kasama, Silvia Tieko;
Martinez, Edson Zangiacomi. Qualidade de vida
relacionada à voz de professores universitários. Rev.
CEFAC, São Paulo , v. 12, n. 2, p. 280-
287, Apr. 2010
Sarno F, Canella DS, Bandoni DH. Mobile health e excesso
de peso: uma revisão sistemática. Rev Panam Salud
Publica. 2014;35(5/6):424–31.
Christmann, M. K.; Scherer, T. M.; Cielo, C. A.;
Hoffmann, C. A.. Tempo máximo de fonação de futuros
profissionais da voz. Rev. CEFAC, São Paulo 2012.
Baring, J. G. & Murgel, E. Cuidado! Barulho demais faz
mal à saúde. Revista Nova Escola, n. 179, p. 29,
janeiro/fevereiro.2005.
Barbosa, S. D. J.; Silva, B. S. Interação Humano-Computador.
Série SBC, Editora Campus-Elsevier, 2010.
Guidini, R. F. et al. Correlações entre ruído ambiental em
sala de aula e voz do professor. Revista da Sociedade
Brasileira de Fonoaudiologia, São Paulo, dez. 2012.
Behlau, M.; Madazio, G., Feijó, D.; & Pontes P. Avaliação
de voz. (2001). In: Behlau M. organizador. Voz: o livro
do especialista. vol 1. Rio de Janeiro: Revinter; 85-172.
Miglioranzi SL, Cielo CA, Siqueira MA. Capacidade Vital
e Tempos Máximos de Fonação de /E/ áfonos e de /S/
em Mulheres Adultas Rev. CEFAC. 2012.
Medaglia, N.C. et al. Sintomas vocais relacionados à
hidratação monitorada. IV Mostra Interna de Trabalhos
de Iniciação Científica, 2008. Centro Universitário de
Maringá, Paraná - Brasil
Behlau, M.; Pontes, P. Higiene Vocal: cuidando da voz. 4.
ed. Rio de Janeiro: Revinter, 2009. 70p.
Brasil. Censo Escolar 2009. Brasília: Ministério da
Educação, 2009.
Brasil. Conselho Nacional de Saúde. Diretrizes e normas
regulamentadoras de pesquisas envolvendo seres
humanos. Resolução 466, de 12 de dezembro de 2012.
Brasil, C.C.P. A voz da professora não pode calar: sentidos,
ações e interpretações no contexto da integralidade em
saúde. 2015. 232 f. Tese – UECE, UFC e UNIFOR,
Fortaleza, 2015.
Free, C. et al. The effectiveness of M-health technologies
for improving health and health services: a systematic
review protocol. BMC Res Notes, v.14, n.5, p.2-7, Out.
2010.
Gonçalves, C.G.O; Penteado, R.Z.; Silvério, K.C.A.
Fonoaudiologia e saúde do trabalhador: a questão da
saúde vocal do professor. Saúde em Revista,
Piracicaba, v. 7, n.15,Jan. / Abr.2005.
Riley, et al. Health behavior models in the age of mobile
interventions: are our theories up to the task?
TranslBehav Med , v.1, n.1Mar. 2011.
Roy, N. et al. Prevalence of voice disorders in teachers and
the general population. Journal of speech, language,
and hearing research, Rockville, v. 47, n. 2, p. 281-293,
Apr. 2004.
Preece, J. et al. Design de Interação: além da interação
homem-computador. 3.Ed. Porto Alegre:Bookman,
2013.
Silva, R.C.; Ferreira, M. A. A tecnologia em saúde: uma
perspectiva psicossociológica aplicada ao cuidado de
Enfermagem. Esc. Anna Nery Rev. Enferm., Rio de
Janeiro, v.13, n.1, p: 169-173, Jan./Mar., 2009.
Whittaker, R. Issues in mHealth: findings from key
informant interviews. J Med Internet Res, Pittsburgh, v.
14, n 5, p.129, Oct. 2012.
Voiceguard: Using mHealth Technology for Vocal Health Promotion
353