Voiceguard: Using mHealth Technology for Vocal Health Promotion

Christina Cesar Praça Brasil

, José Eurico de Vasconcelos Filho

, Daniele de Araújo Oliveira Carlos

Thiago de Oliveira Magalhães

and Raimunda Magalhães da Silva

Pós-Graduação em Saúde Coletiva, Universidade de Fortaleza, Fortaleza-CE, Brazil

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 AraÃžjo Oliveira Carlos D., de Oliveira MagalhÃ

ces T. and MagalhÃ

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

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,

(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

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