Volume 23, 2022

i Editors Julia Nafisi University of Melbourne Melissa Forbes University of Southern Queensland Acknowledgements ANATS would like to thank the editorial board and expert reviewers for their assistance and contribution to Australian Voice: Irene Bartlett Jean Callaghan Helena Daffern Robert Edwin Emily Foulkes Jeannette LoVetri Joan Melton David Meyer Helen Mitchell Scott McCoy Dan Robinson Triniece Robinson-Martin Martin Vácha Jenevora Williams Ron Morris Disclaimer Material published in Australian Voice presents a variety of viewpoints. The views expressed or implied in this publication, unless otherwise stated, should not be interpreted as the official position of The Australian National Association of Teachers of Singing or of the editors. Cover The cover references Schubert’s An die Musik, a song that, in a very personal way, gives thanks to music for its power to fill us with warmth and lift us out of the dreariness of everyday life. Image sourced from https://commons.wikimedia.org/wiki/File:An_die_Musik.jpg ISSN 1325-1317 ISSN 1839-5236 (Online) Australian Voice, Volume 23, 2022 For further information about Australian Voice and the Australian National Association of Teachers of Singing Ltd., visit the Australian Voice website: www.australianvoice.net.au, or the ANATS website: www.anats.org.au. Volume 18, 2016

ii Contents Volume 23 2022 Copyright © Australian National Association of Teachers of Singing Editorial From the Editors iv-v Julia Nafisi and Melissa Forbes Articles Vocal Habilitation in Post-Acute Symptomatic COVID-19 Recovery: A Narrative Review of Strategies for Singing Teachers 1 Daniel T. Jess Understanding the Vocal Skill Set for Contemporary Christian Singers: Insights from Elite Singers 21 Leon Neto and David Meyer Vocal Health and Wellbeing: Behaviours and Confidence in Solo and Choral Classical Singers 29 Timothea Lau, Victoria Flood and Helen F. Mitchell Reclaiming Singing as Art: The Trouble with Mechanics 39 Amanda Cole Towards an Understanding of Outreach and Identity: Professional Opera Singers’ Perspectives of Definitions, Value, and Status of Outreach 49 Jessica L. Leary From Participatory to Online: Exploring Contexts of Group Singing and the Role of the Singer 60 Diane Hughes Forum Contributions Repertoire Considerations for Singing Popular Music 72 Adam Koopmans

iii Contents Volume 23 2022 Copyright © Australian National Association of Teachers of Singing Reviews Class Voice: Fundamental Skills for Lifelong Singing by Brenda Smith and Ronald Burrichter, Plural Publishing 2022 75 Shelli Hulcombe Complete Transcriptions for Piano and Vocal for Weave and Mandarin Skyline by Leigh Carriage, Wagtail Books 2021 78 Melissa Forbes Jazz Singing: A Guide to Pedagogy and Performance by Tish Oney, Roman and Littlefield 2022 80 Sydney Hoel

e d i t o r i a l iv From the Editors Julia Nafisi and Melissa Forbes Post-pandemic and (almost) back to ‘normal’ (albeit a different kind of normal), the world has irrevocably changed. Few other areas have been hit by COVID-19 and ensuing safety measures more than the performing arts, with singers, singing teachers and other professional voice users faced with voice-specific lingering symptoms of the infection. And yet, we power on. Now more than ever we need to produce and promote singing voice research which demonstrates the unique value of singing and the vital role it plays in our lives. In this spirit, we present the 2022 issue of Australian Voice, which showcases new singing voice research from Australia, the United States, and the United Kingdom. This issue comprises six research articles, a forum contribution and two book reviews. Research articles: Vocal Habilitation in Post-Acute Symptomatic COVID-19 Recovery: A Narrative Review of Strategies for Singing Teachers (by Daniel T. Jess) is a multidisciplinary literature review on vocal health issues of singers affected by COVID-19, synthesising knowledge of symptoms from vocology, speech pathology, otolaryngology, psychology, education, singing voice pedagogy, and voice science to frame practice-based strategies to support the vocal habilitation of singers recovering from symptomatic COVID-19. Understanding the Vocal Skill Set for Contemporary Christian Singers: Insights from Elite Singers (by Leon Neto and David Meyer) focuses on contemporary Christian singers (CCS) and the lack of style-appropriate vocal training, aiming to help bridge this gap by identifying the ideal skill set and the best pedagogical approach for the commercial success of CCSs. Vocal Health and Wellbeing: Behaviours and Confidence in Solo and Choral Classical Singers (by Timothea Lau, Victoria Flood and Helen F. Mitchell) investigates the vocal health behaviours of tertiary choral and solo classical singers, as well as their confidence in seeking vocal health information, and their awareness of vocal risks. The authors suggest that future solo and choral training should include education on vocal hygiene and vocal health information to prevent the development of harmful behaviours and reduce the chance of voice disorders. Reclaiming Singing as Art: The Trouble with Mechanics (by Amanda Cole) explores the effects of an ever increasing influence of health science and acoustics on voice teaching, and cautions against a single-minded focus on mechanics in the voice studio. Towards an Understanding of Outreach and Identity: Professional Opera Singers’ Perspectives of Definitions, Value, and Status of Outreach (by Jessica L. Leary) explores the lived experience of professional singers engaged in opera outreach work in relation to language (terminology) and perceptions of identity and status. From Participatory to Online: Exploring Contexts of Group Singing and the Role of the Singer (by Diane Hughes) discusses the contexts of pre- and COVID-19 impacted group singing, exemplified by a purposely composed work, Wordsong, and concludes with a model of transformation from participatory singer to online audience member. Forum Contribution: Repertoire Considerations for Singing Popular Music (by Adam Koopmans) considers the main differences in approaching repertoire between traditional singing contexts (e.g., opera, choral) and more modern styles (e.g., pop, rock, jazz, and country). Book reviews: Class Voice: Fundamental Skills for Lifelong Singing by Brenda Smith and Ronald Burrichter, Plural Publishing 2022 (by Shelli Hulcombe) Complete Transcriptions for Piano and Vocal for Weave and Mandarin Skyline by Leigh Carriage, Wagtail Books 2021 (by Melissa Forbes) Jazz Singing: A Guide to Pedagogy and Performance by Tish Oney, Rowman & Littlefield 2022 (by Sydney Hoel)

a r t i c l e Australian Voice | Volume 23 2022 v We would like to give a special thanks to all authors and reviewers for their outstanding work. There have been some changes to the editorship of Australian Voice, with co-editor Dr Veronica Stewart stepping down and we warmly thank Veronica for her dedication and invaluable input since 2018. Her position has been filled by Associate Professor Melissa Forbes (please see the Australian Voice website to learn more about Melissa). We also have some noteworthy additions to the editorial board, and we sincerely thank all our board members for their service to the journal. Please note that Australian Voice welcomes submissions at any time—all information can be found on www.australianvoice.net.au Julia Nafisi and Melissa Forbes

A r t i c l e https://doi.org/10.56307/PYZY6246 Australian Voice | Volume 23 2022 1 Vocal Habilitation in Post-Acute Symptomatic COVID-19 Recovery: A Narrative Review of Strategies for Singing Teachers Daniel T. Jess* *Australian College of Vocal Arts, *University of Southern Queensland ABSTRACT: The World Health Organisation declared a global health pandemic on March 11, 2020. Over two and a half years later, symptomatic COVID-19 infection and reinfection rates remain problematically high throughout the world. Singers, singing teachers, and other professional voice users affected by COVID-19 report significant vocal, respiratory, psychological, and stamina disturbances that impact their work. Mitigating recovery time is essential for the professional voice user. Limited research has been conducted on vocal health and production for singers affected by COVID-19. This narrative literature review aims to synthesise knowledge of symptoms that affect vocal health and production. Multidisciplinary literature from the vocology, speech pathology, otolaryngology, psychology, education, singing voice pedagogy, and voice science fields were comprehensively searched, screened, reviewed, and synthesised. Findings were used to frame practice-based strategies to support the vocal habilitation of singers recovering from symptomatic COVID-19. KEYWORDS: vocology, singing voice pedagogy, voice disorders, COVID-19 INTRODUCTION On 11th March 2020, the World Health Organisation (WHO) declared a global health pandemic caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2, or COVID-19) (Auth et al., 2022). First discovered in Wuhan, China in December 2019, the virus has since impacted almost every country (Ebinger et al., 2021). Globally, more than 617 million cases and 6.5 million deaths were recorded by WHO as at 9 October 2022 (World Health Organisation, 2022b). COVID-19 is expected to remain problematic for years to come (Skegg et al., 2021; Telenti et al., 2021). While the toll on human health and life is devastating, it is not the only problem of current global concern. Socioeconomic challenges driven by the pandemic caused new inequalities to emerge across aspects of everyday life (Li et al., 2022; Nicola et al., 2020; O'Connor et al., 2022). Many families have been unable to meet their financial commitments for months or years (Khetan et al., 2022). Concerning disparities in the learning experiences of Australian school-aged children have been reported (Tomaszewski et al., 2022), and the pandemic has had a “profound negative effect on the music industry” (Khlystova et al., 2022, p. 1201). Governments have made unpredictable decisions that were not always in the best interests of industry, and many countries remain inadequately prepared to cope with the impacts (Bardosh et al., 2022; Coccia, 2022; Easton et al., 2022). The purpose of this study was to assist singing teachers to better self-prepare for new and ongoing pandemic impacts. Singers, singing teachers, and other professional voice users affected by COVID-19 report significant vocal, respiratory, psychological, and stamina disturbances that impact their work. Mitigating recovery time is essential for the professional voice user. Since the pandemic is recent and ongoing, there are contextual research gaps about how COVID-19 affects different professions, including singing teaching. In response, this multidisciplinary narrative literature review aims to synthesise knowledge of signs, symptoms and manifestations that affect vocal health and production. Multidisciplinary literature from the vocology, speech pathology, otolaryngology, psychology, education, singing voice pedagogy, and voice science fields were comprehensively searched, screened, reviewed, and synthesised. Findings were used to frame practicebased strategies to support vocal habilitation of singers recovering from symptomatic COVID-19. In this context, vocal habilitation refers to processes, methods, tools, and approaches that enable singers to not only return their disordered voice to a normal state, but to build and strengthen it according to the singer’s specific needs (Titze,

J e s s 2 Australian Voice 2022 2019). It involves careful and considered “evaluation, diagnosis, and behavioural intervention” (Titze, 2019, p. 106) to improve vocal health, function and quality. A narrative literature review research design was selected for its ability to synthesise large volumes of emerging literature into one in-depth article (Kloester et al., 2022). The IMRAD structure for narrative reviews was adapted for use (Ferrari, 2015). Constructed in an analytical manner, this paper may help singing teachers avoid problems already explored and identifies multiple gaps to guide future research (Grant & Booth, 2009; Green et al., 2006). RESEARCH QUESTIONS The study’s primary research question asked: what strategies could be used by singing teachers to support vocal habilitation in post-acute symptomatic COVID-19 recovery? The following sub-research questions helped frame and refine the literature search: SRQ 1. What COVID-19 signs, symptoms, and manifestations can be identified in extant and emerging literature? SRQ 2. Which of the identified signs, symptoms, and manifestations affect vocal health and production? SRQ 3. What strategies reported in the literature may assist post-acute COVID-19 vocal habilitation? METHOD Narrative (unsystematic) reviews should transparently report the research methods used. Transparent reporting promotes replicability and overall clarity of key messages (Ferrari, 2015), while improving research rigor, and increasing credibility, reliability, and utility of findings (Green et al., 2006; Marshall & Rossman, 2016; Patton, 2015). The following details how this study was conducted. Information Sources Using multiple databases helps ensure all relevant literature is efficiently searched and reviewed (Green et al., 2006). A literature search of scholarly articles was conducted in June-July 2022 across two databases: Scopus and PubMed. Pre-print servers and Google Scholar were also searched, to ensure consideration of relevant upcoming publications. A second, final search was conducted immediately prior to submission for publication on 5 August 2022 and seven additional articles were included after meeting the criteria below. Search Terms and Delimiting Titles, abstracts, and keywords were searched. Different synonyms were included to optimise search of interchangeable terms. Only English full text articles published 2019-2023 (to capture preprints) were retrieved. Guided by the subresearch questions, three separate searches were conducted: Search 1 – Virus, Symptoms and Voice: COVID-19 OR coronavirus OR SARS-CoV-2 OR covid* AND symptoms OR signs OR manifestations OR prodrome OR indications OR features AND voice OR sing* OR vocal habilitation OR voice habilitation OR vocal recovery OR voice recovery. Search 2 – Virus and Voice: COVID-19 OR coronavirus OR SARS-CoV-2 OR covid* AND voice OR sing* OR vocal habilitation OR voice habilitation OR vocal recovery OR voice recovery. Search 3 – Virus and Professions: COVID19 OR coronavirus OR SARS-CoV-2 OR covid* AND singer OR singing teach* OR voice teach* OR teach* OR actor OR presenter OR lecturer OR professor OR entertainer OR vocal pedagog* OR singing voice pedagog*. The searches returned 29,183, 40,068 and 130,811 results respectively. Using the same search terms on Google Scholar and pre-print servers, an additional seven articles and two practice reference texts were retrieved, resulting in 200,071 articles and books pooled and eligible for screening. Since it is not feasible to review all literature that tenuously relates to the topic (Green et al., 2006), articles were included or excluded based on the following criteria. Screening and Selection Criteria 17,142 duplicates were removed from pooled results. Screening of abstracts, titles and keywords resulted in 688 articles selected for evaluation. This reduced to a more manageable 418 articles after removing single cases and articles with no clear link to the human voice, singing voice pedagogy, or COVID-19 signs, symptoms or manifestations. Articles were then filtered and read according to date and research design. The most recent papers with more robust designs were read first (e.g., systematic, meta, and other reviews, and large sample randomised controlled trials). This

V o c a l H a b i l i t a t i o n i n P o s t - A c u t e S y m p t o m a t i c C O V I D - 1 9 R e c o v e r y Australian Voice 2022 3 was done to reduce the risk of using outdated or incomplete information, since COVID-19 literature is evolving at a rapid rate. It also helped the researcher gain deeper knowledge and understanding of the topic area. A total of 221 articles were excluded on criteria, leaving 197 for final review. Papers were excluded during final review for lack of relevance (47), poor research design (3), exhibiting professional commentary or opinion only (4), or providing insufficient evidence upon which to base conclusions useful to the current study (167). RESULTS SRQ 1. Understanding the Clinical Features of COVID-19 The pathogenesis of COVID-19 is not yet well understood (Maurya et al., 2022; Nitin et al., 2022). It is a highly transmissible virus with viral particle sizes ranging from 0.07 to 0.09μm (Lee, 2020) that has diverse physical and psychological impacts on the body. Viral transmission can occur even when certain types of personal protective equipment (PPE) are used (Hooshyar & Hosseini, 2022; Robinson et al., 2022). COVID-19 primarily transmits between people through “contact with oral-nasal droplets released from infected persons during coughing, sneezing, and talking” (Ranjan, 2022, para. 1). Viral incubation is 2-14 days and symptoms present progressively in the acute and post-acute phases (Amdal et al., 2021; Nitin et al., 2022). While this study focused on post-acute symptomatic COVID-19 infection, cases of asymptomatic infection were widely documented (Gao et al., 2021; Lippi et al., 2021; Oran & Topol, 2021; Qiu et al., 2021; Sah et al., 2021; Tanriover et al., 2022). Since no comprehensive list of all COVID19 clinical features was found, the researcher elected to qualitatively collate a list of all signs, symptoms, and manifestations reported in the 197 articles reviewed. List collation was an uncomplicated process that resulted in an informal, semi-structured and helpful tool used to guide the researcher’s deeper exploration of relevant literature and enhance accuracy of findings. Available on request, the list consolidated more than 200 identified clinical features of COVID-19. The following symptoms were widely reported: cough, fever, dyspnoea (breathlessness), nasal congestion and post-nasal drip, rhinorrhoea (runny nose), sneezing, haemoptysis (coughing up blood), myalgia, headache, psychological and mood disturbances, sore throat, nausea, vomiting, diarrhoea, abdominal pain, loss of appetite (anorexia), skin rashes, fatigue, chills/rigors, and taste and smell changes. Many of these directly or indirectly affect vocal health and production, rationalising the need for this study. A notable systematic review by Al Maqbali et al. (2022) stated the most prevalent symptoms of acute COVID-19 infection were fever (76.2%), cough (60.4%), fatigue (33.6%), and dyspnoea (26.2%). Two other high quality meta-analyses reported that fever (46%-57%) and cough (42%- 44.1%) were most common, while diarrhoea, vomiting, nasal congestion, and fatigue were also prevalent (Ma et al., 2021; Toba et al., 2021). Finally, Lopez-Leon et al. (2021) conducted a systematic review and meta-analysis finding that fatigue prevalence may actually be as high as 58%, while Lechien et al. (2020) noted the prevalence of sore throat was 52.9%. Many Australian singing teachers work with children. COVID-19 affects all age groups and ethnicities, and only slight differences in symptoms between adults and children were observed (Al Maqbali et al., 2022; Badal et al., 2021; Flisiak et al., 2022). Children generally (but not always) experienced less extensive and less severe symptoms compared with adults (Christophers et al., 2022; Zachariah, 2022). In a study of 1,000 paediatric patients, 45% reported complete symptom resolution within 2-8 days after diagnosis, while 94% fully recovered by day 30. The remaining 6% reported ongoing symptoms including fatigue, cough, fever, and reduced sense of smell (Howard et al., 2021). Although rare, COVID-19 can cause unexpected signs and symptoms in children, and can result in severe disease and death (Brüssow, 2022). Worryingly, in a meta-analysis by Toba et al. (2021) radiological findings showed that 35.5% of children had ‘ground glass opacities’ (GGOs) in their lungs. Potentially very serious, GGOs were previously identified in patients suffering severe viral infections including influenza, SARS and MERS, and various pneumonias (Elmokadem et al., 2021). This type of pulmonary fibrosis is not yet well understood and medical professionals are concerned it may have lasting effects, taking months or years to resolve (Frija-Masson et al., 2021; Lee & Wi, 2021). COVID-19 Variants Present Different Symptoms There is considerable diversity in how COVID-19 presents during clinical examination. It is not within

J e s s 4 Australian Voice 2022 the scope of this paper to deeply address how different viral variants of COVID-19 can present different symptoms in terms of type, severity, and prevalence. However, singing teachers may find it helpful, if not slightly comforting, to understand that more recent variants appeared to be less severe than earlier variants. Menni et al. (2022) executed a longitudinal study of 63,002 participants who selfreported their symptoms. They found the Omicron variant had less frequent lower respiratory tract involvement, faster recovery time, and lower probability of hospital admission. This represents an opportunity for future research. Long COVID The chronic phase of COVID-19 is widely referred to as Long COVID (LC). While an official definition is lacking, LC is not necessarily a prolonged period of the same set of symptoms experienced during acute infection (Jennings et al., 2021). LC symptoms are complex and heterogenous in nature (Jennings et al., 2021). It is estimated that 60-80% of people develop at least one chronic symptom after COVID infection (Fernández-de-las-Peñas, 2022; Lopez-Leon et al., 2021). It has been suggested that LC has two defined stages: acute post-COVID (5-12 weeks after symptom onset); and chronic post-COVID (>12 weeks) (Fernández-de-las-Peñas, 2022). Exploring potential features of chronic postCOVID-19 is outside the scope of this study, which is focused on the acute post-COVID stage. Significant research efforts are underway to better understand the impacts of chronic post-COVID. Potential Impacts of Reinfection Research into adaptive immunity and the use of vaccines as a protective measure against COVID19 is ongoing (Dan et al., 2022). Multiple studies have confirmed that COVID-19 reinfection is common and problematic (Dhillon et al., 2021; Koupaei et al., 2022; Özdemir, 2022; Shoar et al., 2021). One systematic review with meta-analysis found that people previously infected with COVID19 had an 81% reduction in odds of reinfection, and 90% had some immunological memory up to 8 months following recovery, which led to a lower risk of reinfection (Chivese et al., 2022). The current concern is that, despite reinfection events appearing similar or less severe than first infection events (Mensah et al., 2022; Nguyen et al., 2022), the impact of multiple infections may be cumulative, potentially causing new and lasting problems (Al-Aly et al., 2022). A pre-print article by Al-Aly et al. (2022) looks to become the first publication to evidence this phenomenon. Since the long-term effects on vocal health and production ultimately remain unknown at present, infection and reinfection risks must be actively mitigated in the studio teaching environment. SRQ 2. COVID-19 Symptoms Affecting Vocal Production An estimated 30-37% of people affected by COVID-19 experience voice disorders (broadly addressed as dysphonia) (Cantarella et al., 2021; Vance et al., 2021). Based on the known prepandemic rate of 46.09%, it is suspected that the rate of dysphonia amongst singers may in fact be much higher during the pandemic (Pestana et al., 2017). Verma et al. (2022) suggested that “all COVID-19 survivors should be screened for speech, swallowing, and hearing-related issues for early rehabilitation if needed” (p. 2531). Frontline singing teachers and vocologists are suitably placed to conduct high-level screening in this regard. Dyspnoea, Pulmonary Fibrosis, Cough, Laryngopharyngeal Inflammation, Dysphonia and Dehydration The literature indicated that signs and symptoms can have a cumulative effect to cause phonation problems, particularly by affecting the respiratory tract (Al Ismail et al., 2021). For example, subglottic airflow, which helps singers adjust vocal intensity, relies on respiratory system integrity. It is also essential for phonation and pneumo-phonoarticulatory coordination (Dassie-Leite et al., 2021). Self-reported voice impairment was associated with decreased respiratory capacity in Tahir et al. (2021). While the prevalence of dyspnoea varied between 21.9% and 45.6%, the difference may be attributed to how studies were conducted and reported (Hentsch et al., 2021; Lopez-Leon et al., 2021). COVID-19 may exacerbate dyspnoea by invading and affecting receptors on the vagal nerve (Hentsch et al., 2021). Inhaled corticosteroids prescribed to help treat dyspnoea may in turn increase vocal fold dryness and extend dysphonic symptoms (Lechien et al., 2022a). Post-nasal drip may further compound these symptoms and recovery (Azzam et al., 2021; Lechien et al., 2022a). COVID-19 reportedly produced pneumonia and ‘ground glass opacities’ in the lungs which may contribute to dyspnoea and extend recovery times (Anastasio et al., 2021; Hentsch et al., 2021). Even mild disease may cause distressing

V o c a l H a b i l i t a t i o n i n P o s t - A c u t e S y m p t o m a t i c C O V I D - 1 9 R e c o v e r y Australian Voice 2022 5 dyspnoea symptoms that last extended periods (Hentsch et al., 2021). Anastasio et al. (2021) suggested similarities between COVID-19 and previous SARS and MERS epidemics. They found COVID-19 patients with severe lung involvement experienced impaired pulmonary function four months after acute infection, raising concerns that pulmonary debility may last months or years. COVID-19 dyspnoea is under-reported and people with mild disease may not recognise they have it. This was referred to as ‘happy’ or ‘silent’ hypoxaemia (low concentration of oxygen in the blood) (Hentsch et al., 2021). Researchers noted that exercise capacity is often reduced, and muscular weakness (in the form of myopathy) may be evident, particularly in the diaphragm (Anastasio et al., 2021). Hence, in practice, singing teachers should assume that students recovering from COVID-19 are likely to have reduced pulmonary ability for some time after acute infection, and design their lesson plans accordingly. COVID-19 is characterised by a dry and unproductive cough (Al Maqbali et al., 2022; Amdal et al., 2021). Affecting between 19-60.4% of people, coughing causes the vocal folds to come together forcefully, leading to swollen and inflamed tissues (Al Maqbali et al., 2022; Al-Ani & Rashid, 2021; Lopez-Leon et al., 2021). It has been associated with dysphonia, simple pharyngolaryngeal dryness, feelings of swelling in the lower throat, localised pain, or a combination. Asiaee et al. (2020) compared the voices of 70 healthy Iranian people (33 male, 37 female) against 64 people with COVID-19 (38 male, 26 female). Participants produced a vowel (primarily /a/) for as long as possible at a comfortable pitch, with a flat tone and constant dynamic. Diagnostic protocols to assess voice-related conditions were used to find that voice breaks were significantly more likely in COVID-19 sufferers than healthy people. The authors suggested that air leakage and incomplete vocal fold closure may result from traumatic impact to vocal folds from coughing and vomiting. Similar findings were reflected in a small (n=22) but robust German study (Bartl-Pokorny et al., 2021). Dysphonia is a blanket term to describe “an alteration in normal voice quality which can be due to structural and/or functional causes” (Neighbors & Song, 2022, para. 1). Commonly referred to as hoarseness, voice fatigue or tiredness, dysphonia may affect between 26.8% and 79% of people with COVID-19 (Aghaz et al., 2022; Azzam et al., 2021; Cantarella et al., 2021; Lechien et al., 2022b). While most dysphonic symptoms are mild, they often persist longer than a month (Cantarella et al., 2021). This was considered a differentiating factor between COVID-19 and other conditions that resolve faster, such as viral laryngitis (Al-Ani & Rashid, 2021). Dysphonia has been linked to COVID-19 diarrhoea, likely due to overall bodily dehydration that leads to “changes in the viscoelastic characteristics of the vocal fold” (Al-Ani & Rashid, 2021, p. 4). In Naunheim et al. (2020), 93.8% of COVID-19 patients presented with abnormal glottis symptoms (mainly glottal closure). Bowing of the vocal folds was observed, but researchers were not sure why, apart from the potential impact of age (Al-Ani & Rashid, 2021). Nasal obstruction and fatigue were related to dysphonia and may prolong symptom duration (Al-Ani & Rashid, 2021; Lechien et al., 2022b). Vocal fold congestion caused by COVID-19 may present problems for dysphonia amongst singers (Azzam et al., 2021). However, no significant association was found between smell and taste disturbances and dysphonia (Al-Ani & Rashid, 2021; Cantarella et al., 2021). Studies addressing impacts on vocal folds and surrounding laryngeal structures are helping researchers to understand the virus’ neuro-invasive potential (Al-Ani & Rashid, 2021; Azzam et al., 2021; Barrera et al., 2022; Hamdi et al., 2022; Jungbauer et al., 2021). While further research is needed, COVID-19 related dysphonia may result from inflammation in the larynx, direct laryngeal nerve invasion, or vocal fold oedema (Aghaz et al., 2022; Azzam et al., 2021). To illustrate these possible impacts, vocal folds are known to express high amounts of angiotensin-converting enzyme 2 (ACE2). This is the receptor COVID-19 uses to launch its attack on the body (Azzam et al., 2021; Cantarella et al., 2021; Lechien et al., 2020). Hence, if the virus directly infiltrates the laryngeal structures in large enough numbers, it can cause localised inflammation and prevent proper vocal function. Alternative research suggested that dysphonia may also be caused by indirect laryngeal inflammation arising from viral infiltration of the epithelia of the nose, lung, abdominal and chest muscles (Cantarella et al., 2021). This knowledge helps illustrate the severe and specific impact that COVID-19 can have on vocal production. In serious cases, intubation and respiratory ventilation may be required to preserve life. In Naunheim et al. (2020), extubated patients reported a myriad of voice production, swallowing and breathing complaints, often related to the glottis (93.8%). Unilateral vocal fold immobility was common (40%), along with narrowing (stenosis) of the posterior (15%) and sub-glottic areas (10%). Watson et al. (2021) provided similar conclusions, and Regan et al. (2021) found that 66% of post-

J e s s 6 Australian Voice 2022 intubation patients were dysphonic. Ventilation devices can impair oral hygiene, raising additional complications (Bohórquez-Ávila et al., 2021). The potential permanency of damage to the vocal apparatus caused by intubation and ventilation remains to be seen (Helding et al., 2022). Neurological Symptoms and the Voice Over 90% of patients presented at least one subjective neurological symptom, with headache, confusion, and dizziness being most reported (Harapan & Yoo, 2021). Increased stress and anxiety may contribute to the 8-15% who suffer post-infection tinnitus (ringing in ears) (Beukes et al., 2021; Lopez-Leon et al., 2021). COVID-19 might also affect sleep patterns, cognition, mental clarity, and other neurological functions (Collantes et al., 2021; Gromova et al., 2021; Harapan & Yoo, 2021; Neculicioiu et al., 2022; Saeed et al., 2022). Generally, these symptoms may affect a singer’s ability to hear pitch accurately (tinnitus) and to remain on task for extended periods of time (fatigue). Psychological Symptoms and the Voice Many singing teachers were forced to rapidly transition to online teaching and did not have the necessary skills or financial means to foster effective online learning (Murdaugh et al., 2020). The prevalence of anxiety, depression, and stress in the broader teaching profession significantly increased during the pandemic (Biasutti et al., 2021; Castillo-Allendes et al., 2021; OzamizEtxebarria et al., 2021a; Ozamiz-Etxebarria et al., 2021b; Santamaría et al., 2021; Selvaraj et al., 2021). Relevantly, Primov-Fever et al. (2020) found singers also experienced greater stress and anxiety and, whether related to this or broader concerns, were found to have practiced more regularly during the pandemic. Stress is a significant risk factor that directly and indirectly impacts vocal production. Anxiety (13%) and depression (12%) were also prevalent during the pandemic (Lopez-Leon et al., 2021). Besser et al. (2022) found that teaching professionals have elevated risk profiles for developing voice disorders during pandemics. Stress was positively related to voice symptoms. The study evaluated 313 university professors from 14 academic colleges. Participants had undertaken their “first week of online synchronous teaching, which was assumed to be the most stressful week of this transition” (p. 291.e210). Professors experienced higher stress levels compared to previous teaching periods (face-to-face). While 6.1% of professors reported stress during prepandemic periods, this increased to 30.4% after being forced to transition to online teaching. Nemr et al. (2021) and Veis Ribeiro et al. (2021) offered similar findings. Stress, anxiety, and depression are also known to increase risk of laryngopharyngeal reflux disease (LPRD), causing temporary or chronic changes to the vocal apparatus (Lechien et al., 2022a; Lechien et al., 2022b; Lechien et al., 2018; Smith & White, 2007). Acute symptoms include redness and swelling of the laryngopharyngeal region and “back flow of gastric content into the oesophagus and upper aerodigestive tract” (p. 1). Exacerbating dysphonia, LPRD can cause refluxrelated nasal obstruction, thick endolaryngeal mucus, oedema and scarring (granulation) of important tissues (e.g., vocal folds) that suffer repeated assault from exposure to stomach contents (Belafsky et al., 2002). LPRD has been associated with asthma, which has implications for some singers (Belafsky et al., 2002). Hence, the effective management of stress, anxiety, and depression is likely to assist vocal habilitation for some students. Oronasal Symptoms and the Voice Common nasal symptoms include allergic rhinitis, runny nose (rhinorrhoea), sneezing, nasal congestion and thick discharge, and post-nasal drip (Amdal et al., 2021). The presence of taste (ageusia) and smell (anosmia) abnormalities does not necessarily mean nasal mucosal tissues are inflamed (Farid et al., 2022; Guan et al., 2022; Lerner et al., 2022; Sharma et al., 2022). However, these chemosensory changes may be caused or worsened by nasal congestion and can be temporary or chronic (Tan et al., 2022; Xu et al., 2022). If present, nasal congestion should be managed to improve vocal health and production. Few COVID-19 case studies reported small superficial lesions in the oral mucosa (Amorim dos Santos et al., 2021; Farid et al., 2022; Sharma et al., 2022). While further research is needed, the presence of plaques, ulcers, blisters, and macules “may be the first sign of the disease or secondary to medications, reduced immunity, vascular compromise, localised or generalised inflammation and neglected oral hygiene” (Farid et al., 2022, p. 10). COVID-19 infection may promote reactivation of previous herpes simplex virus 1 (HSV1) (Cuevas-Gonzalez et al., 2021), causing cold sores or fever blisters on the face. Possibly accompanied by oral dryness, burning sensation or painful swallowing (odynophagia) (Bohórquez-Ávila et al.,

V o c a l H a b i l i t a t i o n i n P o s t - A c u t e S y m p t o m a t i c C O V I D - 1 9 R e c o v e r y Australian Voice 2022 7 2021), oral symptoms should resolve within 6-14 days. Apart from possible localised mild to moderate pain, nothing in the literature suggested that oral symptoms are likely to significantly impact singing voice production. Topical antiseptic mouthwashes containing hydrogen peroxide or chlorhexidine gluconate may help expedite recovery of mild cases, while severe cases require qualified medical diagnosis and intervention (Farid et al., 2022; Petrescu et al., 2022; Rusu et al., 2021). DISCUSSION SRQ 3. Vocal Habilitation Strategies for PostAcute COVID-19 Recovery Strategies to support vocal habilitation of singers during post-acute COVID-19 recovery are presented below. These are based on review findings and are grounded by additional literature where appropriate. First, it is necessary to discuss when singing lessons should and should not proceed. After all, “singers are both the instrument and the player” (Stohrer, 2014, p. 11). The prevention of vocal harm is implied in vocology practice and is always in the singer’s best interest (Titze, 2019). Vocal Rest and an Evidence-Based Timeline for Reintegrating Face-to-Face Lessons Singers should never sing with active sore throat, cough, throat or sinus/nasal inflammation, throat or oral redness or swelling, fever, moderate to extreme breathlessness, reflux, or vomiting. Doing so would pose unacceptable, unnecessary risk of further damage to an already compromised, vulnerable vocal mechanism (Klein & Johns, 2007; Murry & Rosen, 2000). Instead, they should be directed towards total vocal rest until symptoms resolve, seeking qualified medical advice and treatment as needed. If deemed safe, alternative lesson activities may be offered in the interim (e.g., music theory, aural skills development, general knowledge training). In every way, this approach reflects the widespread, historical pedagogical practice of mandating short to intermediate periods of vocal rest to support recovery from conditions such as acute common cold, influenza, laryngitis, tonsilitis, haemorrhagic polyps, pharyngitis, vocal fold haemorrhage, and pneumonia (Haben, 2012). If in any doubt, the student should be referred to a qualified medical practitioner for evaluation and treatment. Health policy changed frequently and unexpectedly during the pandemic. Until recently, most Australian states and territories mandated that people who tested positive with COVID-19 were to self-isolate for a minimum of seven full days. This was first reduced to five days, and from 14 October 2022 mandatory self-isolation was eliminated completely (for example, see Queensland Government (2022)). This policy change should not be interpreted to mean that there is no further risk from COVID-19. Viral shedding is the period during which an infected person can still transmit viral progeny to infect another person, whether they are symptomatic or not. This period ranged “somewhere between 8.5 and 14.5 days…with median of 11 days” (Qutub et al., 2022, p. 2). Critical and immunocompromised patients shed viral progeny up to 20 days (Qutub et al., 2022). Given available evidence, it seems best practice would be to resume in-person singing lessons once a student has cleared a full 11-day period, after first testing positive with COVID-19 (counted as day one). While this may seem overly pragmatic and although it is subject to change based on future health policy, this approach is designed to accommodate the median viral shedding window to help prevent transmission. Immunocompromised students may not be able to return to in-person lessons at all, and this is ultimately a decision for the student and, if relevant, their parent/guardian and medical practitioners. Since it is not ideal for students to miss multiple consecutive lessons, during the proposed 11-day window outlined above, lessons may be held virtually, provided the student has no major active symptoms. Developing Teacher Capabilities for Effective Virtual Vocal Habilitation The effective habilitation of the singing voice is an important, useful capability that advanced singing teachers should be encouraged to develop (Hoch, 2019; Titze, 2019). The pandemic has challenged various teaching and learning capabilities, impacted lesson delivery, student experience and engagement. Multiple questions have been raised about teacher preparedness and skill in conducting online lessons. While face-to-face instruction has all but fully returned in recent months, virtual (online) lessons are likely to remain a feature of singing teaching while COVID-19 continues to pose health threats (Murdaugh et al., 2020). Though it protects parties from cross-infection, virtual teaching is only suited as a temporary, moderately satisfactory replacement for in-person teaching,

J e s s 8 Australian Voice 2022 particularly in the singing teaching context (Murdaugh et al., 2020). In Nemr et al. (2021), “half of the teachers reported making more vocal effort during remote classes” (p. 3). This was surprising, since microphones on most devices adequately pick-up sound when in proximity. The following selfreflexive strategy is proposed to assist singing teachers to avoid accidental vocal over-use. Teachers are encouraged to consciously ‘re-learn’ how to balance their vocal output with respect to their immediate environment, level of selfaudibility (headphones can have a muting effect), and the capabilities and limitations of technology (e.g., microphone, computer, virtual lesson software). Logically, students are likely to experience the same problem, but may be less equipped to identify and manage their own vocal over-use without intervention of the singing teacher. Hence, teachers are encouraged to consciously refine their active listening and visual observation skills to ensure detection of the subtle signs that evidence vocal over-use and intervene accordingly. Knowing when and how to provide virtual student feedback is also helpful. As Nisbet (2003) stated, a practical focus that avoids “too much hot air in the studio lesson” (p. 16) from the teacher is optimal for student learning and implicit memory development. Maxfield (2020) suggested a combination of verbal (in real-time) and written feedback (post-lesson) to promote positive motor learning outcomes. He highlighted the value of waiting a moment before providing verbal feedback after a student’s attempt, and encouraged teachers to provide less frequent feedback, to promote increased self-correction by the student. Maxfield also proposed that it can be helpful to ask students how and when they would prefer to receive feedback. In summation, singing teachers are strongly encouraged to seek opportunities to develop the various “pedagogical, social, managerial, and technical” (Murdaugh et al., 2020, p. 5) skills necessary to prepare and deliver effective, engaging virtual lessons, particularly if vocal habilitation is a goal. Face Masks, Ventilation and Distance: Preventing Infection While Optimising Audibility The protection of teacher and student health should be of primary concern in the studio environment. Protective face masks have been used to slow the global spread of COVID-19. This is important to practice because professional singers disperse more aerosol than amateur singers (Mürbe et al., 2021), as does loud singing versus soft singing, speaking, and breathing (Gregson et al., 2021). Differences in phonation, articulation, and mouth opening also seem to impact aerosol dispersion (Hermann et al., 2021). There are many different designs and types of masks available. Echternach et al. (2021) tested the aerosol dispersion of 5 different singers masks while loud musical pieces were performed. All masks decreased aerosol impulse dispersion to the front of the mask (in the direction the wearer is facing), but dispersion increased to the mask’s sides and top. In Kniesburges et al. (2021), the aerosol dispersion of professional singers performing with masks on “stayed in the singer’s near-field around and above their heads” (p. 6). While masks offer important protection, they also reduce the transmission of sound. In separate studies, Pörschmann et al. (2020) and Goldin et al. (2020) evaluated different types of masks/face coverings, finding significant frequency-dependent loss of sound transmission. Frequencies above 2kHz were especially reduced, and changes in speech directivity and intelligibility noted. Analysed together, it appears that in frequency ranges 3-7 kHz, overall sound loss may lie between 4-6 dB for simple medical masks, increasing to 12-18 dB for more protective N95 masks. Multiple studies addressed mask wearing and auditory perception, though most only considered the speaking voice (Fiorella et al., 2021; Gama et al., 2022; Joshi et al., 2021; Lin et al., 2021; Magee et al., 2020; Oren et al., 2021). These findings have significant implications for singing while wearing a mask. Given available evidence, this author suggests that if teacher and student feel one design of highly protective face mask permits clearer voicework over others of equally comparable protection, then the preferred mask should be worn. Using masks that are less inhibitory to vocal projection may help avoid vocal strain and subsequent voice disorders. Australian teachers and students should use highly protective masks (e.g., N95 respirator masks) that have been tested by the Therapeutic Goods Administration (TGA) and found to comply with three criteria: fluid resistance, particle filtration, and sterility (Therapeutic Goods Administration, 2022). Singing students should also be reminded to ‘sing normally’ while masked up and be self-vigilant by notifying the teacher if pain or other negative vocal sensations are experienced. Vance et al. (2021) presented strategies to reduce risk of viral transmission in the music

V o c a l H a b i l i t a t i o n i n P o s t - A c u t e S y m p t o m a t i c C O V I D - 1 9 R e c o v e r y Australian Voice 2022 9 learning, performance, and practice contexts: “virtual rehearsals or performances, mask-wearing, smaller choirs, outside rehearsal and performance, socially distancing, shorter rehearsals, regularly cleaning commonly touched surfaces and washing hands, avoiding contact with others, and temperature screening” (p. 3). While Westphalen et al. (2021) tenuously suggested trying to limit consonant use during warm-ups to reduce aerosol dispersion, they encouraged a large safety distance between singer and teacher/audience (2-3 meters, provided the room is continuously ventilated). This recommended distance (obtained from data pooled across multiple studies) is greater than the onemetre distance suggested by WHO (World Health Organisation, 2022a). They also noted that face shields and plexiglass separators decreased movement of the initial aerosol jet while singing but are less effective than masks at preventing overall dispersion. Hence, highly protective masks remain preferred for protection when singing, particularly during high-risk periods. Managing Vocal Fatigue, Dyspnoea, and Neuromuscular Symptoms Siqueira et al. (2021) applied the Vocal Fatigue Index (VFI) to 121 singers segmented into professional (PSG) and amateur (ASG) singer comparison groups. The PSG group reported significantly higher vocal fatigue (tiredness and voice impairment) than the ASG. By extension, this suggests that (trained) singing teachers may experience greater vocal fatigue than their (learning) students. Hence, teachers should take proactive steps to avoid vocal fatigue of both parties, including regular periods of vocal rest. Cahalan et al. (2022) reported positive outcomes from a 10-week program of 45-minute online classes consisting of vocal exercises, singing, mindfulness, and breathing retraining. Participants reported significant improvements in dyspnoea, fatigue, pain, voice quality, and communication/cognition symptoms. These findings illustrate the holistic health benefits gained when multidisciplinary activities are incorporated into regular lesson plans. Hence, targeted age- and ability-appropriate mindfulness and breathing exercises can be used as a vocal habilitation tool for singers recovering from post-acute COVID-19. For guidance, see Varner (2022) and Espejo et al. (2020) for basic mindfulness strategies and exercises, and Chapman and Morris (2021) with regard to the accent breathing method. Kishbaugh et al. (2021) offer useful reminders to maintain suitable posture during speaking and singing. They encouraged teachers to introduce more prosody (varied time, rhythm, and intonation in speech) to help motivate students, show compassion, and build stronger studentteacher connections. Taking brief breaks and stretching were also practical ways to reduce fatigue, particularly during virtual lessons. In any event, most singing teachers agree that important benefits arise from having students stand with appropriate posture and bodily alignment while singing (Griffin, 2021). COVID-19 has been linked to malnutrition and frailty, which negatively affect muscle protein synthesis, resulting in loss of skeletal muscle mass and function (Barrea et al., 2022). Diet and hydration have long been part of vocal hygiene conversations for singing teachers (Achey et al., 2016; Hartley & Thibeault, 2014). Ensuring adequate hydration is essential to proper vocal function (Sivasankar & Leydon, 2010). Current Australian guidelines recommend about 10 cups per day for men, 8 for women, and 4-8 cups for children and adolescents depending on age and sex (National Health and Medical Research Council, 2014). Early evidence suggested that consumption of probiotics may reduce symptom duration and severity, particularly “fatigue, olfactory dysfunction and breathlessness, nausea and vomiting and other gastrointestinal symptoms” (Xavier-Santos et al., 2022, p. 174). Hence, teachers are encouraged to promote the idea that having a healthy, balanced diet may assist students to prevent infection, or reduce disease severity and duration (Chughtai et al., 2022; Farzana et al., 2022). Since providing specific professional dietary advice is not within singing teaching scope of practice, qualified advice should be sought as needed (Barrea et al., 2022). Post-viral vocal fold paralysis and paresis (weakness or partial paralysis) may be more common in singers than is currently reported (Helding et al., 2022). While unilateral vocal fold paralysis is usually treatable and often merely results in noisy, hoarse, squeaky, or quiet phonation; acute bilateral vocal fold paralysis can completely obstruct the airway and quickly become a medical emergency (Jungbauer et al., 2021). Hence, it would be valuable for singing teachers to have access to appropriate professional development opportunities where they can learn to aurally identify vocal fold dysfunction (at a high level), based on observed phonation and asking structured questions to explore how the student might perceive their vocal production in terms of felt sensations. In response to a call for increased

J e s s 10 Australian Voice 2022 vocal screening (Verma et al., 2022), this training could help prevent singing students with postCOVID-19 vocal dysfunction from ‘falling through the gaps’, ensuring they are referred to qualified medical and allied health practitioners for proper diagnosis and co-treatment if and as required, with the ultimate goal being effective vocal habilitation. Teachers should also maintain current Senior First Aid and Vocal Health First Aid certification, and have a detailed studio emergency management plan that lists actions to take if a COVID-19-related health emergency arises. Such pre-planning is important because it can have legal and insurance implications. Managing Cough, Mucous, Asthma, and Rhinitis This review found dry cough was prevalent in COVID-19 infections and regularly caused dysphonia. The pharmacological decision to treat or suppress specific types of cough using mucolytics or antitussives is complicated, and qualified medical or pharmacist advice should be sought (Chamberlain et al., 2013; De Blasio et al., 2011; Michael Foster, 2002). Regular steam inhalations can be safely recommended to help manage cough, nasal irritation, and congestion (Parvez et al., 2021; Swain & Sahu, 2021). Nasal irrigation (lavage) using hypertonic saline (sodium chloride) solution may decrease acute COVID-19 infection duration by 1.9 days (Vance et al., 2021). Teachers can safely recommend this topical treatment to students suffering upper respiratory tract congestion, sticky mucus, sneezing, post-nasal drip, sore throat, or sinus inflammation. The use of a neti pot or similar device may also be comfortable and appropriate, however the solution used to irrigate sinuses must be sterile (Horovitz, 2013). Another promising nondrug treatment has been proposed which uses intranasal calcium-rich hypertonic salts solution to hydrate the upper airways (Edwards et al., 2020; George et al., 2022). While a search of National Prescribing Service records returned only one relevant product currently available for purchase in Australia, other products may be available since these therapeutics are currently classed as unscheduled by the TGA (MedicineWise, 2018). Asthma, seasonal allergies, fever, mild pain, and headache are common complaints presented by singing students, even in nonpandemic times. These can all interfere with general wellbeing and vocal production. While some asthma reliever medications are now available over the counter in Australia (Therapeutic Goods Administration, 2019), the diagnosis of asthma and direction to use these medications is not within singing teacher scope of practice. This is reinforced by the fact that asthma can be lifethreatening. Students presenting with asthma-like symptoms (wheezing, chest tightness or pain, or coughing) should see their general practitioner, or a qualified pharmacist for initial advice. Arguably, the same position should be adopted in relation to paracetamol, ibuprofen, aspirin, codeine, fexofenadine, cetirizine, desloratadine, loratadine, nonsteroidal anti-inflammatory drugs (NSAIDs), and similar pain, allergy, and fever-relieving medications. Despite being mostly available over the counter and beneficial in the treatment of certain symptoms, these drugs have many contraindications for use, making qualified advice beneficial (Quincho-Lopez et al., 2021). Supporting Positive Mental Health Outcomes to Improve Vocal Production Meyer et al. (2021) highlighted that “trauma can also have a profound neurophysiological effect on singers” (p. 220). Singing teachers can have positive or negative impacts on student mental health (Miller, 2017). Hence, teachers are encouraged to normalise discussions around mental health and wellbeing with students, and should “cultivate professional relationships with mental health care providers” (p. 220) to refer students out as needed. The increased stress and anxiety caused by the pandemic has been related to widespread fatigue-related dyspnoea (Hentsch et al., 2021). Symptoms of anxiety and distress may be reduced by stimulating the vagal nerve through slow, deep belly and diaphragmatic breathing exercises with long exhalations (De Couck et al., 2019; Gerritsen & Band, 2018; Magnon et al., 2021). In turn, a reduction in these symptoms may help manage dyspnoea symptoms (Hentsch et al., 2021). While individual teachers will likely have multiple breathing exercises at the ready, the key to success here is focusing on longer exhalations (Gerritsen & Band, 2018). Hence, the use of Farinelli breathing (FB) exercises is indicated here. Though not directly related to COVID-19, FB exercises delivered impressive improvements in respiratory function in people suffering chronic obstructive pulmonary disease (Ittinirundorn et al., 2022). Finally, Meyer et al. (2021) suggested singing teachers should aim to provide positive, engaging, and enjoyable learning experiences. By prioritising self-regulation, teachers can confidently incorporate awareness about the

V o c a l H a b i l i t a t i o n i n P o s t - A c u t e S y m p t o m a t i c C O V I D - 1 9 R e c o v e r y Australian Voice 2022 11 different traumas the pandemic has caused into voice lessons. To achieve this, teachers might “develop a plan and communicate it, establish connection rituals, choose connection over productivity, validate students’ feelings, break tasks into smaller segments, show appreciation for effort, focus on positive resources, and be aware of the student’s self-regulation” (pp. 220-221). CONCLUSION The long-term prognosis of COVID-19 sufferers remains unclear and further research is needed across multiple domains. Limited research has been conducted in the context of singing voice pedagogy, vocology, and COVID-19 symptoms. This review found the impacts of COVID-19 infection on vocal health and production can be considerable and often chronic. These findings have wide-ranging implications for singing teachers and students. It is anticipated this narrative review will provide Australian singing teachers with important, useful background information on COVID-19 symptoms, their interrelationships and effects on vocal health and production. Research gaps have been identified to guide future focus, and vocal habilitation strategies across multiple pedagogical domains were presented. Several passing comments on relevant limitations to singing teaching scope of practice were also offered to promote professional dialogue. LIMITATIONS TO THE REVIEW Various limitations were applied to this review to narrow scope. It does not address symptomatic differences between COVID-19 virus variants (e.g., Delta, Omicron), preventative treatments including vaccination, rare or outlier disease complications (sequalae), co-morbidities, symptom frequency or prevalence. While select medical treatments are referred to where knowledge of it as a potential vocal habilitation tool may be useful to the teacherstudent relationship, such treatments largely fall outside scope of singing teaching practice. ACKNOWLEDGEMENTS The author would like to acknowledge the generous contribution of time and knowledge freely contributed by the late Emeritus Professor of Voice Elizabeth Reid, Angus Harrop, Clinical Pharmacist and PhD Student at the Pharmacy Australia Centre of Excellence (University of Queensland), and Dr Loki Johnk, Consultant Intensivist at Mater Health. REFERENCES Achey, M. A., He, M. Z., & Akst, L. M. (2016). Vocal hygiene habits and vocal handicap among conservatory students of classical Singing. Journal of Voice, 30(2), 192-197. https://doi.org/https://doi.org/10.1016/j.jvoice. 2015.02.003 Aghaz, A., Shahriyari, A., Panahiaboozar, S., Jadidi, H., Khoshgoftar, M., Choupani, E., & Hemmati, E. (2022). Prevalence of dysphonia in patients with COVID-19: A systematic review and meta-analysis. Journal of Modern Rehabilitation, 16(2), 131-138. https://doi.org/10.18502/jmr.v16i2.8582 Al Ismail, M., Deshmukh, S., & Singh, R. (2021). Detection of COVID-19 through the analysis of vocal fold oscillations [Conference Paper]. 2021 IEEE International Conference on Acoustics, Speech, and Signal Processing, ICASSP 2021, Toronto, Canada. Al Maqbali, M., Al badi, K., Al Sinani, M., Madkhali, N., & Dickens, G. L. (2022). Clinical features of COVID-19 patients in the first year of pandemic: A systematic review and metaanalysis. Biological Research for Nursing, 24(2), 172-185. https://doi.org/10.1177/10998004211055866 Al-Aly, Z., Bowe, B., & Xie, Y. (2022). Outcomes of SARS-CoV-2 reinfection. Research Square. https://doi.org/https://doi.org/10.21203/rs.3.rs1749502/v1 Al-Ani, R. M., & Rashid, R. A. (2021). Prevalence of dysphonia due to COVID-19 at Salahaddin General Hospital, Tikrit City, Iraq. American Journal of Otolaryngology - Head and Neck Medicine and Surgery, 42(5), Article 103157. https://doi.org/10.1016/j.amjoto.2021.103157 Amdal, C. D., Pe, M., Falk, R. S., Piccinin, C., Bottomley, A., Arraras, J. I., Darlington, A. S., Hofsø, K., Holzner, B., Jørgensen, N. M. H., Kulis, D., Rimehaug, S. A., Singer, S., Taylor, K., Wheelwright, S., & Bjordal, K. (2021). Health-related quality of life issues, including symptoms, in patients with active COVID-19 or post COVID-19: A systematic literature review. Quality of Life Research, 30(12), 3367-3381. https://doi.org/10.1007/s11136-021-02908-z Amorim dos Santos, J., Normando, A. G. C., Carvalho da Silva, R. L., Acevedo, A. C., De Luca Canto, G., Sugaya, N., Santos-Silva, A. R., & Guerra, E. N. S. (2021). Oral manifestations in patients with COVID-19: A living systematic review. Journal of Dental Research, 100(2), 141-154. https://doi.org/10.1177/0022034520957289 Anastasio, F., Barbuto, S., Scarnecchia, E., Cosma, P., Fugagnoli, A., Rossi, G., Parravicini, M., & Parravicini, P. (2021). Medium-term impact of COVID-19 on pulmonary function, functional capacity and quality of life. The European

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J e s s 20 Australian Voice 2022 Therapeutic Goods Administration. (2022, 5 August 2022). Testing of face masks and respirators: TGA Laboratories testing report . Retrieved 6 August from https://www.tga.gov.au/testing-face-masksand-respirators Titze, I. R. (2019). The rationale and history of vocology. Voice & speech review, 13(1), 106-111. https://doi.org/10.1080/23268263.2018.14398 67 Toba, N., Gupta, S., Ali, A. Y., ElSaban, M., Khamis, A. H., Ho, S. B., & Popatia, R. (2021). COVID-19 under 19: A meta-analysis. Pediatric Pulmonology, 56(6), 1332-1341. https://doi.org/10.1002/ppul.25312 Tomaszewski, W., Zajac, T., Rudling, E., te Riele, K., McDaid, L., & Western, M. (2022). Uneven impacts of COVID-19 on the attendance rates of secondary school students from different socioeconomic backgrounds in Australia: A quasi-experimental analysis of administrative data. Australian Journal of Social Issues, 1-20. https://doi.org/https://doi.org/10.1002/ajs4.219 Vance, D., Shah, P., & Sataloff, R. T. (2021). COVID19: Impact on the musician and returning to singing; A literature review. Journal of Voice. https://doi.org/10.1016/j.jvoice.2020.12.042 Varner, E. (2022). Mindfulness access points in general music: singing, breathing, and self-awareness. Journal of General Music Education, 35(2), 43- 46. https://doi.org/10.1177/27527646211060294 Veis Ribeiro, V., Silva, K. D., Guedes-Granzotti, R. B., César, C. P. H. A. R., Pinatti, P. A., Santos, N. M., & Dornelas, R. (2021). Stress and autonomic dysfunction symptoms related to voice in Brazilian university professors during the covid-19 pandemic. Logopedics Phoniatrics Vocology. https://doi.org/10.1080/14015439.2021.19394 13 Verma, H., Shah, J., Akhilesh, K., & Shukla, B. (2022). Patients’ perspective about speech, swallowing and hearing status post-SARS-CoV-2 (COVID19) recovery: E-survey. European Archives of Oto-Rhino-Laryngology, 279(5), 2523-2532. https://doi.org/10.1007/s00405-021-07217-2 Watson, N. A., Karagama, Y., Burnay, V., Boztepe, S., Warner, S., & Chevretton, E. B. (2021). Effects of coronavirus disease-2019 on voice: our experience of laryngeal complications following mechanical ventilation in severe coronavirus disease-2019 pneumonitis and review of current literature. Current opinion in otolaryngology & head and neck surgery, 29(6), 437-444. https://doi.org/10.1097/MOO.0000000000000 768 Westphalen, C., Kniesburges, S., Veltrup, R., Gantner, S., Peters, G., Benthaus, T., Jakubaß, B., Köberlein, M., Döllinger, M., & Echternach, M. (2021). Sources of aerosol dispersion during singing and potential safety procedures for singers. Journal of Voice. https://doi.org/10.1016/j.jvoice.2021.03.013 World Health Organisation. (2022a, 10 May 2022). Advice for the public: Coronavirus disease (COVID-19). Retrieved 27 July from https://www.who.int/emergencies/diseases/nov el-coronavirus-2019/advice-for-public World Health Organisation. (2022b, 31 July 2022). WHO Coronavirus (COVID-19) Dashboard. World Health Organisation. Retrieved 09 October from https://covid19.who.int/ Xavier-Santos, D., Padilha, M., Fabiano, G. A., Vinderola, G., Gomes Cruz, A., Sivieri, K., & Costa Antunes, A. E. (2022). Evidences and perspectives of the use of probiotics, prebiotics, synbiotics, and postbiotics as adjuvants for prevention and treatment of COVID-19: A bibliometric analysis and systematic review. Trends in Food Science and Technology, 120, 174-192. https://doi.org/10.1016/j.tifs.2021.12.033 Xu, W., Sunavala-Dossabhoy, G., & Spielman, A. I. (2022). Chemosensory loss in COVID-19. Oral Diseases. https://doi.org/https://doi.org/10.1111/odi.1430 0 Zachariah, P. (2022). COVID-19 in children. Infectious Disease Clinics of North America, 36(1), 1-14. https://doi.org/10.1016/j.idc.2021.11.002 BIOGRAPHY Dr. Daniel Jess is Senior Lecturer and Chair of Vocology and Voice Pedagogy at the Australian College of Vocal Arts. An accomplished opera and musical theatre performer and music director, Daniel also teaches singing at San Sisto College and is an Australian authority on practice-based leadership capability development. He has published research in the leadership, music and innovation fields. Daniel regularly presents at conferences, adjudicates Eisteddfods and is currently Deputy Chair of the Board at InCommunity.

A r t i c l e https://doi.org/10.56307/FNXD5489 Australian Voice | Volume 23 2022 21 Understanding the Vocal Skill Set for Contemporary Christian Singers: Insights from Elite Singers Leon Neto* and David Meyer # *Liberty University School of Music, #Janette Ogg Voice Research Center at Shenandoah Conservatory ABSTRACT: The American Academy of Teachers of Singing (AATS), advocates that CCM singers should be taught with dedicated pedagogical approaches for each style. Recent studies, however, suggest that most contemporary Christian singers (CCS) do not receive style-appropriate vocal training. It is possible that voice teachers are not fully aware of the skill set necessary for a CCS to be successful. In this context, elite CCSs, as models of excellence, may be able to help the voice community bridge this gap and identify the ideal skill set and the best pedagogical approach for the commercial success of CCSs. For this study, we interviewed three top selling, elite CCSs with extensive experience and recognised as highly representative of their style, aiming to understand the ideal vocal skill set of commercially successful CCSs. According to the participants, ideal CCS voices should use a pop sound and not sound too classical, should sing easily, comfortably, and with freedom. The singing should be not distracting and use good diction in order to be able to communicate the message clearly. Among the most relevant findings is the suggestion that CCSs have a heavy and demanding vocal load and are at risk for vocal injury. This finding is consistent to previous studies that suggest similar issues. We hope that our findings will help the development of more appropriate private studio strategies for CCSs. Future research for this population of singers may include analysis of worship applied voice curricula. INTRODUCTION Contemporary Christian singers (CCS) are a growing category of religious music singer (Brown, 2012). Terminology related to this style of singing has been debated for several years. The term “Contemporary Christian Music singers” or “CCM singers” was used initially, however the acronym “CCM” is now strongly associated with Contemporary Commercial Music, a term coined by Jeannette LoVetri (LoVetri, 2002). To avoid confusion, we will use the terms CCS (Contemporary Christian Singer) and WL (Worship Leader) for the purpose of this study. We understand that these terms are not ideal, but in the United States these terms are commonly accepted in the singing community. Contemporary Christian music and particularly the Praise and Worship style (P&W), has achieved great economic success in the music industry and even surpassed more established genres such as classical and jazz (Nielsen Christian Soundscan, 2016; Ingalls, 2008; Lindenbaum, 2013). P&W is the preferred musical style used by CCSs. Within P&W style, songs are usually performed in congregational worship services and have easy-to-learn melodies, a comfortable range, and often feature repetitive choruses (Neto, 2010). Even when performed in a concert setting, songs are used for communal worship within P&W style. CCSs in many cases fill multiple roles, acting simultaneously as worship leader, singer/songwriter, producer, and even pastor (Radionoff, 2015). Because of the similarity of roles and vocal characteristics, CCSs and Worship Leaders (WL) are sometimes grouped as a single category of singers (Neto, 2010; Dawson, 2005; Robinson, 2003). Monique Ingalls (Ingalls, 2008) likens their music and vocal production to poprock, and Howard suggests that of all popular music styles, rock is the strongest influence on contemporary Christian music (Howard, 1992). Some authors have logically concluded that CCSs/WLs should be classified as a sub-set of contemporary commercial music (CCM) singers (Weekly & LoVetri, 2009; Robinson, 2011). The American Academy of Teachers of Singing (AATS) advocates that CCM singers should be taught with dedicated pedagogical approaches for each style (NATS, 2008). Dawson, however, suggests that most CCSs/WLs are not trained primarily in contemporary styles (Dawson, 2005, p. 9). In spite of the growing number of training opportunities for CCSs/WLs, it is possible that these singers are not receiving the most appropriate type of preparation and training for their specific style demands (Radionoff, 2015). Due to the scarcity of studies on this population of singers, it is possible that voice teachers are not aware of the skill set necessary for a CCS to be successful. If this dearth of knowledge is not addressed, an under-served population of singers

M e y e r a n d N e t o 22 Australian Voice 2022 may have suboptimal vocal training and be at-risk of higher rates of vocal pathology. The term “elite” typically refers to “a group of people considered to be superior in a society or organisation” (Concise Oxford English Dictionary, 2008), and elite singers often represent models of excellence (as selected by the marketplace) for each music style (Hall, 2014; Hines, 2012; Brower, 1996). However, there may be a disconnect between what voice teachers and elite Christian singers see as the ideal voice for CCSs. An investigation on elite CCSs may help the voice community bridge this gap and identify the ideal skill set and the best pedagogical approach to help voice students, potential professional CCSs, achieve commercial success. PURPOSE The purpose of this study was to investigate the self-identified vocal skill set of commercially successful CCSs/WLs, as perceived by top selling, elite CCSs with extensive experience and recognised as highly representative of their style. This study aimed to answer the following research questions: What vocal skill set do elite CCSs observe in singers of this style with commercial potential? What do elite CCSs perceive to be the ideal vocal characteristics of CCSs/WLs? METHOD We obtained data through semi-structured interviews, using a qualitative study approach, most appropriate for naturalistic inquiry (Erlandson, Skipper, Allen, & Harris, 1993; Patton, 1990). The methodology for this present study was based on a previous study with similar goals, targeting music producers specialised in contemporary Christian music (Neto & Meyer, 2016). The current study used a similar methodology because it addresses a similar research problem, albeit seeking insights from a different population (elite CCS singers). We hope that these results will help identify skills that elite CCS singers believe are necessary for success in their profession. Participants included in this study were top selling professional CCSs, Dove or Grammy award winners or nominees, with extensive experience in the market and recognised as highly representative of the style. Participants Due to the nature of our sampling criteria, we opted for an expert sampling method approach. Expert sampling is a purposive sampling technique that targets participants who have a distinct expertise (Zafar, Ganguly, Gummadi, & Ghosh, 2015). We quickly realised that elite CCSs represent a very small and specific population in the US, are difficult to contact and with extremely busy schedules. In that sense, expert sampling, which typically includes small sample sizes, seemed to be the most appropriate and viable option for our study (Zafar, Ganguly, Gummadi, & Ghosh, 2015; Bruce, Langley, & Tjale, 2008). As mentioned before, we based our methodology on a previous study; in that particular study, three music producers specialised in contemporary Christian music were asked to name singers that best represent the vocal qualities necessary for successful CCS. We selected our potential participants from data collected in our previous study (Neto & Meyer, 2016). After gathering data from the cited study, we ranked the CCSs by the following criteria: 1) CCSs named by all three producers; 2) CCSs named by two producers; 3) CCSs named by only one of the producers; 4) Multiple Grammy or Dove award winners; 5) Single Dove and Grammy award winners; 6) Single Dove or Grammy award winners; 7) Grammy and Dove award nominees; 8) Grammy or Dove ward nominees. Singers who were not at least nominated for a Grammy or Dove award at the time of our study, were not considered. The Dove Awards is the most prestigious award in the Christian music industry (GMA, 2022). The Grammy Awards is the main music industry award and includes a category for contemporary Christian music (Grammy Awards, 2022). We then proceeded with contacting the singers according to the rank, starting with the highest to the lowest rank. The singers were contacted via e-mail, mostly through their official webpages. The singers who did not have an official webpage were contacted via social media webpages. After proceeding with the sampling protocol, contacting CCSs according to our pre-determined ranking, we received four responses. We identified the three singers with higher rankings and discarded the fourth one. Two of the participants were interviewed by Skype and one of them by phone. Data collection Data for our study were collected through semistructured interviews. Each interview took between

U n d e r s t a n d i n g t h e V o c a l S k i l l S e t f o r C o n t e m p o r a r y C h r i s t i a n S i n g e r s Australian Voice 2022 23 twenty and twenty-five minutes. The participants were interviewed via Skype or by phone and the interviews were recorded using Voice Record, a recording application for iPad, and MP3 Skype recorder software for Skype interviews. All interviews were conducted and recorded by the first author (L.N.). Only the audio of the interviews was recorded. After the transcription, the interviews were peer checked by the second author (D.M.) and member checked by the participants. Each CCS received a transcript of his/her interview and were asked to check if their ideas were accurately transcribed. The participants had a chance to delete, add, or change the transcript content. None of the participants made any corrections. The participants answered the following interview questions: 1. We all know that an ideal Christian singer should have a solid theological background and an unquestionable ministry calling; but, from a strictly vocal perspective, how would you describe the basic characteristics of successful CCS voices? 2. What do you think makes a good voice for a CCS? 3. What type of vocal training do most CCSs you know have? 4. What type of vocal training do you think CCSs should have? 5. How important is it for the voice teacher of a CCSs to have performing and training experience in contemporary Christian music styles? 6. Is there anything that you would like to add or that I might have forgotten to ask? Human Ethics Approval All interviews were conducted in full compliance with Shenandoah University IRB policies and procedures. The participants freely consented to their participation and to the publication of these results through a signed consent form. Analysis We applied a qualitative content analysis approach to our data (St. Pierre & Jackson, 2014). Two levels of codes were created: “parent” codes, broader, easier to apply, defining major concepts that apply to the research questions, and “children” codes, which were more detailed, nuanced and harder to apply in reliable ways, but helped to enrich the content (Gough & Scott, 2000) (See Figure 1 for a complete list of codes). These codes were based on the methodology used in the previous study (Neto & Meyer, 2016). The interviews were transcribed and then coded thematically, using the qualitative research software Dedoose 7.0.23®. Parent codes were applied first and then children codes. This process was applied twice in each interview by the primary researcher and checked for accuracy by the secondary researcher. After coding the interviews, we selected parent codes with occurrences in all three participants and identified key words or themes that could summarise each coded statement. We then proceeded to locate keywords with similar meaning across these occurrences. After that, we applied the same protocol to children codes. Keywords or themes relevant to the research questions and with occurrence in more than one participant were considered significant. We did this process until we reached saturation and the same keywords started to appear constantly in cooccurrences. Figure 1. Parent and children codes

M e y e r a n d N e t o 24 Australian Voice 2022 RESULTS The largest occurrences of parent codes were: Training (59), Voice Characteristics (44), Artistry and Expression (29), Vocal Technique (22), and Vocal Health (17). The largest occurrences of children codes were: Style (18), Classical Training (16), Range (13), Tone (11), and Repertoire selection (9). (See Figure 2 for a complete list of code application). The largest co-occurrences were: Artistry and Expression x Style (21), Training x Classical Training (18), Voice Characteristics x Tone (17), Voice Characteristics x Range (14), and Voice Characteristics x Voice type (11). Parent codes with occurrences across all three participants were: Voice Characteristics, Vocal Technique, Artistry and Expression, Training, Vocal Health, and Personality. Children codes with occurrences in all three participants were: Tone, Range, Voice Type, Registration, Repertoire selection, Style, and Classical training. For the purposes of reporting results, the participants will be represented as follows: Singer 1 (S1), Singer 2 (S2), and Singer 3 (S3). All quotations and excerpts extracted from the interviews will be represented in italics. Parent codes Under the parent code Training, the participants seem to suggest that CCSs should seek for some type of vocal training; this can be verified in keywords and expressions such as Hone your craft (S1), Practice (S3), Preparation (S3), and Mentor (S3). S3 used the expression skilled and trained, as a religious command to encourage CCSs to seek constant training. The participants were not specific in terms of what is the ideal type of training for CCSs, but keywords such as Belmont (S1), American Idol (S1), Speech level singing (S2), Easy singing (S2), and Blaylock (S2) may suggest a commercial (CCM) approach. At the same time, the participants in general think that classical singing is beneficial for the training of CCSs, as they applied terms such as Appropriate singing (S1), Good technique (S2), Singing properly (S1), and Open throat (S2), when asked about classical training for CCSs. The participants also employed terms that suggest that knowledge and experience with sound reinforcement technology is important for the training of CCSs: Recorded material (S2), Sound systems (S2), Ear monitors (S2), Mic technique (S2). When asked about what type of training most CCSs they know have, the participants said that most have No training (S2), Some training (S3), Basic vocal technique (S2), or Singing in church (S1). Under Voice Characteristics, we identified the keywords Common voice (S2), Normal (S2), Not beautiful (S2), Not Great singer (S1), and Vulnerable voice (S1), suggesting that CCS voices have conversational vocal textures. The participants seem to encourage vocal features such as Rasp (S1), Rough sound (S2), Cut through the noise (S2), and Sing hard (S1), but at the same time suggest that CCS voices should be Not too strained (S1), have a Clear sound (S1), Clarity (S2), and Little vibrato (S3). In terms of Artistry and Expression, the participants suggested that CCS singing should be straightforward (S2), Not flowery (S2), Not distracting (S2), Intimate (S3), Comfortable (S1), with Freedom (S1), and Simplicity (S2). The participants also seem to place some emphasis on singing with Passion (S1) and Intent (S3), in order to deliver the Message (S3) appropriately. Under Vocal Technique, we identified keywords like Proper (S1), Fuller sound (S2), Support (S2), Posture (S1), Chest voice (S1), Flip (S1), Head voice (S3), and Placement (S3). Also under this parent code, the participants seem to place particular importance on diction, using keywords such as Enunciate (S1), Understand (S1), Pure vowels (S2), and Proper vowels (S2). The participants demonstrated some concerns about CCSs’ Vocal health, particularly due to their constant Tours (S1) and Concerts (S2), employing terms such as Hard singing (S1), Strained (S1), Phlegm (S2), Fatigue (S2), Forced singing (S2), Injure yourself (S2), Trouble (S2), Hoarse (S3), and Tired (S3). The participants suggested that Rest and water (S2), Warm up (S2) and knowledge about Physiology (S3), are important measures to maintain good vocal health and promote Longevity (S2). In terms of Personality, the participants suggested that CCSs should be Available (S1), Love people (S1), have a Heart (S2) for the ministry and be willing to Serve (S3). Children codes Under the children code Style, the participants seem to suggest that CCSs should have a Pop sound (S1), Not classically (S2). The participants also emphasized Simplicity (S2), Not a ton of licks (S2), Not distracting (S2), Not too much stuff (S3) when discussing P&W style. In the same sense, the participants seem to denote the congregational nature of P&W style when using terms like Crowd

U n d e r s t a n d i n g t h e V o c a l S k i l l S e t f o r C o n t e m p o r a r y C h r i s t i a n S i n g e r s Australian Voice 2022 25 (S2), Audience (S3), Broad (S2), and Christian Radio (S2). Under Range, the participants also reiterated the communal characteristic of P&W style with terms such as Sing along (S1) and Congregation (S2). The participants described CCS voices in terms of range, as Close range (S1), D to F (S1), Limited scope (S2), and Tender place (S3). The participants seem to suggest that Repertoire Selection is an important skill for CCSs. Under this children code, we identified terms such as All about the song (S1), Original artist (S3), Not too hard (S1), Appropriate (S3), Intimate (S3), and Personal (S3). Figure 2. Code application DISCUSSION In general, the participants seem to suggest that CCSs are singers with common, normal voices. S2 mentioned about CCSs voices: a voice that is not distracting, a voice that sort of blends in, almost a voice that kind of represents the normal. The reason for this assessment may be related to the characteristics of P&W style: P&W songs are written within a limited scope of range and in a key in which, you know, the common man or women can easily sing it, even the ones who do not consider themselves singers (S2). The simplicity of P&W repertoire is also reflected in the participants’ description of the range of CCSs as closed and limited. S1 explains: if you are wanting people to sing along, it definitely needs to be in that kind of range that kind of everyone can kind of sing with. In this sense, middle voices and not extreme voices, would probably fit better the style: you are looking for a little bit more normal than you are the extreme (S2). At the same time, the participants suggested that although CCS voices are ordinary and common, some kind of uniqueness is valued. S1 mentioned: I still think there’s something to their voice that is… it draws you in. S2 states about ideal CCS voices: a voice that kind of cuts through the noise. It is difficult to make a conclusion about what the participants intended to say, because these expressions are vague and subjective. However, it is possible to identify more specific examples of how this uniqueness can be expressed in CCS voices. S1 states: she has this unique little rasp to her voice, you know, that makes it hers, while S2 mentions a successful CCS with a rough sound. This is particularly surprising, considering that the participants were all in agreement about clarity, clear sound and straightforward as ideal characteristics of CCS voices. The way the participants described CCS voices as pop sound and Christian radio sound, is consistent with previous studies that emphasised the commercial, pop-rock nature of contemporary Christian music. The participants suggested that classical voice training may be beneficial to CCSs, but they were clear in stating that ideal CCS voices should not sound as if they’re singing an opera aria, because it doesn’t fit the genre (S2). These statements are relevant in terms of identifying what pedagogical approach is more appropriate for the training of CCSs and corroborate the AATS statement (NATS visits AATS, 2008) that advocates for a specific, commercial training for CCM styles. Participants’ concerns about CCSs vocal health were particularly relevant to this study. S1

M e y e r a n d N e t o 26 Australian Voice 2022 describes what they consider to be a good and healthy CCS: I can’t imagine he hasn’t had some training to help him not kill his voice every night. S1 adds that You can’t tour and take care of your voice and all of that without singing properly. S2 seems to agree and adds that I think all Christian singers should learn basic vocal technique. Because if you’re gonna be doing concerts, you know, and you stand there for hour and a half, two hours, you’re gonna need to be on developing some longevity to that voice, or you’ll injure yourself. All three participants seem to see some connection between vocal health and vocal training. In our study we identified eight instances when there was a co-occurrence of these two codes (Vocal Health x Training). S2 demonstrated concern when stated that most CCSs he knows, do not have any type of vocal training: a lot of them get in trouble because of that. S2 also states that a lot of Christian musicians need to learn how to warm up properly. S3 even suggested that physiological knowledge about vocal functions is a key component for CCSs to promote vocal health. In terms of training, the participants were not specific about what technique or pedagogical approach is most appropriate for CCSs. Although most of the participants spoke positively about traditional classical training, they also emphasised that the ideal vocal sound of CCSs should be commercial, contemporary and not classical. S2 mentioned speech level singing and Blaylock technique. Further research could potentially clarify if these methods have appropriate elements for training CCSs. The participants mentioned that a good technique for CCSs should help them sing easily, comfortably, and with freedom. The two technical aspects with the largest occurrence were breathing and diction. S2 mentioned that singing is 95% breathing anyway, while S3 mentioned that If I could go and work with a worship team and suggest one thing to them, it would be, learn to breathe. I think when you learn to breathe properly, I think everything else begins to fall in place. Diction seems to be extremely important due to the confessional, religious nature of P&W style. Clearly communicating the text of the music is primary. S2 explains: in Christian music, the overriding element that’s most important, is the message. So, I think it’s important that Christian singers use good diction. In that sense, S2 even suggests that Italian diction could be beneficial for CCSs: if you can learn to sing pure vowels, and then just wrap those consonants around it, it will help the diction of your singing, will help you create a much rounder, fuller sound, and will create the message, make it much more powerful ‘cause people can understand you. Style appears to be another performance aspect for CCSs that needs to be serving the main purpose of delivering the message. The participants mentioned terms such as simplicity, not a ton of licks, not distracting, not flowery, and straightforward when describing CCS voices. The participants seem to suggest that a CCS’s performance style should be clean, with few embellishments and conveying the message of the primary. Also emphasising the importance of delivering the message for CCS performances and the congregational nature of P&W style, S2 stated the importance of good intonation: he just needs to be in tune, so he doesn’t become a distraction to the worshipers. CCSs are a sub-set of CCM singers, therefore it was not surprising that the participants suggested that CCSs should feel comfortable with using microphones and other types of sound reinforcement. The fact that the participants identified CCS sound as pop, may be enough to suggest some type of microphone technique, since pop-rock sound by its own nature is an electronically reinforced sound. CONCLUSION While the data presented in this study provide a useful insight into the skill set of successful CCSs/WLs, the small sample size does not support broader generalisations. The specificity and high profile of our participants proved to be a challenge. Singers at this level have busy schedules with limited time for interviews. Their level of expertise, however, was invaluable to our research. We hypothesised that insights from CCS elite singers would be valuable for singing voice pedagogues. The participants of our study are extremely representative of CCSs style and have enjoyed careers with great success. Among the most relevant findings is the suggestion that CCSs have a heavy and demanding vocal load, and may face elevated risk of vocal injury. This finding is consistent with previous studies (Dawson, 2005; Robinson, 2011). It is also noteworthy that our elite CCS participants themselves have little to no formal vocal training in Western classical singing styles. While stylespecific training is warranted, current CCS training is largely based on Western classical singing (Robinson, 2011). The authors hope that training standards for CCSs may increasingly reflect the musical demands these singers will experience. We hope that these findings may encourage the development of style-appropriate applied voice curricula for worship degrees that optimally prepare

U n d e r s t a n d i n g t h e V o c a l S k i l l S e t f o r C o n t e m p o r a r y C h r i s t i a n S i n g e r s Australian Voice 2022 27 CCSs to meet their specific technical and stylistic needs. We further hope that these findings may aid in the development of appropriate private studio strategies for CCSs. Future research for this population of singers, may include analysis of worship applied voice curricula, investigation of microphone techniques, and P&W repertoire analysis. REFERENCES Brower H., Cooke, J. F. (1996). Great singers on the art of singing. Courier Corporation. Brown, C. (2012). Selling faith: Marketing Christian popular culture to Christian and non-Christian audiences. Journal of Religion and Popular Culture, 24(1), 113-129. doi:10.3138/jrpc.24.1.113. Bruce. J. C., Langley, G. C., & Tjale, A. A. (2008). The use of experts and their judgments in nursing research: An overview. Curationis, 31(4), 57-61. Dawson A. (2005). Voice training and church singers: The state of vocal health of church singers of contemporary commercial styles in charismatic evangelical churches. [Masters Thesis, Queensland Conservatorium, Griffith University]. Erlandson, D. A., Skipper, B. L., Allen, S. D. & Harris, E. L. (1993). Doing naturalistic inquiry: A guide to methods. SAGE. GMA Dove Awards. https://doveawards.com/ Published 2022. Gough, S., & Scott, W. (2000). Exploring the purposes of qualitative data coding in educational enquiry: Insights from recent research. Educational Studies, 26(3), 339-354. Grammy Awards. https://www.grammy.com/ Published 2022. Hall, K. (2014). So you want to sing music theater. Scarecrow Press. Harrison, M. F. (2005). “ERACE-ing” the color line: Racial reconciliation in the Christian music industry. Journal of Media and Religion, 4(1), 27- 44. doi:10.1207/s15328415jmr0401_3. Hines, J. (1982). Great singers on great singing. Hal Leonard Corporation. Howard, J. (1992). Contemporary Christian music: Where rock meets religion. Journal of Popular Culture, 26(1), 123-130. Ingalls, M. (2008). Awesome in this place: Sound, space, and identity in contemporary north American evangelical worship. [PhD. Dissertation, Univeristy of Pennsylvania]. ProQuest Dissertations and Theses Gobal. doi:10.1017/CBO9781107415324.004. Lindenbaum, J. (2013). The neoliberalization of contemporary Christian music’s new social gospel. Geoforum, 44, 112-119. doi:10.1016/j.geoforum.2012.10.007. LoVetri, J. (2002). Contemporary Commercial Singing: More than one way to use the vocal tract. Journal of Singing, 58(3), 249-252. NATS Visits AATS. (2008). Journal of Singing, 65(1), 7-10. Neto, L. (2010). Contemporary Christian music and the “praise and worship” style. Journal of Singing, 67(2), 195-200. Neto, L. & Meyer, D. (2016). Understanding the vocal skill set for contemporary Christian singers: Insights from expert producers. [Three-Article Dissertation, Shenandoah Conservatory of Shenadoah University]. Nielsen Christian Soundscan. (2016, February 2). Nielsen Christian Soundscan, best Christian/Gospel selling albums. Retrieved February 2, 2016. http://www.nielsen.com/us/en/insights/reports/2 016/2015-music-us-year-end-report.html. Patton, M.Q. (1990). Qualitative evaluation and research methods. SAGE. Radionoff, S. (2015). The SVS & contemporary Christian music—Part 1: A brief overview. The Journal of the New York Singing Teacher's Association, March-April 2015, 4-5. Robinson, D. K. (2003). Contemporary worship leaders and their environments: To what extent is the vocal health of the contemporary worship leader within the charismatic christian church affected by cultural and environmental factors associated with the role? [Masters Thesis, Queensland Conservatorium, Griffith University]. Robinson, D. K. (2011). Contemporary worship singers: Construct, culture, environment and voice. [Doctoral Dissertation, Queensland Conservatorium, Griffith University]. Soanes C. & Stevenson A. (2008). Concise Oxford English dictionary (11th ed. rev). Oxford University Press. St. Pierre, E. A., & Jackson, A. Y. (2014). Qualitative data analysis after coding. Qualitative Inquiry, 20(6), 715-719. Weekly, E. M., LoVetri, J. L. (2009). Follow-up contemporary commercial music (CCM) survey: Who’s teaching what in nonclassical music. Journal of Voice, 23(3), 367-375. doi:10.1016/j.jvoice.2007.10.012. Zafar, M. B., Bhattacharya, P., Ganguly, N., Gummadi, K., & Ghosh, S. (2015). Sampling content from online social networks: Comparing random vs. expert sampling of the twitter stream. ACM Transactions on the Web (TWEB), 9(3), 12-33. doi:10.1145/2743023. BIOGRAPHY Dr. David Meyer. A leading voice pedagogue and scientist, Dr. David Meyer is an active performer, teacher, and vocologist. He is Director of the Janette Ogg Voice Research Center and serves

M e y e r a n d N e t o 28 Australian Voice 2022 as Associate Professor of Voice and Voice Pedagogy at Shenandoah Conservatory. Meyer is a member of the Scientific Advisory Board of the Voice Foundation and co-chairs the NATS Voice Science Advisory Committee. In 2010 he received the Van L. Lawrence Fellowship, a prestigious national award in recognition of his contributions to the field of teaching singing and the use of voice science. Dr. Meyer’s students have won numerous awards and have sung in major venues worldwide. Dr. Leon Neto is a multi-instrumentalist Christian artist, educator, and researcher. He has worked in numerous capacities in the music industry, including producer, musician, singer, and arranger in almost a hundred different albums. Dr. Neto was the first researcher accepted for publication on topics related to contemporary Christian music in the Journal of Singing and the Journal of Voice, two prestigious academic journals in voice science. He presents regularly at conferences and travels overseas frequently for concerts, lectures, and missionary work. Dr. Neto is an associate professor of voice, guitar, and ethnomusicology at Liberty University School of Music.

A r t i c l e https://doi.org/10.56307/MRRB6629 Australian Voice | Volume 23 2022 29 Vocal Health and Wellbeing: Behaviours and Confidence in Solo and Choral Classical Singers Timothea Lau*, Victoria Flood#, Helen F. Mitchell* *Sydney Conservatorium of Music, The University of Sydney #Faculty of Medicine and Health, The University of Sydney, ABSTRACT: All singers require good health to perform and have needs unique to their instrument. Both solo and choral university singing may have an increased vocal load, exacerbating their risk of injury. This study aimed to investigate the vocal health behaviours and confidence of tertiary choral and solo classical singers. Thirty-three singers (F=84.8%, solo=15, choral=18) took part in a questionnaire about voice behaviours, confidence seeking vocal health information and awareness of vocal risks. Solo singers (70%) reported more voice difficulties compared to choral singers (47%). Solo singers dedicated significantly more time to maintaining vocal health (p= 0.03). Both groups had similar confidence in judging vocal health information. All singers struggled to judge poor vocal behaviours and did not have a good grasp of vocal health/hygiene. Solo singers engaged in potentially voice harming behaviours such as long periods of speaking or voice use at work more frequently. Students were unsure where to find reliable sources of vocal health information and how to access health professionals. Future solo and choral training should include education on vocal hygiene and vocal health information to prevent the development of harmful behaviours and reduce the chance of voice disorders. KEYWORDS: Vocal health, vocal hygiene, solo singers, choral singers, health training Learning classical singing is a complex process that requires fine muscular control and understanding. Classical singing requires the mastery of specific skills (Howard et al., 2007). For most classical singing students, studying singing is a way in which they can learn to achieve an efficient and easy vocal production that forms the foundation for their future professions (Nowell, 2004). Young singers understand the importance of vocal techniques as contributing factors to good singing; however, it is unclear how much emphasis these singing students assign to their mental and physical health. In particular, the vocal demands placed on university level singers are high (Achey et al., 2015). The combination of singing during voice lessons, ensemble rehearsals and individual practice increases the risk of vocal fatigue and injury (Gaskill et al., 2013). This lack of awareness during the student years may lead to singers being unprepared to manage the demands of professional life (Wynn Parry, 2004). All musicians have challenges around maintaining good health to perform (Ackermann et al., 2014; Bragge et al., 2006; Kenny & Ackermann, 2015), however singers have needs that are unique to their instrument (Achey et al., 2015; Kreutz et al., 2009). Singers, as professional voice users, require good physical and mental health to perform optimally. The vocal instrument is sensitive to stress and psychological pressure increases the tension in the laryngeal muscles, causing vocal difficulties to emerge (Seifert, 2005). This effect of stress is not limited to the anxiety caused by performance, but also due to academic studies and daily life pressures (Achey et al., 2015; Seifert, 2005). Unlike instrumental musicians, singers need to take into consideration social and recreational use of their voice (Tepe et al., 2002). They need to be aware of how the volume and type of voice use, stress, avoiding damaging behaviours such as shouting over noise, and hydration, can affect vocal longevity (Achey et al., 2016). The risk of injury increases as vocal load intensifies, as well as the physiological manifestation of performance anxiety prior to a public or non-public performance (Studer et al., 2014). University singing students often participate in choral and solo singing simultaneously, and each style can present distinct challenges. Solo and choral singing require different approaches to intonation, pitch quality, acoustic load and intensity and these differing styles of singing may result in conflicting techniques, impacting vocal health (Ekholm, 2000; Nerland, 2007; Olson, 2010). In choral singing, there is less energy in the singer’s formant (Letowski, Zimak & Ciolkosz-Lupinowa, 1988;(Rossing, Sundberg & Ternstrom, 1987). Vibrato tends to be wider in solo singing rather than choral singing (Rossing et al., 1987). This “dampening” of the voice may be done to achieve choral blend (Reid et al., 2007). As a result, voice

L a u e t a l 30 Australian Voice 2022 teachers advise students to avoid concurrent solo and choral performance due to these conflicting vocal techniques (Ekholm, 2000). These varying methods of activity, and constant use of their instrument, highlights how maintaining good health is a lifestyle for singers (Achey et al., 2016). Singers are particularly sensitive to their vocal health and as a result, actively seek out vocal health information compared to their non-singing counterparts (Perkins et al., 2017). As professional voice users, singers are more at risk of developing vocal disorders (Achey et al., 2015; Latham et al., 2016; Petty, 2012). Singing is an integral aspect of singers’ identity and they are more likely to become distressed by voice difficulties (Oakland et al., 2012; Sapir et al., 1996), though they often do not adhere to vocally safe behaviours (BroaddusLawrence, 2000). Singing students prefer to consult their teachers about voice disorders rather than seek advice from medical or health professionals. Petty (2012) found that singing students were thirteen times more likely to have searched for medical advice on vocal difficulties than their non-singing counterparts, though their sources were undefined (Petty, 2012). Another study found that singing students were unsure of where to find reliable sources of information and were concerned with the quality and accuracy of voice-related health advice (Perkins et al., 2017). Kwak et al. (2014) found that advanced singers did not possess significantly more knowledge of the voice and its management than those who were more novice. Pedagogues’ own experiences of vocal health education in one-to-one teaching lead inevitably to a variation in vocal health education (Nerland, 2007). Regardless of the experience of singing students, they regard their teachers as the gatekeepers and primary source of information for vocal health (Petty, 2012). Though medical and health professionals are seen as the most reliable sources of health information, they are associated with voice disorder management, rather than with prevention (Braun-Janzen & Zeine, 2009; Petty, 2012). Attitudes towards managing health begin early in a musician’s education (Voltmer, 2010) and young singers are often left to manage and explore their vocal limits, unaware of the need or benefits of vocal rest (Gaskill et al., 2013). Professional singers continue to perform while sick and take on high vocal loads to support employment (Bartlett & Wilson, 2017). It appears there is a lack of health promotion in solo and choral singing education to prevent the development and perpetuation of negative vocal health behaviours (Ziegler & Johns, 2012). The aim of this study is to investigate solo and choral singers’ understanding and awareness of vocal health and hygiene and explore their healthmanagement behaviours. METHOD Ethics The institutional Human Research Ethics Committee approved this study. All participants were given a Participant Information Statement and indicated consent before completing and submitting the online questionnaire. Study Design Solo and choral classical singing students at a conservatorium within an Australian university completed an online vocal health awareness questionnaire and reported their voice use and habits and health-seeking behaviours. Participants Participants were aged 18 and above. All solo singers were undertaking training in classical singing at a conservatorium. Choral singers were trained in an auditioned, professionally performing Sydney youth choir singing classical choral repertoire. Participants were recruited through purposive sampling. Advertisements for the study were made via flyers, social media groups, eLearning websites and in person. A total of 33 students participated in the survey, with 18 solo trained singers, and 15 choral trained singers. Most singers were undergraduate students at university (75.8%) (n=25), and 24.2% (n=8) were postgraduate students. The majority were female (84.8%) (n=28) and the most common age group was 18-22 years (48%) (age categories ranged from 18 years to >30 years). Eighty-four percent of singers reported that voice was their primary instrument (84.8%) (n=28) with 24.2 % (n=8) studying an instrument in addition to voice. Sixty-one percent of all participants stated they had greater than eight years of vocal study. A betweengroup analysis showed no significant differences between cohorts, therefore both groups of singers were comparable. Questionnaire The questionnaire consisted of four sections: demographics; students’ frequency and

V o c a l H e a l t h a n d W e l l b e i n g Australian Voice 2022 31 environment of voice use; ratings on student confidence in seeking and following vocal health information; potential risk factors for voice difficulties (after Batterham et al., 2014; Sataloff, 1987). Data Analysis All quantitative data analyses were performed using SPSS 22 (SPSS IBM, NY, USA). Demographic data is presented as descriptive frequencies. MannWhitney U tests were used to assess any statistical differences between solo and choral singers for the variables 1) age group; 2) years of study at university and 3) years of voice study. Chi-squared tests were utilised to analyse for any statistical differences between the cohorts for the variables 1) gender; 2) language and 3) voice as main instrument. Fischer exact tests were used to evaluate significant differences between groupings for the variables 1) degree and 2) studies an instrument other than voice. These initial analyses revealed no differences in baseline characteristics between the two groups, suggesting that groups were well-matched. This implies that any differences in further analysis can be attributed to the differences between choral and solo singers, not to any background variables. Data was separated into two groups (solo vs choral singers) for analysis of responses related to general vocal health and voice use. Variables for general vocal health were analysed for significant differences between cohorts using Fischer exact tests and Chi-squared tests. Mann-Whitney U tests were performed on variables 1) priority of voice practice and 2) voice use when sick, to reveal any statistical significance. Data pertaining to vocal health confidence have been grouped into four cohorts for analysis (solo vs choral singers, and undergraduate students vs postgraduate students). This analysis was completed to investigate specialised classical voice training and years of experience on vocal health confidence. A measure of the central tendencies between these groups were measured using the Mann-Whitney U test for all questions related to vocal health confidence. Qualitative responses to the open-ended questions were used to triangulate and support the quantitative data analysis. RESULTS As initial analyses showed that solo trained singers and choral trained singers were comparable, statistical analyses for the below variables were completed. General Vocal Health Seventy-one percent of solo trained students reported experiencing voice difficulties compared to 46.7% choral singers (Figure 1). Solo singers were twice as likely (45% vs. 27%) to experience vocal fatigue (Figure 1). Solo singers reported engaging in potentially risky vocal behaviours more frequently than choral singers (i.e. long periods of speaking; 83% vs. 67%) (Figure 1). However, there were no statistical differences between solo and choral singers in their vocal health behaviours. All singers (solo and choral) discussed that most of their voice use is “singing in choirs” (P04) and “speaking conversationally” (P06). Most choral singers reported that they mainly used their voices for “singing and for talking” (P22). In contrast, solo singers reported using their voice as an aid in teaching, conducting, or composing, for example: demonstrating when teaching individual vocal students; demonstrating when directing choirs; in choirs as a tenor; preparing and presenting vocal recitals. (P33) Three solo singers mentioned that they frequently used their voice for extracurricular activities and work. One of these solo singers mentioned the high vocal load of their employment and the long hours required: Speaking - I often use my voice for long periods of time at work, where I make presentations and communicate with team members. (P05)

L a u e t a l 32 Australian Voice 2022 Figure 1. Student responses to questions on general vocal health behaviours. Vocal Load Practice Prioritising voice practice did not differ between solo and choral singers (Figure 2). A large proportion of participants from both groups reported that they only “sometimes” prioritised vocal practice (44.4% of solo singers vs. 40.0% of choral singers) (Figure 2). Singing whilst sick Forty-two percent of all singers (42.4%) stated that they “sometimes” had to manage singing whilst unwell, but results did not differ between solo singers and choral singers (Figure 3). The most common strategies that participants used to look after their voice whilst sick was to “rest” their voices and sing in a low range, for example: “I try to sing low-medium range music and avoid singing and talking loudly.” (P02) Notably, solo singers commented that they would increase the monitoring of the sensations of their body and voice. This often referred to symptoms of pain and fatigue felt whilst singing when sick, for example: Figure 2. Students’ Likert scale reponses to how often they prioritise voice practice.

V o c a l H e a l t h a n d W e l l b e i n g Australian Voice 2022 33 Figure 3. Students’ Likert scale repsonses to how frequently they needed to manage singing whilst sick. Figure 4. Percentage of students warming up before voice use at work, general voice use, and before singing lessons. Warm up more meticulously and carefully. Be wary of any signs of pain, strain, or fatigue. Rely more than normal on breathing to avoid strain. Avoid extremes of register and take more frequent breaths. (P03) Warming up The number of solo singers who warmed up before voice use (78.8% vs 52.9%) was almost double that of choral singers (Fig 4). Solo singers were more attentive to warming up their voices before work as they were more likely to be involved in employment that required high vocal loads. Though there was a higher proportion of solo singers, these differences were not statistically significant (Fig 4). Both solo and choral singers drew on the warmup exercises they used for their singing voice for their speaking voice, for example: Same way I would before singing for myself: a lot of breathing exercises, humming and then singing scales and other pitch-based exercises. (P17) All singers discussed how their warmups focused primarily on preparing their voice throughout their vocal range, pitch, vowel sounds to aid forward placement of the voice, breath management and flexibility of the articulators. Vocal warm up differed depending on the time of day, for example: If it is in the morning, basic physical warm up, some sirens, stretches, loosen tongue tension, wake up breathing muscles. (P19)

L a u e t a l 34 Australian Voice 2022 Though the majority of singers commented on warming their vocal musculature, one participant reported on a mental focus of warming up to increase kinaesthetic awareness of their articulators and larynx: I warm up before I teach or do a more meditative exercise to create awareness of relaxing my jaw and my tongue, so everything is loose when I speak. (P31) Vocal Health Confidence Solo singers vs choral singers Results showed that solo students dedicated significantly more time to maintaining their vocal health compared to choral singers (p= 0.03) (Figure 5). Most solo and choral singers stated that they felt “somewhat confident” finding information and a professional to look after their voice, appraising vocal health information, and discussing vocal health information. Most choral singers rated themselves “usually confident” in response to their familiarity with reading vocal health information. In contrast, solo singers rated themselves as only “somewhat confident” (40.0% vs 33.3%). Solo singers felt either “usually” or “always” confident (usually confident= 27.8%, always confident= 27.8%) with receiving vocal health information in comparison to many choral singers who rated themselves as “somewhat confident” (40.0%). When asked about their confidence around judging the accuracy of vocal health information, more choral singers rated themselves as “somewhat confident” than solo singers (53.3% vs 16.7%, Figure 5. Likert scale responses to the statement “Despite other things in my life, I make time for good vocal health.” with solo singers’ confidence ratings ranging between “usually confident”, “a little confident” and “not confident”. However, these results were not statistically significant. In response to the following Likert scale statements (e.g., keeping their voice healthy, having enough information to manage vocal health, comparing sources of vocal health information, prioritising good vocal health, ensuring they have information to effectively manage their vocal health, finding suitable vocal health information, setting vocal health goals, maintaining good vocal health, having all the information to look after their vocal health), a majority of both solo and choral singers “agreed” to prioritising the need for vocal health information and the management of their own vocal health. Undergraduate v postgraduate students Postgraduate students were significantly less confident in discussing vocal health information compared to undergraduate singers (p=0.029) (Figure 6). Postgraduates were also less confident in comparing sources of vocal health information (p=0.015) (Figure 7). While this appears counterintuitive, Kwak et al. (2014) found that the more experienced singers are, the more they understand that their knowledge is limited, and continual professional learning is needed. The majority of both undergraduate and postgraduate singers rated themselves as “somewhat confident” in

V o c a l H e a l t h a n d W e l l b e i n g Australian Voice 2022 35 finding information on vocal health. Similarly, a large proportion of both cohorts responded with “agree” to the following statements (e.g., prioritising good vocal health, ensuring they have all the information to manage their vocal health, setting goals for vocal health, maintaining vocal health). For all remaining questions, postgraduate students had lower confidence than undergraduate students, but none were statistically significant. Figure 6. Likert scale reponses to the question “How confident are you in discussing vocal health information?” DISCUSSION This study explored the vocal health responsibility and awareness of solo and choral singers, and the influence of singing experience on the seeking of health information. The solo singers in this cohort more frequently experienced vocal difficulties and were drawn to employment and social activities that were potentially harmful for their voice. These results are consistent with studies that report professional voice users, such as singers, are more likely to report a history of vocal difficulties than non-professional voice users (Achey et al., 2015; Latham et al., 2016; Sapir et al., 1996). A recurring behaviour of solo singers was their reluctance to take vocal rest when sick. Though both choral singers and solo singers performed at a high level, solo singers were more likely to give into the pressure of performing whilst unwell. These pre-professional solo singers were non-compliant with recommended vocal hygiene strategies (Broaddus-Lawrence, 2000). Solo singers may feel that illness is a taboo (Kwak et al., 2014) and be reluctant to take vocal rest due to the negative impact it may have on their career. Additionally, solo singers put in extra effort to ensure they engaged in a variety of ensembles, taught, and took external auditions (Achey et al., 2015). This tendency of solo singers to seek out activities that require high levels of talking and

L a u e t a l 36 Australian Voice 2022 Figure 7. Likert scale reponses to the statement “I always compare different sources of vocal health information to see what is best for me” singing may allow them to gain experiential knowledge unavailable to them in their degrees. In this study, there were no significant differences between solo and choral singers, but solo singers tended to be drawn to more harmful behaviours. Compared to the choral singers, solo singers were more aware that good vocal habits should be extended beyond just their singing voice (Achey et al., 2015). These solo singers demonstrated more emphasis on warming up prior to their work as many undertook employment that involved high vocal loads or singing. Despite this awareness and specialised training, the solo singers in this study were not better equipped with knowledge to manage their vocal health than the choral singers (Broaddus-Lawrence, 2000). In this study, both choral and solo singers were equally confident in finding health information and professionals and appraising and discussing vocal health information. However, most choral singers rated themselves as more confident than solo singers when questioned about their familiarity with reading vocal health information. Solo singers were also less confident in receiving and judging the accuracy of vocal health information compared to choral singers. This aligns with previous studies where solo singers were significantly (p ≤ 0.0001) more likely to have searched for voice-related medical information than choral singers, yet at the same time were unsure of the reliability of these undetermined sources (Petty, 2012). This study showed that solo singers were less consistent than choral singers in their confidence in vocal health information from their education. Nerland (2007) discussed how the one-to-one teaching style used in conservatoires can vary according to performance teacher which may account for the wide range of confidence in vocal health amongst the solo singers in this study. The findings concur with Kwak et al. (Kwak et al., 2014) that though solo singers have specialised training, they were not better equipped with information and skills to care for their vocal health, compared to choral singers. The postgraduate singers had more years of specialised training yet felt less confident than undergraduate singers in the management of their own vocal health and reading, receiving, comparing analysing, and judging health information. Kwak et al. (2014) found that advanced singers did not possess significantly more knowledge of the voice and its management than those who were novices. This uncertainty in finding vocal health information may have also impacted the postgraduate singers’ ability to find a health professional well-suited to their needs (Braun-Janzen & Zeine, 2009). This suggests that there may be a gap in the health education of singers in tertiary training and emphasis of ongoing learning. Singers’ confusion, and negative experiences with health and medical professionals highlights the need for consistent vocal health education. CONCLUSIONS AND FUTURE DIRECTIONS This study was a preliminary investigation into the vocal health responsibility behaviours and vocal health awareness of classical solo and choral singing students at university. Solo singers were conscious of the hazards that their employment p