INTRODUCTION {#sec0001}
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The COVID-19 pandemic has created a new, unfamiliar, and unusual condition, both globally and locally. The "stay at-home" restrictions, together with the enforced physical distancing policy, have led to a critical disruption of personal and community life, of industry and economy, and especially of the world of culture and art. Most countries have adopted a policy of prohibiting group gathering. This has led to global cancelation of numerous performances, music festivals, concerts, musical tours, and even stopped studio recordings and rehearsals for an unknown period. After approximately 2 months, several countries have gradually started to examine \"back to normal\" strategies. Nonetheless, it is expected that the singing and music industry would return to performing live in front of audiences long after other industries return to normal activity due to the specific nature of the music industry, which gathers large crowds in close proximity, making physical distancing practically impossible.

In addition to the general policies advocated by local and global authorities, it was also reported that the public are less likely to attend future musical and singing events, even when they are allowed.[@bib0001] Moreover, people are more inclined to return to visiting museums, zoos, and sport events than to attending concerts or music shows.[@bib0002] This ongoing condition, along with the restrictions on gathering, imposes special difficulties on the artistic voice users. They are prohibited from practicing, rehearsing, performing, and expressing themselves in front of an audience. Furthermore, performance cancellation policies and the uncertainty about their professional and financial future raise the artists' concerns, worries, and even anxiety.[@bib0003] This is pertinent, first, because live performances are the most substantial income source for these artists.[@bib0004] Second, musicians and singers are generally more likely to struggle with stress, anxiety, and even with substance abuse.[@bib0004], [@bib0005], [@bib0006] Hence, a pandemic like the COVID-19, which stops all professional activities, dramatically impacts singers and performers.

Interestingly, the vast majority of medical research on artistic voice users focuses on vocal attrition, and highlights the importance of reducing trauma to the larynx and the vocal folds due to strenuous, or over use.[@bib0005] ^,^ [@bib0007] However, the situation evoked by the COVID-19 pandemic has introduced a new and challenging condition, in which singers and actors use their voices to a lesser extent than they do normally. This unique situation imposed on the voice artists may be termed \"voice avoidance,\" yet its physiological, behavioral, and emotional ramifications are unknown.[@bib0008] In addition, professional vocalists are used to closely interacting with their peers, band- or orchestra-members, as well as with their conductors, singing teachers and voice therapists. Being deprived of these contacts for feedback and support may cause additional stress. The uniqueness of this condition, and the immense need to communicate and perform for their audience, has driven many artists to conduct online performances. And indeed, such virtual concerts are performed by numerous singers in almost all musical genres.

The present study was a preliminary attempt to examine how artistic voice users perceive this period of "voice avoidance" imposed on them during the time of the COVID-19. Specifically, we were interested to learn whether they experience changes in their voice and voice-related behaviors, and whether this may be related to their stress and anxiety. Moreover, because the current circumstances could prompt stress and anxiety over existential, financial, and social issues for all people, it was deemed necessary to include in this study a control group of nonprofessional voice users.

MATERIALS AND METHODS {#sec0002}
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Study design and participants {#sec0003}
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This study was approved by the Tel-Aviv University Ethics Committee (\#0001314-1), and it was conducted after all participants have completed and signed an informed consent form. The study was designed as an observational cross-sectional study, using an online survey constructed for it. The survey was distributed to professional artistic voice users through local singers and actors associations, as well as through voice teachers and coaches, and by addressing voice or singing students in local contemporary and classical music training programs. The control group consisted of nonprofessional speakers who volunteered for the study. They were recruited randomly from university staff and students and from related family members and acquaintances. The sampling procedure in both groups was a combination of convenience and snowball sampling. All participants were native Hebrew speakers who live in the center of Israel.

As the COVID-19 pandemic created a unique and dynamic situation, it was deemed necessary to limit the time allocated for data collection. Hence, data were collected over a period of 1 week (last week of April 2020). During that time, local regulations enforced full quarantine for all people, and a "stay-at-home" policy. Accordingly, all schools, colleges, industry, and public areas were closed, including all kind of social gathering and artistic performances. The only exceptions were vital medical treatments and purchasing grocery products.

Of the total of 110 study participants, 57 (51.8%) were professional voice users and 53 (48.2%) were controls. Within the professional group, 34 (66.7%) were singers and 19 (33.3%) were actors. Power analysis, performed with G\*Power v.3.1.9.4 software,[@bib0009] showed that these group sizes were sufficient to detect medium-sized group differences, as expressed by Cohen\'s *d* of about 0.50, with error probability of 0.05 and power of 0.80.

Approximately two-thirds (64.5%) of the sample were women. Participants\' age ranged from 18 to 70 years (M = 37.72, SD = 13.70). The majority of the participants were married (61.8%), nonsmokers (86.4%), and did not report heartburn (83.6%). All these characteristics were not significantly different between the professionals and the control group, as shown by a *t* test and chi-squared tests (all *P* \> 0.10).

Measures {#sec0004}
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A *Voice COVID-19 questionnaire* (VC-19) was designed for the present study. It included 20 items accompanied by a five-point response scale ranging from 0 = \"Never\" to 4 = \"Always.\" The questionnaire was intended to cover five content areas: (1) General concern about voice (one item); (2) Current voice difficulties (six items); (3) Vocal training (two items); (4) Current stress (four items); and (5) Vocal hygiene (seven items). Questionnaire items and psychometric data are presented in the Results section.

*Singing Voice Handicap Index* (SVHI-10)[@bib0010] is a short-form instrument for assessing self-perceived singing voice problems. Its 10 items are accompanied by five-point response scale ranging from 0 = \"Never\" to 4 = \"Always.\" This questionnaire was completed only by singers. A summative score was computed of all SVHI-10 items, with internal consistency (Cronbach\'s coefficient alpha) of 0.88.

*Generalized Anxiety Disorder* (GAD-7)[@bib0011] is a seven-item self-report questionnaire designed to assess person\'s current anxiety level. The response scale ranged from 0 = \"Never\" to 3 = \"Almost every day.\" A summative score was computed for all GAD-7 items, with Cronbach\'s alpha of 0.88. It should be noted that within this study, the SVHI-10 and the GAD-7 questionnaires were administered only as a means for validation of the main study questionnaire, and not for providing additional collaborative data.

Statistical analysis {#sec0005}
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Analyses were performed with SPSS v.25 software. Structure validity of the VC-19 questionnaire was tested with a Principle Component Analysis followed by factor analysis with Varimax rotation. Loadings of at least 0.45 were considered sufficient for ascribing an item to a factor. Scale reliabilities were assessed as internal consistency with Cronbach\'s coefficients alpha. Coefficients of 0.70 and above were considered as supporting reliability. Descriptive statistics of research variables, all of which are continuous, were calculated as means and standard deviations, and correlations between them were estimated as Pearson coefficients. Comparisons between research groups were performed with *t* tests. All results with error probability *P* \< 0.05 were considered as statistically significant.

RESULTS {#sec0006}
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Psychometric analysis of the VC-19 questionnaire {#sec0007}
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The first item of the VC-19 questionnaire, \"I worry about my voice,\" was designed to serve as a single-item \"General concern\" measure. The responses to the remaining 19 items were subjected to a Principle Component Analysis, which yielded six components with eigenvalues greater than unity. Scree test (Cattell criterion) suggested that four of them should be retained for rotation, with the eigenvalue of the fourth factor being 1.48, and that of the next factor being 1.19. This four-factor structure generally replicated the initial questionnaire design, and is presented in [Table 1](#tbl0001){ref-type="table"} .TABLE 1Summary of the Results of the Factor Analysis Performed on the Voice COVID-19 Questionnaire (Factor Loadings, Eigenvalues, and Percent of Explained Variance)TABLE 1ItemVoice DifficultiesVocal TrainingCurrent StressVocal HygieneMy voice is more hoarse than usual0.73My voice sounds differently than usual0.78It is difficult for me to sing loudly0.67Reaching high notes is more difficult0.80I feel pain while singing0.59My singing ability has changed0.78I practice my voice0.92I perform vocal warmup exercises0.93I sing more than usual0.71I worry about my financial state0.53I feel stressed0.63I worry about my health0.79I worry about my family\'s health0.77I speak more than usual0.54My dietary habits have changedI smoke more than usualI shout more than usual0.72I drink more water than usualI consume more alcohol than usual0.62Eigenvalue4.902.101.701.48Percent of explained variance25.811.068.927.78[^1]

The "vocal hygiene" construct fared poorly in this analysis. The item "I sing more than usual\" was loaded on the "vocal training" factor, thus it was decided to add it to this factor. The items \"My dietary habits have changed,\" \"I smoke more than usual,\" and \"I drink more water than usual\" were not loaded highly on any factor and hence were omitted from the factor. The remaining three items of the "vocal hygiene" factor exhibited poor reliability (alpha = 0.44), and thus also could not be used; leading to omission of this construct from the analyses. The remaining three composite scales were calculated as sums of item scores and exhibited acceptable reliability, with alpha = 0.85 for "voice difficulties"; alpha = .86 for "vocal training"; and alpha = 0.69 for "current stress." The validated CV-19 questionnaire is presented in the appendix, for future research and clinical application.

Descriptive analysis {#sec0008}
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Distribution of research measures and their intercorrelations are presented in [Table 2](#tbl0002){ref-type="table"} . As expected, the one-item "general concern" about own voice was positively correlated with all other research measures, both voice-specific and related to general stress. The "voice difficulties" scale was significantly correlated with both "vocal training" and "current stress" scales. It was also strongly correlated with the SVHI-10 scores. In addition, data show a strong correlation between the "current stress" scale and the GAD-7 scores.TABLE 2Distribution and Intercorrelations (Pearson Coefficients) of Research MeasuresTABLE 2MeasureMeanSDGeneral ConcernVoice DifficultiesVocal TrainingCurrent StressSVHI-10General concern1.351.09--Voice difficulties3.133.200.51[‡](#tb2fn3){ref-type="table-fn"}--Vocal training5.904.680.47[‡](#tb2fn3){ref-type="table-fn"}0.31[†](#tb2fn2){ref-type="table-fn"}--Current stress8.332.760.36[‡](#tb2fn3){ref-type="table-fn"}0.38[‡](#tb2fn3){ref-type="table-fn"}0.19[\*](#tb2fn1){ref-type="table-fn"}--SVHI-1013.186.800.50[†](#tb2fn2){ref-type="table-fn"}0.77[‡](#tb2fn3){ref-type="table-fn"}−0.030.12--GAD-75.413.890.30[†](#tb2fn2){ref-type="table-fn"}0.28[†](#tb2fn2){ref-type="table-fn"}0.160.51[‡](#tb2fn3){ref-type="table-fn"}0.24[^2][^3][^4]

As noted, SVHI-10 scores were collected only from the professional singers. The mean score obtained for this group was higher than the equivalent scores reported for singers without voice problems by the scale developers (Mean = 8.40, SD = 0.71; N = 99), *t*(37) = 4.32, *P* \< 0.001 (degrees-of-freedom were adjusted to account for unequal variances in the two samples).

Comparison of research groups {#sec0009}
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The distribution of the research variables is presented separately for the two research groups (voice professionals and controls) in [Table 3](#tbl0003){ref-type="table"} . As shown, the voice professionals exhibited higher scores on all scales, compared to the controls, and all group differences were statistically significant. Data also show that although all measures yielded significant group differences, the voice-specific \"general concern,\" "voice difficulties," and "vocal training" subscales demonstrated relatively larger differences between the groups, compared to the more general "current stress" scale and the GAD-7 scores.TABLE 3Comparison of Research Measures Between Professionals and Control GroupsTABLE 3Research GroupProfessionalsControlMeasureMean (SD)Mean (SD)*t* ValueGeneral concern2.00 (0.96)0.66 (0.73)8.16[‡](#tb3fn2){ref-type="table-fn"}Voice difficulties7.65 (4.64)4.02 (3.97)4.39[‡](#tb3fn2){ref-type="table-fn"}Vocal training5.35 (2.92)0.74 (1.04)11.20[‡](#tb3fn2){ref-type="table-fn"}Current stress8.89 (2.61)7.72 (2.80)2.28[\*](#tb3fn1){ref-type="table-fn"}GAD-76.19 (4.33)4.57 (3.19)2.23[\*](#tb3fn1){ref-type="table-fn"}[^5][^6]

Finally, the differences between the singers and actors within the "professional" group on all subsubscales of the VC-19 and in GAD-7 scores were examined. A significant difference was found between the two subgroups in "vocal training," with singers exhibiting higher levels of "vocal training" (M = 6.13, SD = 2.76) than actors (M = 3.79, SD = 2.64), *t*(55) = 3.06, *P* = 0.003. No significant differences were found for all other measures (detailed statistics are not presented).

DISCUSSION {#sec0010}
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The VC-19 questionnaire developed for this study included four major factors that differentiated between voice artists and controls during the time of the COVID-19 pandemic. The "voice concern" and "voice difficulties" subscales were intercorrelated and correlated with all other measures, indicating that those who experience more difficulties are also more anxious and concerned about their voice. The strong correlation between GAD-7 and the "current stress" subscale of the VC-19 confirms the experience of stress at the time of the study, especially among the artistic voice users.

Artistic voice users versus controls {#sec0011}
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The artistic voice users experienced more difficulties with their voice, compared to controls. In addition, they scored significantly higher on both GAD-7 and on the "current stress" subscale. The explanation to these findings may be twofold. First, it is suggested that voice artists are more influenced than others by the special condition of the COVID-19 pandemic, both professionally and ecomonically, as well as psychologically.[@bib0003] ^,^ [@bib0008] Because they view vocalizing and performing a basic necessity, being deprived of these is stressful to them. Second, artistic voice users are more prone to stress and anxiety in general.[@bib0012] Hence, this unique condition is experienced by them more gravely than by others. This conclusion is also supported by the higher scores on the SVHI-10 questionnaire exhibited by the singers in our study, compared to normative values.[@bib0010] This indicates heightened self-awareness and concern about voice during the time of the study. These findings highlight the importance of professional and psychological support for this population in general, and especially during unusual and stressful times.

Singers versus actors {#sec0012}
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Singers and actors exhibited similar scores on all study measures, with the only exception of the "voice training" subscale. In other words, while singers and actors reported similar concerns about their voice and similar levels of anxiety, the singers have reported practicing their voice more during this time. This is explained by the differences in professional education and vocal training of singers and actors,[@bib0013] which may have led to lower vocal awareness in actors. Consequently, singers tend to channel their stress to practicing, more than actors do.

Strengths and weakness of the study {#sec0013}
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This study is unique as it is the first to empirically examine and quantify the subjective experience of artistic voice users during the specific time of the COVID-19. As such, it provides a valid and reliable measure of this unusual experience. An additional strength is the fact that it captured the unique condition evoked by the pandemic, at its social and vocational restriction peak, as all data were collected within a single week.

Three limitations of the study should be noted. First, sample size was restricted by the time constraints, in an attempt to balance between capturing the specificity of the condition and acquiring a sufficient sample size. Therefore, a larger sample of artistic voice users may have provided additional insights. Second, our study was intended to examine professional artistic voice users as a whole. Therefore, we did not inquire about their laryngeal condition or prior treated voice disorders. Consequently, our sample may include both healthy and dysphonic participants. Future research may examine potential differences between these subgroups. Finally, the current study examined a group of artistic voice users and compared them to a group a nonprofessional voice users. Future research may use individual case studies or in-depth interviews, to provide additional individual perspectives on this condition.

CONCLUSION {#sec0014}
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Voice professionals and especially singers experience the COVID-19 pandemic as a stressful time, which bears negative effects on their voice. This is aggravated as they are not allowed to practice and perform regularly, and they lack their needed feedback and support. Providing continuous practice and support, even during strenuous times, may improve their functional and emotional status.

APPENDIX {#sec0015}
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COVID-19 Voice (CV-19) Questionnaire {#sec0016}
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Please respond to the following questions based on your experience over the past two weeks, during the time of the COVID-19 pandemic.NeverAlways1.I worry about my voice012342.My voice is more hoarse than usual012343.My voice sounds differently than usual012344.It is difficult for me to sing loudly012345.Reaching high notes is more difficult012346.I feel pain while singing012347.My singing ability has changed012348.I practice my voice012349.I perform vocal warmup exercises0123410.I sing more than usual0123411.I worry about my financial state0123412.I feel stressed0123413.I worry about my health0123414.I worry about my family\'s health01234

We wish to acknowledge and dedicate this manuscript to the memory of Ms. Dana Yedwab, our beloved teacher and colleague, who passed away at the time this publication was in preparation.

Declarations of interest: none.

[^1]: Note: Loadings lower than 0.45 are not shown in the Table.

[^2]: *P* \< 0.05.

[^3]: *P* \< 0.01.

[^4]: *P* \< 0.001.

[^5]: *P* \< 0.05.

    ^†^*P* \< 0.01.

[^6]: *P* \< 0.001.
