|Year : 2012 | Volume
| Issue : 1 | Page : 11-18
Validation and reliability of Arabic voice handicap index-10
Communication and Swallowing Disorders Unit, ENT Department; Research Chair of Voice, swallowing, and Phoniatrics Disorders (RCVASD), King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||3-Jan-2020|
MD, PhD Mohamad Farahat
ENT Department, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital, P.O Box 245, Riyadh, 11411
Source of Support: None, Conflict of Interest: None
Background And Objective: The voice handicap index-10 (VHI-10) questionnaire is widely used and is self-administered by the patient. It saves time for both patient and clinician as it is a 10-item questionnaire compared to the 30-item questionnaire in the original version of VHI. The purposes of the present study were to generate an Arabic version of the VHI-10, and to evaluate its validity, consistency, and reliability in normal and voice-disordered Arabic population.
Setting And Design: This is a prospective study that has been carried out at Communication and Swallowing Disorders Unit, King Saud University.
Subjects And Methods: The validated Arabic VHI-10 was administered to 100 patients with variable voice disorders and 165 control subjects. Internal consistency and test re-test reliability were evaluated. The results of the pathological and the control groups were compared.
Results: The Arabic VHI-10 showed high internal consistency (Cronbach’s α = 0.88). Excellent test–retest reliability was found for the total scores of the Arabic VHI-10 (r = 0.920, P = 0.001). There was a significant difference between VHI-10 scores of the control and the voice disordered group (P < 0.001).
Conclusion: This study demonstrated that Arabic VHI-10 is a valid tool for self-assessment of voice disorders that can be used by Arabic language speakers.
Keywords: VHI-10- voice disorders- dysphonia- Arabic version
|How to cite this article:|
Farahat M. Validation and reliability of Arabic voice handicap index-10. Saudi J Otorhinolaryngol Head Neck Surg 2012;14:11-8
| Introduction|| |
Instrumental and perceptual approaches are commonly and widely used for evaluation of voice disorders. The clinical applications of such approaches are well established ,,,. Although there are various tools that have been developed to measure the quality of life in dysphonic patients, the voice handicap index (VHI) is considered one of the most accepted and widely recognized self-assessment tool for patients with voice disorders both in the research and clinical applications .
Since then, the VHI (30-item questionnaire) was translated and adapted to many languages including known as the VHI-10, was developed for clinical use and has been shown to the Arabic language and was demonstrated to reliably quantify the subjective perception of handicap experienced by voice patients ,,,,,,,. More recently, a modification of the original 30-item VHI, be highly related to the original VHI .
This 10-item questionnaire was shown to provide a valid reflection of the patient self perception of his or her voice handicap with comparable results obtained from the full version of the original VHI . In addition, the VHI-10 was assessed in comparison with the Vocal Performance Questionnaire (VPQ) and was shown to be a consistent and valid tool .
Unlike the original VHI that provides a total score representing the sum of 3 sub-scores (functional, physical, and emotional), the VHI-10 delivers only a total score. Based on the previous study by the authors for validation of the Arabic VHI-30 , there was an interest in providing an Arabic version of the concise VHI-10 questionnaire for Arabic speaking voice patients. Similar work was done to develop a Hebrew VHI-10  after adopting the original VHI-30 to the same language in an earlier study . Therefore, the purposes of the present study were to develop an Arabic version of the VHI-10, and to evaluate its validity and consistency when applied to normal and voice-disordered Arabic population.
| Materials and Methods|| |
Development of Arabic VHI-10:
The translation process of the VHI-10 into Arabic language was adopted from the procedure used previously for Arabic translation of the original VHI . In this process, the original English version of the VHI-10 (Appendix 1) was translated into Arabic by two Arabic bilingual experienced phoniatricians (Consultants of communication, voice, and swallowing disorders). Items on the questionnaire were, then, back-translated into English, and compared with the original items by a qualified professional translator familiar with American English and Arabic. The back translation was subsequently sent to the investigators for review and comments. The Arabic version of the VHI-10 was then pilot-tested with 10 consented Saudi subjects with voice disorders. Subsequently, the VHI-10 was amended according to their suggestions after reviewing the pilot data. Additional explanatory phrases for some questions in which we noticed difficulties for the participants to understand clearly were subsequently added. For example, in item number 7, the word (strain) has been further explained by adding a word similar in meaning to (effort) which is more appropriate to the Arabic language. The final result was a culturally modified Arabic VHI-10 (Appendix 2). Previous studies have shown that despite cultural adjustments, the VHI remains a valid tool and shows a high correlation with the original VHI ,. Two independent, experienced and bilingual phoniatricians judged all items of the final Arabic version of VHI-10 as being relevant to the purpose it was meant for. It was then administered along with the Arabic VHI-30 for both the patients and the control groups after being consented. Only subjects who can read Arabic language were included in the study thus few people who are illiterate were excluded.
The study was approved by the Institutional Review Board of the College of Medicine, King Saud University. A voice-disordered group consisted of one hundred dysphonic adult Saudi patients were included in the study after being consented. Those subjects were recruited from the patients presented to the voice clinic at King Abdulaziz University Hospital, Riyadh, Saudi Arabia from November 2008 till June 2009. There were 63 males and 37 females with a mean age of 30 years (age range 21–62 years). A control group consisting of 165 subjects participated in the study. These subjects were assembled from persons accompanying the voice disorder patients, those attending the ENT department for reasons other than a voice disorder, and clinical staff members. The mean age of the 165 subjects constituting the control group was 27 years (age range 20–60 years). Eighty three of the control group subjects (50.3%) were females and 82 (49.7%) were males. The consented subjects in the control group reported no history of voice complaints or treatment for a voice disorder. None had a complaint about his/her voice on the day of assessment or at least one month previously. Subjects were told to disregard past history of minor allergies and mild flu or cold.
Patients in the voice disordered group were classified into 5 groups according to the diagnoses. The vocal fold mass lesions group included 22 patients with vocal fold nodules, polyps, cysts, and neoplasms. The inflammatory lesions group included 28 patients with Reinke’s edema, contact granuloma, and suspected laryngopharygeal reflux disease., The group of neurogenic lesions included 16 patients with unilateral vocal fold paralysis, paresis, and spasmodic dysphonia. Fifteen patients were included in the group of non-organic disorders including muscle tension dysphonia, phonasthenia, functional aphonia and puberphonia. Finally the “other” group included 19 patients with different laryngeal pathologies that were not fitting into any of the previously described groups such as vocal fold scaring, sulcus vocalis, and laryngeal trauma.
The internal consistency of the Arabic VHI-10 was assessed using Cronbach’s alpha coefficient. A value greater than 0.7 was considered as satisfactory. A value greater than 0.8 was considered as “good” and greater than 0.9 as “excellent”. Test-retest reliability was assessed by estimating the intra-class correlation coefficient (ICC) for the total VHI-10. Spearman Rank correlation coefficient was done between the total score of VHI-30 and VHI-10 and also between the three domains of Arabic VHI-30 and corresponding questions in the Arabic VHI-10 among cases.
Furthermore, the mean scores of the individual items and total scores of the Arabic VHI-10 in the patients’ group were compared to that of the control group using Mann-Whitney test. The significance level was set to 0.05 throughout. The Statistical Package for the Social Sciences, Version 11 (SPSS Inc, Chicago, IL) was used for all statistical analyses.
| Results|| |
Sixty three males and 37 females were included in the voice disordered group with a mean age of 30 years (age range 21–62 years). The mean total VHI-10 score of this group was 30 (SD 11) with a minimum to maximum range being from 0 to 40 out of a maximum total score of 40. Forty seven subjects (28%) in the control group had an overall VHI-10 score of zero. The range of scores in the controls was 0 to 24. The results of the VHI-10 for both patients and control are demonstrated in [Table 1]. On the other hand, [Table 2] shows the results of the VHI-30 for both the patients and the control groups.
|Table 1: Functional, physical, emotional, and overall VHI-10 items in voice patients compared to the controls.|
Click here to view
|Table 2: Functional, physical, emotional, and overall VHI-30 items in voice patients compared to the controls.|
Click here to view
The effect of gender and age on the participant’s VHI-10 scores was examined. Based on Spearman’s correlation test, there was no statistically significant gender correlation (P = 0.33). At the same time, no significant correlation was found between subjects’ scores on the VHI-10 and their ages (r = 0.065, P = 0.289).
The overall estimated internal consistency of the Arabic VHI-10 was good for the study group (α= 0.88). Correlation coefficient between the sum score of each domain in VHI-30 and the corresponding questions in VHI-10 was significantly high (r = 0.95, 0.87, 0.90, and 0.95 for the functional, physical, emotional, and the grand total respectively) [Table 3]. Twenty of the 100 (20%) dysphonic patients completed the Arabic VHI-10 twice over a period of 2 weeks to 1 month. Intra-class Correlation Coefficient showed excellent test-retest reliability for the total scores of the Arabic VHI-10 (r = 0.920, P = 0.001).
|Table 3: Spearman Rank Correlation Coefficient between the sum score of each domain of VHI-30 and the corresponding VHI-10 items score among cases.|
Click here to view
The results ofthe VHI-10 showed statistically significant difference between the patients and the control groups, for both the overall and the individual items scores (P < 0.001) [Table 1]. At the same time comparable results were demonstrated on comparing the VHI-30 results for the patients and the control group [Table 2].
On comparing the results of the VHI-10 scores of patients in the different five sub-groups of voice disorders, the score distribution differed to a statistically significant extent between the five diagnoses subgroups (P 0.05-0.001). The mean VHI-10 score in the neurogenic subgroup was (24.75±7.04) ranging from 15 to 37, (19.15±9.42) in the “other” subgroup ranging from 6 to 40, (15.93±10.66) in the mass lesions subgroup ranging from 0 to 35. In the non-organic disorders subgroup it was (15.5±9.09) ranging from 0 to 34, and finally it was (11.53±8.78) ranging from 0 to 33 in the inflammatory subgroup. These distributions are being illustrated in [Figure 1].
|Figure 1: Distribution of VHI-10 scores among voice-disordered subgroups.|
Click here to view
| Discussion|| |
Although VHI-10 is more concise than VHI-30, it has been proved to be a valid, consistent, reliable, and less time consuming tool for self-assessment of voice problems . This is the first study aiming at generating an Arabic version of VHI-10. It was based on a previous study that aimed at formulating an Arabic VHI-30 . The results of the present study indicate that the Arabic version of the VHI-10 has strong internal consistency for subjects with voice disorders. These findings are in agreement with the original study by Rosen et al  and with the Hebrew  and Chinese  versions of the VHI-10. Moreover, the data from the present study indicate that the Arabic VHI-10 may be considered when attempting to identify patients with voice problems. This is indicated by the significant difference that was demonstrated between the voice disordered and the control groups. These results were in agreement with the findings of Amir et al  and Lam et al . This confirms that the validity of the Arabic VHI-10 is preserved when the 30-item questionnaire of Arabic VHI is reduced to only 10 items, which is easier and less time consuming for both the patients and the clinicians.
When subjects in the voice disordered group were compared according to the type of voice disorder they have, the neurogenic subgroup had the highest overall VHI-10 scores, followed by subjects in the “other” subgroup, the mass lesion subgroup, the non-organic subgroup and the inflammatory subgroup, in that order. Although the classification we used in our study varied a little from other related studies, there was general agreement of having the highest scores being reported in the neurogenic subgroups. Hsiung et al  reported that the glottic insufficiency group received the highest VHI scores in their study, followed by the vocal mass group and the functional voice disorder group. In another study by Rosen et al , three dysphonic groups of patients were evaluated before and after treatment and it was found that the highest pre-treatment handicap scores were obtained by patients with unilateral vocal fold paralysis followed by patients with benign vocal fold lesions. The lowest scores were returned by patients with muscle tension dysphonia. Similar results were obtained by Lam et al , Helidoni et al  and Amir et al  who also indicated that the neurogenic group had the highest VHI scores. The results of the latest three studies were similar to the current study in reporting the lowest scores among patients in the inflammatory subgroups. Accordingly, it was obvious from the above results that voice-disordered patients vary in their perceived voice problem according to the type voice disorder they have. Patients feel their highest voice handicap with neurogenic lesions and their lowest with the inflammatory type of lesions. Patient who has vocal fold paralysis with glottal gap has difficulty in phonating or raising his/her voice in a background noise. Therefore, he/she will feel more affected (handicapped) than a patient who is suffering from an intermittent or remittent voice problem, as phonasthenia or laryngopharyngeal reflux.
In voice-disordered group of the current study, the mean scores of the functional and physical items of Arabic VHI-10 were almost the same and high in comparison to the mean scores of the emotional items. This indicates that the emotional items were the least that have been affected by the patient’s voice complaint. Similar results were reported in the study of Malki et al  for validation of the Arabic VHI-30. This can be attributed to the cultural difference between Arab and western countries that makes Arab people put more emphases on the functional and physical impact of their voice problem that are more related to their profession and work demands than the emotional effects.
| Conclusion|| |
Despite being a 10-item questionnaire, the Arabic VHI-10 maintained its validity and reliability as a self-assessment tool for patients with voice problems. The Arabic VHI-10 showed comparable results to that of the Arabic VHI-30 in significantly differentiating voice patients from healthy subjects. It has been proved to be an easy and less time consuming tool for clinicians to understand the manner in which patients perceive their voice handicap.
This study was supervised by the Research Chair of Voice, Swallowing, and Phoniatrics Disorders (RCVAS), King Saud University. Mrs. Al-Johara Al-Ameer is greatly acknowledged for her assistance in recruiting candidates for participation in this study and for her help in data entry.
| Appendex 1|| |
VOICE HANDICAP INDEX-10
These are statements that many people have used to describe their voices and the effects of their voices on their lives Circle the response that indicates how frequently you have the same experience.
| Appendex 2|| |
| References|| |
Woo P. Quantification of videostrobolaryngoscopic findings: measurements of the normal glottal cycle. Laryngoscope.
Heman-Ackah YD. Diagnostic tools in laryngology. Curr Opin Otolayngol Head Neck Surg.
Baken RJ. Clinical measurement of speech and voice. Needham Heights, MA: Allyn and Bacon; 1987.
Yamaguchi H, Shrivastav R, Andrews ML, et al. A comparison of voice quality ratings made by Japanese and American listeners using the GRBAS scale. Folia Phoniatr Logop.
Jacobson BH, Johnson A, Grywalsky C, et al. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol
Nawka T, Wiesmann U, Gonnermann U. Validierung des Voice Handicap Index (VHI) in der deutschen fassung. HNO.
Hsiung MW, Lu P, Kang BH, Wang HW. Measurement and validation of the Voice Handicap Index in voice disordered patients in Taiwan. J Laryngol Otol.
Guimarães I, Abberton E. An investigation of the Voice Handicap Index with speakers of Portuguese: preliminary data. J Voice.
Pruszewicz A, Obrebowski A, Wiskirska-Woznica B, Wojnowski W. Complex voice assessment: Polish version of the Voice Handicap Index (VHI). Otolaryngol Pol.
Amir O, Ashkenazi O, Leibovitzh T, et al. Applying the Voice Handicap Index (VHI) to dysphonic and nondysphonic Hebrew speakers. J Voice.
Verdonck-de Leeuw IM, Debodt M, Woisard V, et al. Validation of the Voice Handicap Index by assessing equivalence of 7 European translations. Presented in the 6th Pan European Voice Conference (PEVOC6), London, England; 2005.
Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T. Validation and cultural modification of Arabic voice handicap index. Eur Arch Otorhinolaryngol.
Batalla BN, Santos PC, González BS, et al. Adaptation and validation to the Spanish of the Voice Handicap Index (VHI-30) and its shortened version (VHI-10). Acta Otorrinolaringol Esp.
Rosen CA, Lee AS, Osborne J, et al. Development and validation of the Voice Handicap Index-10. Laryngoscope.
Deary IJ, Webb A, Mackenzie K, et al. Short, self-report voice symptom scales: psychometric characteristics of the Voice Handicap Index-10 and the Vocal Performance Questionnaire. Otolaryngol Head Neck Surg.
Amir O, Tavor Y, Leibovitzh T, Ashkenazi O, et al. Evaluating the validity of the Voice Handicap Index-10 among Hebrew speakers. Otolaryngol Head Neck Surg.
Lam P, Chan K, Kwong E, Yiu E, et al. Cross-cultural Adaptation and Validation of the Chinese Voice Handicap Index-10. Laryngoscope.
Rosen CA, Murry T, Zinn A, Zullo T, Sonbolian M. Voice Handicap Index change following treatment of voice disorders. J Voice.
Helidoni ME, Murry T, Moschandreas J et al. Cross-cultural adaptation and validation of the voice handicap index into Greek. J Voice.
[Table 1], [Table 2], [Table 3]