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ORIGINAL ARTICLE

Translation and validation of the voice handicap index in Hindi

Rakesh Datta, Ashwani Sethi, Shashank Singh, Ajith Nilakantan, MD Venkatesh Departments of E.N.T. & Head and Neck Surgery, A.C.M.S. & Associated B.H.D.C., New Delhi and A.F.M.C., Pune, India

ABSTRACT Objectives: To adapt the voice handicap index (VHI) for usage in Hindi and evaluate its internal consistency, reliability, and clinical validity in cases of dysphonia. Setting: Tertiary healthcare centers. Materials and Methods: The original VHI was translated into Hindi and was completed by 175 patients with voice disorders and 84 asymptomatic subjects. Internal consistency was analyzed through Cronbach’s alpha coefficient. For test-retest reliability, the Hindi VHI was filled twice by 63 randomly selected patients and assessed through the Spearman rank correlation coefficient test. For the clinical validity assessment, the scores obtained in the pathological group were compared with those found in asymptomatic individuals through the Kruskal-Wallis test. Also, the correlation between VHI and the patients’ self-perceived grade of voice disorder was assessed. Finally, the effect of age and gender on overall VHI and its three subscales was analyzed. Results: Internal consistency was found to be good (alpha = 0.95); the test-retest reliability was high (r = 0.95). Nonparametric Kruskal-Wallis analysis revealed that the control group scored significantly lower than the dysphonics. The overall VHI score positively correlated with the patients’ self-perceived grade of voice disorder (r = 0.44). In the voice-disorder group, age and gender were not correlated to the overall VHI score and to their three domains. Conclusion: The Hindi VHI so developed is a valid and reliable measure for use in the Hindi-speaking population.

Access this article online Website: www.laryngologyandvoice.org DOI: 10.4103/2230-9748.76131 Quick Response Code:

Key words: Quality of life, Vocal handicap index, dysphonia

INTRODUCTION The field of voice disorders has seen numerous advances in diagnostic and therapeutic modalities in the recent past. However, most of the diagnostic modalities assessing voice disorders measure voice in objective terms.[1] Unfortunately, none of these assessments reflects the ‘true’ suffering of the patients or the level of handicap that a patient is suffering from as a result of the voice disorder.[2] In order to assess the quality of life of the patients suffering from voice disorders and their level of handicap due to the disorder, quite a few instruments have been developed in the past, such as the Voice-Related Quality of Life,[3] the Vocal Performance Questionnaire,[4] the Voice Participation Profile,[5] the Voice Address for correspondence: Dr. Rakesh Datta, Department of ENT- Head Neck Surgery, Army College of Medical Sciences, Base Hospital Delhi Cantt, Delhi - 110010, India. E-mail: [email protected] 12

Symptom Scale,[6] Dysphonia Severity Index,[7] and the Voice Handicap Index (VHI)[8] (Annexure I). The VHI is a patient-based self-assessment tool and is considered to be the most relevant, patient-friendly, and versatile tool available at present to assess the voicerelated quality of life.[9] This tool consists of 30 items that are equally distributed (10 each) over the following three domains: functional, physical, and emotional. The VHI has been acknowledged as a valid and reliable diagnostic tool by the Agency of Healthcare Research and Quality in 2002.[10] Since the original instrument is in English, its usage in the non-English population has prompted translations into many different languages worldwide including German,[11] Portuguese,[12] Polish,[13] Chinese,[14] Dutch,[15] Hebrew,[16] Spanish,[17] Greek,[18] and Arabic.[19] Recently, shorter versions of the VHI consisting of 10 items (VHI-10) have been developed and found to be highly related to the original VHI.[17,20] However, there is no translation available in Hindi, Journal of Laryngology and Voice | January-June 2011 | Vol 1 | Issue 1

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a language spoken by a large number of people in India. Moreover, before accepting the usage of the translated instrument, it needs to be properly validated. It is with this in mind that the present study was undertaken with the aim to develop a translated version of the VHI and validate its use clinically.

MATERIALS AND METHODS Development of Hindi version of the VHI The VHI was initially translated by one of the coauthors into Hindi. This was then discussed between the authors and selected bilingual colleagues dealing with voice disorders to ensure correctness and remove ambiguity. A school teacher was asked to retranslate the Hindi instrument in English to locate inaccuracies. Thus, after deliberations, the final version was arrived at and approved for use in the study (Annexure II). After the authors were satisfied with the translated version of the instrument, it was administered as per the requirements of the study.

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Test-Retest reliability In order to evaluate the reproducibility or reliability of the Hindi VHI, Spearman rank correlation coefficient was used in the 63 Hindi VHI forms that were filled twice by 63 dysphonic individuals, 10 to 14 days apart. Validity In order to assess the validity of the Hindi VHI, two parameters were analyzed. First, the overall VHI scores of the dysphonic individuals were correlated with their selfperceived dysphonia using the Spearman rank correlation coefficient. Second, the domain scores and total VHI scores of dysphonic group was correlated with the control group using the Kruskal-Wallis test. Correlation with age and gender The effect of age and gender on the overall VHI scores in the dysphonic and control groups was analyzed using the Spearman rank correlation coefficient and Kruskal-Wallis tests.

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The mean total VHI scores for the dysphonic and control groups were 43.72 (SD = 17.28) and 1.12 (SD = 0.82), respectively [Tables 1 and 2]. The mean of the physical domain was slightly higher as compared with the means of the functional and emotional domains.

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Statistical analysis The following parameters were statistically analyzed: Internal consistency The internal consistency of Hindi VHI was assessed using Cronbach’s alpha coefficient. Values in excess of 0.8 are considered “good” and those above 0.9 are “excellent.” To confirm the internal consistency, a correlation was done between each item and total VHI scores and each domain and the total VHI scores, using Spearman rank correlation coefficient.

RESULTS

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Number of patients

Subjects The subjects were consecutive patients of dysphonia reporting to the outpatient of the ENT department, who could read and understand Hindi (n = 175). They were 107 men and 68 women with the mean age of 38.6 years (age range = 15– 72 years; SD = 15.03) [Figure 1]. They were included in the study after obtaining a prior consent. Additionally, they were also asked to rate their perceived severity of dysphonia on a numeric scale from 0 to 3 (0 - normal, 1 - mild, 2 - moderate, and 3 - for severe). For normal controls (n = 84), subjects were chosen from medical students and people coming to the hospital with unrelated symptoms. The mean age of the control group was 29.5 years (age range = 18–60 years; SD = 12.33), with 48 men and 36 women. This group included subjects with no history of voice disorders in the past.

Procedure The 175 dysphonic patients and 84 normal controls were asked to fill the Hindi version of VHI. In addition, 63 of the dysphonic patients were asked to fill the VHI again after an interval of 10 to 14 days in order to assess the test-retest reliability of the index. The VHI items were then statistically analyzed to assess the validity, internal consistency, and testretest reliability of the Hindi version of VHI.

Age group Figure 1: Showing age distribution of patients

Journal of Laryngology and Voice | January-June 2011 | Vol 1 | Issue 1

Internal consistency The overall estimated internal consistency was excellent (Cronbach’s alpha = 0.95). The estimated correlation, using 13

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Table 1: Mean scores for the functional, physical, and emotional domains and total VHI scores in 175 dysphonic patients who completed the Hindi version of VHI VHI domain (maximum possible score)

Mean

Functional (40) Physical (40) Emotional (40) Total VHI (120)

14.46 15.14 14.17 43.72

SD

5.80 5.97 6.26 17.28

Minimum– Maximum score 0–40 0–40 0–40 0–120

Table 2: Mean scores for the functional, physical, and emotional domains and total VHI scores in 84 controls who completed the Hindi version of VHI VHI domain (maximum possible score)

Mean

SD

Minimum–Maximum score

Functional (40) Physical (40) Emotional (40) Total VHI (120)

0.48 0.48 0.16 1.12

0.50 0.64 0.37 0.82

0–40 0–40 0–40 0–120

VHI - Voice handicap index

VHI - Voice handicap index

Spearman rank correlation coefficient, was high for all the three domains/total VHI (r = 0.84, 0.84, and 0.86 for functional, physical, and emotional domains, respectively). Similarly, estimated correlation between items/total VHI was found to be high using Spearman rank correlation coefficient [Table 3]. Test-Retest reliability Excellent test-retest reliability was identified for the 63 subjects who completed the Hindi VHI twice over a period of

Table 3: Item/total VHI correlation and measurement of the reliability of the 30 items in Hindi VHI using Spearman rank correlation coefficient

Functional domain

Physical domain

Emotional domain

Cronbach’s alpha VHI - Voice handicap index

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Item

Item/total VHI correlation

F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 E1 E2 E3 E4 E5 E6 E7 E8 E9 E10 0.95

0.62 0.63 0.40 0.53 0.57 0.41 0.62 0.56 0.48 0.57 0.60 0.63 0.40 0.70 0.69 0.40 0.57 0.48 0.47 0.40 0.76 0.54 0.65 0.48 0.55 0.57 0.66 0.44 0.55 0.57

10 to 14 days using the Spearman rank correlation coefficient (r = 0.95; P0.05) 0.31 (>0.05) 0.39 (>0.05)

VHI - Voice handicap index

Table 6: Measurement of correlation between gender and individual domains and total VHI scores in the dysphonic patients using Kruskal-Wallis test Gender Functional Physical Emotional Total VHI

Male Female Male Female Male Female Male Female

n

Mean

SD

P value

107 68 107 68 107 68 107 68

13.87 15.74 14.59 16.48 13.48 15.61 41.94 47.68

5.21 6.75 5.57 6.77 5.41 7.40 15.52 20.07

0.27 0.13 0.16 0.09

VHI - Voice handicap index

communication across the world. Thus, any impairment in the normal mechanism of voice generation can cause a significant disability to an individual in performing routine and important activities with a resultant handicap. This makes it imperative for a clinician dealing with voice disorders to understand this handicap of a patient presenting with a voice disorder. Although, advanced diagnostic tools are helpful in identifying the pathology responsible for the impairment, it may not necessarily reflect the true handicap of the patient.[21] The VHI primarily assesses this important aspect of the patients’ suffering because of their voice disorders. The present study was aimed at developing a Hindi version of VHI that can be used in the assessment of severity of handicap due to voice disorders in the Hindi-speaking population as no such tool exists for this population. The important attributes that affect the ability of such a questionnaire to collect the data are the validity, reliability, and homogeneity. Validity of the tool is the ability to measure what it seeks to quantify. In our study, the validity was assessed on two parameters. First, the total VHI scores of the patients were correlated with their self-perceived grade of voice disorder. This correlation was found to be significant in our study, similar to some previous studies in the past.[17] Second, the domain scores and total VHI scores of dysphonic group was correlated with the control group. We found a statistically significant difference between the dysphonic and the control groups, for the overall VHI scores and each of the functional, physical, and emotional domains scores separately, which proves that the VHI discriminates individuals who suffer from a voice disorder from those who do not, thus making it a valid tool. The reliability reflects the reproducibility of the data collected using the tool. In our study, the reliability of the Hindi version of the VHI was tested by correlating the results of the questionnaires filled twice (after an interval of 10–14 days) by 63 of the patients selected randomly. The correlation was Journal of Laryngology and Voice | January-June 2011 | Vol 1 | Issue 1

significant, thus making it a reliable tool, similar to a few of the studies in the past.[14,17-19] The reliability or the homogeneity of the questions was assessed using Cronbach’s alpha in our study. A value of 0.95 was obtained in our study, thereby proving the reliability of the questionnaire. In addition to this, a strong correlation was observed between the individual items and the total VHI scores, as well as between the three domains and the total VHI scores. These results were similar to some of the studies in the past.[16,17,19] In our study, the dysphonic group had a slightly higher mean physical domain score as compared with the mean functional and emotional domain scores. Similar results have been reported in some of the studies in the past.[12,14,15,19] This has been explained on the basis of a higher familiarity and association of the patients with the physical symptoms of voice disorders as compared with the functional and emotional symptoms.[12,14,15,18,21] This signifies that the physical domain of VHI is the most prominent self-perceived parameter of voice disorders. In our study, although older individuals were found to have higher overall VHI scores, there was no significant correlation between the age and individual domain scores or the total VHI scores in either the control group or the dysphonic group. These findings were similar to some of the studies in the past.[12,14,18,19] The female patients in our study showed higher mean individual domain scores (for all the three domains) and total VHI scores as compared with the males. However, this difference was statistically insignificant and there was no correlation between the gender and the VHI scores in our study. These results were similar to some of the studies in the past.[16,18,19] The results of our study suggest that this Hindi version of 15

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the VHI is a valid and reliable tool that can be used in the assessment of self-perceived severity of voice problems in our Hindi-speaking population. Thus, it may help the clinicians dealing with Hindi-speaking populations understand why these patients seek help for their voice disorders and how significantly is the problem affecting them. However, the Hindi-speaking population is widely distributed across India with minor/major differences in syntax, grammar, and word meanings. The potential limiting effect of these differences remains to be seen. Another limitation of this tool is in the assessment of the large illiterate Hindi-speaking population in our country. These limitations may be overcome with the development of more elaborate and extensive tool that encompasses the variations in the various aspects of this language across the country and can be administered orally for the benefit of those who cannot read.

CONCLUSION We would like to conclude that the Hindi version of VHI developed in this study is a valid and reliable tool that can be applied to the Hindi-speaking population of our country. It can not only give us an idea of the patients’ perception of their voice disorder, but also help the clinician to understand the degree of functional, physical, and emotional suffering of the patient and act accordingly, and not merely on the basis of the objective findings.

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derived Voice Symptom Scale. J Psychosom Res 2003;54:483-9. 7. Wuyts FL, De Bodt MS, Molenberghs G, Remacle M, Heylen L, Millet B, et al. The dysphonia severity index: An objective measure of vocal quality based on a multiparameter approach. J Speech Lang Hear Res 2000;43:796-809. 8. Jacobson BH, Jonson A, Grywalski C, et al. The Voice Handicap Index (VHI): Development and validation. Am J Speech Lang Pathol 1997;6:66-70. 9. Franic DM, Bramlett RE, Bothe AC. Psychometric evaluation of disease specific quality of life instruments in voice disorders. J Voice 2005;19:300-15. 10. Agency for Healthcare Research and Quality. Criteria for determining disability in speech-language disorders. Evidence report/technology assessment 2002. 11. Nawka T, Wiesmann U, Gonnermann U. Validation of the German version of the Voice Handicap Index. HNO 2003;51:921-30. 12. Guimaraes I, Abberton E. An investigation of the Voice Handicap Index with speakers of Portuguese: Preliminary data. J Voice 2004;18:71-82. 13. Pruszewicz A, Obrebowski A, Wiskirska-Woźnica B, Wojnowski W. Complex voice assessment: Polish version of the Voice Handicap Index (VHI). Otolaryngol Pol 2004;58:547-9. 14. Lam PKY, Chan KM, Ho WK. Cross-cultural adaptation and validation of the Chinese voice handicap index-10. Laryngoscope 2006;116:1192-8. 15. Hakkesteegt MM, Wieringa MH, Gerritsma EJ, et al. Reproducibility of the Dutch version of the voice handicap index. Folia Phoniatr Logop 2006; 58: 132-8. 16. Amir O, Ashkenazi O, Leibovitzh T, Michael O, Tavor Y, Wolf M. Applying the Voice Handicap Index (VHI) to dysphonic and nondysphonic Hebrew speakers. J Voice 2006;20:318-24. 17. Núñez-Batalla F, Corte-Santos P, Señaris-González B, LlorentePendás JL, Górriz-Gil C, Suárez-Nieto C. Adaptation and validation to the Spanish of the Voice Handicap Index (VHI-30) and its shortened version (VHI-10). Acta Otorrinolaringol Esp 2007;58:386-92. 18. Helidoni ME, Murry T, Moschandreas J, Lionis C, Printza A, Velegrakis GA. Cross-cultural adaptation and validation of the Voice Handicap Index into Greek. J Voice 2010;24:221-7. 19. Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T. Validation and cultural modification of Arabic voice handicap index. Eur Arch Otorhinolaryngol 2010;267:1743-51. 20. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope 2004;114:1549-56. 21. Hsiung MW, Pai L, Wang HW. Correlation between voice handicap index and voice laboratory measurements in dysphonic patients. Eur Arch Otorhinolaryngol 2002;259:97-9.

Source of Support: Nil, Conflict of Interest: None declared.

Journal of Laryngology and Voice | January-June 2011 | Vol 1 | Issue 1

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ANNEXURE I: VOICE HANDICAP INDEX[8] VOICE HANDICAP INDEX 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. 0 - never; 1 - almost never; 2 - sometimes; 3 - almost always; 4 - always PART I 1

My voice makes it difficult for people to hear me 2 People have difficulty understanding me in a noisy room 3 My family has difficulty hearing me when I call them throughout the house 4 I use the phone less often than I would like to 5 I tend to avoid groups of people because of my voice 6 I speak with friends, neighbors, or relatives less often because of my voice 7 People ask me to repeat myself when speaking face-to-face 8 My voice difficulties restrict personal and social life 9 I feel left out of conversations because of my voice 10 My voice problem causes me to lose income

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My voice sounds creaky and dry I feel as though I have to strain to produce voice 6 The clarity of my voice is unpredictable 7 I try to change my voice to sound different 8 I use a great deal of effort to speak 9 My voice is worse in the evening 10 My voice “gives out” on me in the middle of speaking

PART III 1

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I run out of air when I talk The sound of my voice varies throughout the day People ask, “What’s wrong with your voice?”

PART II (CONT...)

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I am tense when talking to others because of my voice 2 People seem irritated with my voice 3 I find other people don’t understand my voice problem 4 My voice problem upsets me 5 I am less outgoing because of my voice problem 6 My voice makes me feel handicapped 7 I feel annoyed when people ask me to repeat 8 I feel embarrassed when people ask me to repeat 9 My voice makes me feel incompetent 10 I am ashamed of my voice problem

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ANNEXURE II – THE TRANSLATED VHI INSTRUMENT

Journal of Laryngology and Voice | January-June 2011 | Vol 1 | Issue 1

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