Journal of Laryngology and Voice

ORIGINAL ARTICLE
Year
: 2011  |  Volume : 1  |  Issue : 1  |  Page : 12--17

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

Correspondence Address:
Rakesh Datta
Department of ENT- Head Neck Surgery, Army College of Medical Sciences, Base Hospital Delhi Cantt, Delhi - 110010
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«SQ»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«SQ» 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«SQ» 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.



How to cite this article:
Datta R, Sethi A, Singh S, Nilakantan A, Venkatesh M D. Translation and validation of the voice handicap index in Hindi.J Laryngol Voice 2011;1:12-17


How to cite this URL:
Datta R, Sethi A, Singh S, Nilakantan A, Venkatesh M D. Translation and validation of the voice handicap index in Hindi. J Laryngol Voice [serial online] 2011 [cited 2021 Mar 3 ];1:12-17
Available from: https://www.laryngologyandvoice.org/text.asp?2011/1/1/12/76131


Full Text

 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 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 voice-related 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, 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.

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.{Figure 1}

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 test-retest reliability of the Hindi version of VHI.

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.

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 self-perceived 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.

 Results



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

Internal consistency

The overall estimated internal consistency was excellent (Cronbach's alpha = 0.95). The estimated correlation, using 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]. {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 10 to 14 days using the Spearman rank correlation coefficient (r = 0.95; P<0.001).

Validity

There was a significant correlation between the VHI scores and the patients' self-perceived dysphonia, as measured using Spearman rank correlation coefficient (r = 0.44; P<0.001). VHI scores showed 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 [Table 4].{Table 4}

Age and gender correlation

Although the average age of the dysphonic group was higher than the control group, the effect of age was not statistically significant, as there was no significant correlation between the age and individual domain scores or the total VHI scores in either the control group or dysphonic group [Table 5].{Table 5}

The mean individual domain scores and total VHI score was slightly higher in the females in the dysphonic group. However, there was no statistically significant correlation between the gender of the patient and the VHI scores [Table 6]. {Table 6}

 Discussion



Undoubtedly, voice is an extremely essential mode of 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 significant, thus making it a reliable tool, similar to a few of the studies in the past. [14],[17],[18],[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 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.

References

1Woo P. Quantification of the videostrobolaryngoscopic findins-measurements of the normal glottal cycle. Laryngoscope 1996;106:1-27.
2Benninger MS, Ahuja AS, Gardner G, Grywalski C. Assessing outcomes for dysphonic patients. J Voice 1998;12:540-50.
3Hogikyan ND, Sethuraman G. Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice 1999;13:557-69.
4Carding P, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with non-organic dysphonia. J Voice 1999;1:72:104.
5Ma EP, Yiu EM. Voice activity and participation profile: Assessing the impact of voice disorders on daily activities. J Speech Lang Hear Res 2001;44:511-24.
6Deary IJ, Wilson JA, Carding PN, MacKenzie K. VoiSS: A patient-derived Voice Symptom Scale. J Psychosom Res 2003;54:483-9.
7Wuyts 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.
8Jacobson BH, Jonson A, Grywalski C, et al. The Voice Handicap Index (VHI): Development and validation. Am J Speech Lang Pathol 1997;6:66-70.
9Franic DM, Bramlett RE, Bothe AC. Psychometric evaluation of disease specific quality of life instruments in voice disorders. J Voice 2005;19:300-15.
10Agency for Healthcare Research and Quality. Criteria for determining disability in speech-language disorders. Evidence report/technology assessment 2002.
11Nawka T, Wiesmann U, Gonnermann U. Validation of the German version of the Voice Handicap Index. HNO 2003;51:921-30.
12Guimaraes I, Abberton E. An investigation of the Voice Handicap Index with speakers of Portuguese: Preliminary data. J Voice 2004;18:71-82.
13Pruszewicz A, Obrebowski A, Wiskirska-WoŸnica B, Wojnowski W. Complex voice assessment: Polish version of the Voice Handicap Index (VHI). Otolaryngol Pol 2004;58:547-9.
14Lam PKY, Chan KM, Ho WK. Cross-cultural adaptation and validation of the Chinese voice handicap index-10. Laryngoscope 2006;116:1192-8.
15Hakkesteegt MM, Wieringa MH, Gerritsma EJ, et al. Reproducibility of the Dutch version of the voice handicap index. Folia Phoniatr Logop 2006; 58: 132-8.
16Amir O, Ashkenazi O, Leibovitzh T, Michael O, Tavor Y, Wolf M. Applying the Voice Handicap Index (VHI) to dysphonic and non-dysphonic Hebrew speakers. J Voice 2006;20:318-24.
17Núñez-Batalla F, Corte-Santos P, Señaris-González B, Llorente-Pendás 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.
18Helidoni 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.
19Malki 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.
20Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope 2004;114:1549-56.
21Hsiung MW, Pai L, Wang HW. Correlation between voice handicap index and voice laboratory measurements in dysphonic patients. Eur Arch Otorhinolaryngol 2002;259:97-9.