Introduction: The Voice Handicap Index has been shown Adaptacin y validacin del ndice de incapacidad
to be a valid instrument for assessing self-perceived handicap vocal (VHI-30) y su versin abreviada (VHI-10) al espaol
associated with dysphonia. Introduccin y objetivos: El ndice de incapacidad vocal
Objectives: To test the psychometric properties of the Spanish (Voice Handicap Index) es un instrumento vlido para la
version of the VHI-30 (Voice Handicap Index) and its valoracin del menoscabo asociado a la disfona que
shortened version VHI-10. percibe el paciente. El objetivo es valorar las propiedades
Subjects and method: The original VHI-30 was translated psicomtricas de la versin castellana del VHI-30 y su
into Spanish and was completed by 232 dysphonic patients versin abreviada VHI-10.
and 38 non-dysphonic individuals. Prospective instrument Sujetos y mtodo: El VHI-30 original se tradujo al idioma
validation was performed. espaol y lo contestaron 232 pacientes con disfona y 38 su-
Results: Results showed high test-retest reliability, and high jetos sanos. Se realiz una validacin prospectiva del in-
item-total correlation for both Spanish VHI-30 and VHI-10. strumento.
Internal consistency demonstrated to Cronbachs alpha of Resultados: Se encuentra una alta fiabilidad test-retest y
.93 and .86 respectively, and a significant correlation was altas correlaciones tem-total tanto para el VHI-30 como
found between the VHI scores and the patients self-rated para el VHI-10. La coherencia interna demuestra valores
dysphonic severity. alfa de Cronbach de 0,93 y 0,86 respectivamente, y se en-
Conclusions: The present study supports the use of Spanish contr una correlacin significativa entre las puntua-
versions of VHI-30 and VHI-10 because of their validity and ciones del VHI y la valoracin de los pacientes de la sev-
reliability. eridad de su disfona.
Conclusiones: El presente estudio apoya el uso de las
Key words: Voice Handicap Index. Spanish version. Voice versiones en espaol del VHI-30 y del VHI-10 por su
disorders. validez y fiabilidad.
INTRODUCTION
questionnaires. To determine the correlation between the appropriateness of grouping the items in the three sub-scales
total scores on the Spanish version of the VHI-30 and the into which the original questionnaire is divided.
VHI-10 and self-perceived dysphonia, Pearsons method
was applied. To determine if there are significant differences Analysis of the Items and Comparison Between the VHI-30
between the VHI-30 and the VHI-10 between the dysphonic and the VHI-10
group and the control group, an ANOVA and Tukeys The mean scores on each item were compared between
procedure for multiple comparisons were used. the control and dysphonic groups. In order to determine
the sensitivity of the VHI-10, Pearsons correlation was used,
Analysis of the Factorial Structure as was the analysis of proportions between the total scores
The principal component analysis applied to each item, on the spanish version of the VHI-10 and VHI-30. If the
complemented by Varimax rotation, enabled us to study the proportion between the VHI-10 and the VHI-30 is <0.333,
the Spanish version of the VHI-10 is less sensitive than the Table 3. Demographic Characteristics of the Participants
VHI-30 in evaluating voice impairment. Males, Females, Mean (SD),
Disorder n (%)
n (%) n (%) Years
Dysphonic group 162 40 (24.7) 122 (75.3) 37.1 (12.3)
RESULTS
Vocal polyp 47 (29)
Test-Retest Reliability Reinkes oedema 24 (14.8)
Forty patients completed the questionnaire on 2 occasions
Nodules 40 (24.7)
separated by between 2 and 8 weeks, without having received
any treatment whatsoever during the intervening period. Vocal cyst 7 (4.3)
Test-retest reliability was found to be good for both the VHI- Vocal paralysis 3 (1.9)
30 (r=0.822; P<.001) as well as for the VHI-10 (r=0.852; P<.001).
Sulcus 1 (0.6)
Table 4. Item/Total Correlation and Measurement of the Reliability Table 5. Item/Total Correlation and Measurement of the Reliability
of the 30 Items in the VHI-30 of the 10 Items in the VHI-10
Table 7. VHI-30 Factor Analysis (Varimax) Table 8. Mean Differences in the Item Scores Between the Dysphonic
and the Control Groups
Factors
Items Functional Scale Physical Scale Emotional Scale
1 2 3 4 5
Item Difference Item Difference Item Difference
F1 0.34 7.9E-02 0.19 0.10 0.72
F1 1.31 P1 1.61 E1 0.97
F2 0.36 9.3E-02 0.24 6.7E-02 0.73
F2 1.44 P2 2.50 E2 0.31
F3 0.12 0.13 0.16 0.15 0.76
F3 0.80 P3 2.51 E3 0.65
F4 0.11 3.6E-02 0.15 6.3E-03 0.32
F4 0.83 P4 2.21 E4 1.82
F5 0.19 4.5E-02 0.82 0.13 0.19
F5 0.83 P5 2.17 E5 0.60
F6 0.14 9.4E-02 0.8 0.17 0.22 F6 0.70 P6 2.06 E6 0.38
F7 0.4 0.15 1E-02 9.7E-02 0.29 F7 1.12 P7 1.01 E7 0.53
F8 0.38 0.31 0.57 0.2 0.14 F8 1.20 P8 2.05 E8 0.18
F9 0.27 0.32 0.5 0.41 0.13 F9 0.82 P9 1.87 E9 0.52
F10 9.7E-02 0.12 0.42 0.57 3.5E-02 F10 0.43 P10 1.77 E10 0.33
P2 0.83 5.9E-02 0.11 8.5E-02 5.4E-02 Table 9. Pearsons Correlation Between the Total Scores on the
VHI-30, the VHI-10, the Degree of Severity of the Dysphonia Rated
P3 0.75 0.10 6.3E-02 0.22 0.22
by the Patient and the Harmonics to Noise Ratio (HNR)
P4 0.73 4E-02 1.9E-02 0.18 0.28
VHI-30 VHI-10 Degree HNR
P5 0.77 0.16 0.13 8.7E-02 0.14
VHI-30 1.000 0.957 0.782 0.154
P6 0.67 6.9E-02 0.2 8.3E-02 9.8E-02 0.000 0.000 0.016
P7 0.38 0.18 0.28 0.35 8.6E-02 VHI-10 0.957 1.000 0.755 0.115
0.000 0.000 0.168
P8 0.72 0.14 0.15 0.18 0.25
Grado 0.782 0.755 1 0.130
P9 0.62 0.11 0.23 2.8E-02 3.8E-02
0.000 0.000 0.040
P10 0.67 0.25 0.26 6.9E-02 4.1E-02 HNR 0.154 0.115 0.130 1..000
E1 0.26 0.41 0.47 0.41 0.15 0.016 0.168 0.040
E3 0.23 0.19 6.5E-02 0.56 7E-02 Table 10. Ratio of the Total Scores Between the VHI-10 and the VHI-
30, Analyzed Separately in Each Group of Participants
E4 0.59 0.37 0.25 0.14 0.2
Group VHI-10:VHI-30 Ratio (SD)
E5 0.27 0.13 0.22 0.71 0.1
Dysphonia
E6 0.1 0.45 0.32 0.47 0.15
Polyp 0.47 (0.11)
E7 0.17 0.56 0.29 0.18 0.12 Reinkes oedema 0.48 (0.12)
Nodules 0.46 (8.8) E-02
E8 0.11 0.85 4E-02 0.12 8.2E-02
Functional dysphonia 0.33 (0.19)
E9 0.22 0.52 0.16 0.48 5E-02
Control group 0.33 (0.12)
E10 0.16 0.81 6E-02 8.6E-02 8.5E-02
The purpose of this study was to assess the psychometric patient group and the preoperative questionnaires, which
properties of the Spanish version of the VHI-30 and VHI- proves that the VHI discriminates individuals who suffer
10. The results reveal strong internal consistency and test- voice impairment from those who do not. The validity
retest reliability for both questionnaires. Validity is of the questionnaire is also maintained for the short form
demonstrated by the significant correlations achieved (VHI-10).
between the total scores and patient self-perceived Cronbachs alpha coefficient was used to assess reliability
severity of dysphonia. Both the control group, as well as or the homogeneity of the questions; this method allows for
the questionnaires completed following treatment values between 0 and 1. An =.93 was obtained for the VHI-
presented lower total scores than those corresponding 30 and =.86 for the VHI-10, thereby proving the reliability
to the dysphonic group and the control of the dysphonic of both questionnaires.
The study of the mean VHI-30 and VHI-10 scores and the of item F10 is The problem with my voice determines a
analysis of proportions seeks to demonstrate the robustness decrease in my income, and was replaced by My voice
of the VHI-10 items. If they were less sensitive than the VHI-30 problem affects my performance at work because many
in detected voice impairment, the ratio between the VHI-10 professionals who use their voices at work do not suffer a
and VHI-30 would be <0.33. The ratios found were wage decrease due to voice impairment and this sentence
consistently higher, which indicates that the VHI-10 is a includes those patients who are also affected economically.
strong representation of the VHI-30 in Spanish, as Finally, it must be pointed out that this translation and
demonstrated for the original questionnaire.7 validation is based on the Spanish that is spoken in Spain;
The item/total correlation detected for the VHI-30 and hence, the questionnaire should be adapted and validated
VHI-10 indicates the linear correlation between the item and for application in the various spanish-speaking countries.
total score obtained. Those that do not exceed a value of 0.35
must be discarded or reformulated. All the items
corresponding to the VHI-30 and VHI-10 exceed this figure; CONCLUSIONS
hence, they contribute to the questionnaires reliability.
The principal component analysis performed in this study The present work proves the validity and reliability of
sought to analyze the appropriateness of maintaining the the VHI-30 and VHI-10 translated into Spanish.
3 originally established sub-scales of the VHI-30 (functional, Given that the VHI-10 loses none of its usefulness or
physical, and emotional) in the Spanish version. validity, the authors recommend its use as a robust tool that
This study shows that all the items of the physical sub- is easier to complete and manage than the VHI-30.
scale are grouped around a single factor, whereas the items Each country or region should adapt the questionnaires
pertaining to the functional and emotional sub-scales are to the linguistic or cultural differences with respect to the
distributed among four different factors, although a tendency Spanish spoken in Spain.
is seen towards a preferential grouping around 2 of them.
In order to improve this section of the study, more completed
questionnaires would be needed by individuals with a wider REFERENCES
variety of voice disorders. The interpretation of this finding
1. Jacobson BH, Jonson A, Grywalski C, et al. The Voice Handicap Index (VHI):
is that, for the Spanish version of the VHI, the factorial development and validation. Am J Speech Lang Pathol. 1997;6:66-70.
structure of the questionnaire as reported by its author1 is 2. Hogikyan ND, Sethuraman G. Validation of an instrument to measure
maintained. Voice-Related Quality of Life (V-RQOL). J Voice. 1999;13:557-69.
3. Carding P, Horsley IA, Docherty GJ. A study of the effectiveness of voice
Insofar as the VHI-10 is concerned, the decision was made therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice.
to translate the one developed by Rosen et al instead of 1999;1:72-104.
4. Ma EP-M, Yiu EM-L. Voice activities and participation profile: assessing the
describing a different one using the Spanish translation of impact of voice disorders on daily activities. J Speech Lang Hear Res.
the VHI-30 as the starting point so as to avoid adding more 2001;44:511-24.
variations. Thus, this work focused on studying the translated 5. Deary IJ, Wilson JA, Carding PN, MacKenzie K. VoiSS: A patient-derived
Voice Symptom Scale. J Psychom Res. 2003;54:483-9.
VHI-10; it was found to be reliable and neither usefulness 6. Franic DM, Bramlett RE, Bothe AC. Psychometric evaluation of disease
nor validity is lost with respect to the VHI-30 in Spanish specific quality of life instruments in voice disorders. J Voice. 2005;19:300-
15.
when evaluating a patients voice impairment. 7. Rosen CA, Lee AS, Osborne J, et al. Development and validation of the voice
The lack of correlation between the HNR values and the handicap index-10. Laryngoscope. 2004;114:1549-56.
8. Wilson JA, Webb A, Carding PN, et al. The Voice Symptom Scale (VoiSS) and
scores on both questionnaires is striking, given that this the Vocal Handicap Index (VHI): a comparision of structure and content.
objective parameter is closely related to the severity of the Clin Otolaryngol. 2004;29:169-74.
dysphonia and the pathological spectrogram.14 9. Hsiung MW, Pai L, Wang HW. Correlation betweeen voice handicap index
and voice laboratory measurements in dysphonic patients. Eur Arch
This finding may be an indication that the VHI is an Otorhinolaryngol. 2002;259:97-9.
instrument that other voice parameters do not affect. An 10. Searis Gonzlez B, Nez Batalla F, Corte Santos P, Surez Nieto C. ndice
de incapacidad vocal: factores predictivos. Acta Otorrinolaringol Esp.
analysis of the evolution of objective pre- and post-operative 2006;57:101-8.
voice parameters would make it possible to clarify this point. 11. Lam PKY, Chan KM, Ho WK, Kwong E, Yiu EM, Wei WI. Cross-cultural
adaptation and validation of the Chinese voice handicap index-10.
The cultural affinities between the area for which the Laryngoscope. 2006;116:1192-8.
questionnaire was originally designed and the one in which 12. Pruszewicz A, Obrebowski A, Wiskirska-Wonzika B, Wojnowski W. Complex
this translation and validation for Spanish speakers was voice assessment: Polish version of the Voice Handicap Index (VHI).
Otolaryngol Pol. 2004;58:547-9.
carried out are such that VHI can be reliably used without 13. Guimares I, Abberton E. An investigation of the Voice Handicap Index
major question-content modifications. In this work, the with speakers of Portuguese: preliminary data. J Voice. 2004;18:71-82.
14. Nez Batalla F, Corte Santos P, Sequeiros Santiago G, Searis Gonzlez B,
suggestions provided by the different collaborators were Surez Nieto C. Evaluacin perceptual de la disfona: correlacin con los
collected and taken into consideration. The literal translation parmetros acsticos y fiabilidad. Acta Otorrinolaringol Esp. 2004;55:282-7.