Cross-Cultural Adaptation and Validation of the Voice

Handicap Index Into Croatian

Ana Bonetti and Luka Bonetti, Zagreb, Croatia

Summary: This article presents preliminary results of cultural adaptation and validation of the Croatian version of

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Voice Handicap Index (VHI). The translated version was completed by 38 subjects with voice disorders and 30 subjectswithout voice complaints. Compared with the subjects in the control group, subjects with voice disorders had signifi-cantly higher average total VHI score and scores in each of the three VHI domains (functional, physical, and emotional).Cronbach alpha for total VHI was .94, and coefficients obtained for the three VHI subscales were as follows: a¼ .87 forfunctional, a ¼ .88 for physical, and a ¼ .85 for emotional subscales. Intraclass correlation coefficient estimation wasalso high, for both total VHI (0.92) and subscales (0.85 for functional subscale, 0.87 for physical subscale, and 0.81 foremotional subscale). The overall VHI score positively correlated with auditory perceived grade of dysphonia. In thegroup with voice disorders, age was not correlated to the total VHI or the subscales. Also, there was no significant dif-ference between male and female voice subjects in total VHI or the subscales. Preliminary findings of this research in-dicate that the Croatian VHI could provide a reliable and clinically valid measure of patient’s current perception of voiceproblem and its reflection on the quality of life.Key Words: VHI–Quality of life–Croatian version.

INTRODUCTION

Contemporary clinical practice has advanced toward comprehen-sive understanding of treatment outcome as a complex interactionof disease and patients’ well-being.1 Suchmultidimensional viewon thematter created the need to evaluate clinical intervention notonly with physical or physiological variables but also by investi-gating quality-of-life variables, which represent personal experi-ence of the disease and its impact on everyday life. Investigationof the quality of lifemay reveal information on genesis of the dis-ease and its general and specific mental, social, or professionalconsequences,2 thus contributing to the process ofmakingclinicalchoices and decisions and to the assessment of their efficiency.This holistic concept of clinical evaluation is clearly useful inthe field of voice disorders, where instrumental, aerodynamic,and perceptive measures, despite giving detailed description ofvoice quality, fail to describe handicap caused by its change.3–9

In other words, because voice is the foundation of humancommunication and therefore incorporated in every aspect of lifethrough interpersonal interactions, severity of voice disordercannot be fully expressed just by defining the change in itsquality, but only in combination with the description ofmagnitude of lifestyle changes from the individual perspective.For example, Murry et al10 found that the nature of consequencesof a voice disorder is different for vocal professionals andnonprofessionals.

Because the complete insight in individual rehabilitativeneeds cannot be accomplished without information about theimpact of voice disorder on everyday activities, it is in thebest interest of everyone involved in the process of voice

ted for publication July 12, 2012.the Department of Speech and Language Pathology, Faculty of Education andation Sciences, University of Zagreb, Croatia.ss correspondence and reprint requests to Ana Bonetti, Department of Speech ande Pathology, Faculty of Education and Rehabilitation Sciences, Borongajska cesta0 Zagreb, Croatia. E-mail: anab@erf.hrl of Voice, Vol. 27, No. 1, pp. 130.e7-130.e14997/$36.003 The Voice Foundationx.doi.org/10.1016/j.jvoice.2012.07.006

rehabilitation to have at their disposal an instrument createdfor the purpose of measuring voice handicap. The results ofvoice handicap assessments help both the patient and clinicianto determine priorities in rehabilitation, which creates theopportunity to tailor intervention’s content and implementa-tion in such a manner that the patient receives exactly whathe or she needs, in a way that suits them best. Such an instru-ment, designed to measure quality of life after the occurrenceof voice disorder, is not available in clinical practice in thefield of voice disorders in Croatia. It therefore seemed reason-able to direct the efforts on investigation of the possibility toadapt one of the existing instruments created for that purposein other language.Quality of life is usually assessed by self-assessment ques-

tionnaires. Considering the fact that their administration intwo or more points in time provides valuable information onhandicap reduction (ie, efficiency of the treatment),11–13

practical gain of their use is enormous because they areeconomic and very easy to administer, with excellent orsatisfactory psychometric properties.12 Among several self-assessment questionnaires (Voice-Related Quality of Life[V-RQOL], Voice Handicap Index [VHI], Vocal PerformanceQuestionnaire [VPQ], Voice Activity and Participation Profile[VAPP], and Voice Symptom Scale [VoiSS]) designed to mea-sure quality of life after the occurrence of voice disorder,6–8,14

VHI stands out as the most widely used and with greatestpsychometric potential.8,9,14

VHI is an ordinal self-assessment scale, which ultimately pro-duces an unstandardized index representing the degree of pa-tient’s self-perceived problems that originated from voicedisorder; the index expresses the severity of voice difficultiesthrough their impact on everyday activities.7 VHI consists of30 items organized in three subscales: functional, physical,and emotional, respectively. Every item is scored on a five-pointLikert-type scale with scores ranging from 0 (answer never) to4 (answer always) and with the range of the overall score from0 to 120, where increase in the overall score means greater

Ana Bonetti and Luka Bonetti Cross-Cultural Adaptation and Validation of the VHI 130.e8

handicap. VHI has been translated to many languages,12,13,15–26

and international comparisons focused on identifying thedifferences between translated versions due to linguistic orcultural reasons proved that VHI is ‘‘. consistent tool forassessing the validity and reliability of self-perceived voice hand-icap.’’15,19 Past researches documented good internal consistencyand test-retest reliability of the VHI,7 its correlation with patientimpressions of voice disorder severity,7,15 sensitivity to differentetiology,7,16 and its usefulness in treatment evaluation.27–31 Andalthough significant correlation was reported between VHI anddysphonia severity index (objective multidimensional measureof voice quality),32 VHI generally does not correlate with objec-tive voice measures.18,33–35 This indicates that the assessment ofvoice disorder needs to encompass different approaches toevaluate specific dimensions of vocal dysfunction—subjectivesymptoms and personal impressions of difficulties, voicequality after the occurrence of voice disorder, and functionalaspect of the disorder.21

Considering numerous confirmations of its clinical useful-ness and wide acceptance of its use for self-rating of voicehandicap as well as the fact that Croatian clinical practice inthe field of voice disorders has not got similar instruments atthe disposal, this article examines the possibility of adaptationof the VHI to the Croatian language by preliminary investiga-tion of psychometric features of Croatian translation of theVHI and comparison of the results of its administration in thegroup of dysphonic and control subjects.

METHODS

Subjects

Translated VHI was administrated on 38 subjects with dyspho-nia (eight males and 30 females) aged between 20 and 64 years(mean age, 40.29 years). Their voice disorders were diagnosedand categorized by an ear, nose, and throat (ENT) specialist asmass lesions (19 subjects), inflammation (14 subjects), or neu-rogenic (five subjects).

Selection was made considering the following: (1) chrono-logical age 18+ years, (2) the presence of dysphonia at thetime the Croatian translation of the VHI was administered, con-firmed by an ENT or a speech-language pathologist (SLP), re-sulting from different etiology, except of transient vocaldifficulties like the ones connected with upper respiratory tractinfections and allergies, and (3) the absence of any other factors(eg, mental or sensory), which could interfere with datacollection.

Control group consisted of 30 subjects (five males and 25 fe-males) aged between 22 and 56 years (mean age, 35 years).Basic demographic characteristics of these subjects were asclosely as possible matched with the ones in dysphonic group,to eliminate the influence of general variables on VHI scores.36

These subjects were selected considering the following:(1) chronological age 18+ years, (2) no history of voice disor-ders, except of transient vocal difficulties like the ones con-nected with upper respiratory tract infections and allergies,(3) good vocal health at the time the Croatian translation ofthe VHI was administered, confirmed by perceptive voice qual-

ity evaluation by two SLPs, and (4) the absence of any otherfactors, which could interfere with data collection.

Procedure

Original VHI7 was translated independently by two SLPs expe-rienced in the field of voice disorders and an English professor.Afterward, consultations were carried out to adjust the originalitems to Croatian cultural and linguistic habits and, the firstCroatian version of the VHI was ready for back translation toEnglish by a professional translator. Again the comparisonswere made between original and retranslated versions of theVHI by an ENT specialist and SLP, both experienced in the fieldof voice disorders and fluent in English. After minor interven-tions, final version of the Croatian translation of the VHI wasproduced (see Appendix), which was administered individuallyto each subject. The voice subjects completed the translatedquestionnaire in the ENT clinic, where they entered medicaltreatment, after the written approval to conduct the researchwas obtained from the head of the clinic. Nonvoice subjectscompleted the questionnaire at the Faculty of Education andRehabilitation Sciences, University of Zagreb. Because thenumber of successfully completed questionnaires increases ifthe subjects are well informed about the items and possible an-swers,37 every subject received directions on how to completethe questionnaire. Because personal and medical data were col-lected, a written approval for their analysis was obtained fromevery subject.

To assess the validity of the Croatian translation of the VHI,the perceptive voice evaluation was also carried out by the sameSLPs enrolled in the translation of the original VHI. They inde-pendently graded dysphonia on a five-point scale during thesustained phonation task, carried out as a part of evaluation ofsubjects with voice disorders, with 0 representing normal voicequality and grades from 1 to 4 representing mildly, moderately,severely, and profoundly disordered voice quality, respectively.Individual grades from the two judges were averaged to geta single grade for every subject with dysphonia, which wasthen used as a part of validity assessment of the Croatian trans-lation of the VHI.

Statistical analysis

Statistical analysis was conducted by using SPSS Statistics 17.0(IBM Corporation). Demographic and voice-related data wereanalyzed descriptively for dysphonic and control groups aswell as for dysphonic subgroups (mass lesions, inflammation,and neurogenic). Cronbach alpha coefficient was generated todetermine internal consistency of the Croatian version of theVHI and its subscales; a value greater than .9 was consideredexcellent, a value between .9 and .8 was considered good, anda value less than .8 was considered satisfactory.38 An intraclasscorrelation coefficient (ICC) was used as a measure of repeat-ability of the questionnaire or the reproducibility15 of four sum-mary VHI variables: functional VHI (F), physical VHI (P),emotional VHI (E), and total VHI (T). The ICC is the ratio ofvariance between subjects and total variance,15 and was consid-ered to be an indicator of test-retest reliability, or consistency ofvoice handicap evaluation.

Journal of Voice, Vol. 27, No. 1, 2013130.e9

As determined by Shapiro-Wilk test, distribution of individ-ual results created the need to examine clinical validity of theCroatian version of the VHI by using nonparametric statistics.The Kruskal-Wallis test was used to compare three dysphonicsubgroups. VHI subscale scores and the overall VHI score be-tween different pairs of subgroups were compared by usingMann-WhitneyU test. Possible differences were tested betweendysphonic and control groups, subgroups of dysphonic sub-jects, as well as subgroups of dysphonic and control group.Kolmogorov-Smirnov two-sample test was used to test possibledifferences in the VHI score and subscores between male andfemale subjects in the dysphonic group, which seemed appro-priate due to test’s sensitivity to differences in the distributionsbetween small samples.

Finally, Spearman rank correlation coefficient was calculatedto examine the relationship between age and VHI subscalescores and the overall VHI score as well as between average au-ditory perceived grade of dysphonia and VHI subscales andoverall score. The accepted level of significance for all statisti-cal analysis was 0.05.

RESULTS

Descriptive analysis of the data collected by administering theCroatian version of the VHI on 38 dysphonic and 30 controlsubjects is given in Table 1. Mean, standard deviation (SD), me-dian, minimal and maximal scores, quartiles, and normality testare reported for each of the four summary VHI variables (F, P,E, and T).

Compared with dysphonic group, mean and median scoresfor VHI subscales and total VHI in the control group were sev-eral times lower. The same can be observed for dispersion of theresults, which indicates more homogeneous self-ratings in thecontrol group. The average scores in dysphonic group were12.4 for F subscale (SD, 8.1), 20.4 for P subscale (SD, 8.5),10 for E subscale (SD, 7.4), and 44.1 (SD, 21) for overallVHI. The average scores in control group were 2.5 for F sub-scale (SD, 2.4), 4.1 for P subscale (SD, 4.3), 1.3 for E subscale(SD, 2), and 7.8 (SD, 7.2) for overall VHI. There is an overlap infunctional and emotional subscores between the groups withinone SD range, whereas overlap of scores on physical subscale

TABLE 1.

Descriptive Analysis of the Results of 38 Dysphonic Subjects an

and on Overall VHI (T)

Group VHI N Mean SD M

Dysphonic subjects F 38 12.4 8.1 1

P 38 20.4 8.5 2

E 38 10 7.4

T 38 44.1 21 4

Control subjects F 30 2.5 2.4

P 30 4.1 4.3

E 30 1.3 2

T 30 7.8 7.2

and especially on total VHI can be noticed only in the rangeexceeding one SD. These relations are also shown in Table 1.Absolute frequencies of the scores showed that 26–30 of con-

trol subjects selected to answer the 30 VHI items with answersnever and almost never. Indeed, across 30 VHI items, answersalmost always and always altogether appear only three times inthe control group. On the contrary, absolute frequencies of thescores in dysphonic group were different for different VHIsubscales. More than 50% of dysphonic subjects answerednever or almost never onmost of the functional items. However,on items concerning speech loudness and intelligibility (itemsF1–F3 and F7), 20–27 dysphonic subjects made a choicethat suggests more frequent problems in functional aspect oftheir communication (answers sometimes, almost always, oralways).Most frequently chosen answer on the physical subscale in

dysphonic group was sometimes, followed by the answer almostalways, especially on the item that investigates the strain duringvoice production (item P5). One-third of dysphonic subjects didnot find items concerning the impression of voice quality byothers or themselves to be relevant for their communication(answers never or almost never on items P3 and P7).On items E1, E3, and E4 on the emotional subscale, which

investigate frustration over voice quality and understanding ofthe voice problem by communication partners, more than50% of dysphonic subjects selected the answers sometimes,almost always, or always. Other emotional items were mostlyanswered with never (in half of the cases). It is interesting tonotice that only five dysphonic subjects answered never onitem E4 (My voice upsets me).The results of the descriptive analysis for dysphonic sub-

groups show similar average scores and their dispersion instructural and inflammatory groups, but considering other de-scriptive data (the range of the results and quartiles), self-rating of vocal handicap was somewhat higher in inflammatorysubgroup. Central tendency and basic variability measures cal-culated for neurologic subgroup indicate even greater self-ratedvocal handicap. Compared with the average F, P, E, and Tscores in mass lesion and inflammatory subgroups, neurologicsubgroup had 3–4 units higher F score, 4–7 units higher P score,4–5 units higher E score, and 17–21 units higher overall VHI

d 30 Control Subjects on Three VHI Subscales (F, P, and E)

edian

Minimum–

Maximum

Lower/Upper

Quartile

Shapiro-Wilk

W P

2.5 0–27 (27) 4/19 0.95 0.09

1 2–38 (36) 13.5/25.5 0.99 0.98

8 0–28 (28) 4.8/14 0.92 0.01

0.5 9–88 (79) 26/62.5 0.95 0.07

2 0–9 (9) 0/4.3 0.9 0.00

3 0–15 (15) 0/7 0.9 0.00

0 0–9 (9) 0/2.3 0.7 0.00

6 0–22 (22) 1/14 0.9 0.00

TABLE 2.

Descriptive Analysis of the Scores of Dysphonic Subgroups on Three VHI Subscales (F, P, and E) and on Overall VHI (T)

Subgroup VHI N Mean SD Median

Minimum–

Maximum

Lower/Upper

Quartile

Shapiro-Wilk

W P

Mass lesions F 19 11.37 7.92 11 1–24 (23) 16/19 0.91 0.09

P 19 18.26 9.20 18 2–38 (36) 13/25 0.98 0.98

E 19 9.05 4.99 8 4–21 (17) 7/12 0.87 0.02

T 19 39.95 19.01 38 12–72 (60) 32/57 0.91 0.08

Inflammatory F 14 12.43 8.14 12.5 0–26 (26) 7/19 0.97 0.85

P 14 21.29 7.42 22.5 8–35 (27) 17/24 0.96 0.78

E 14 9.79 9.32 7 0–27 (27) 2/27 0.88 0.06

T 14 43.79 22.45 41.5 9–88 (79) 26/79 0.95 0.60

Neurogenic F 5 16 8.97 17 2–27 (25) 16/18 0.91 0.46

P 5 25.5 7.26 29 15–33 (18) 22/30 0.92 0.50

E 5 14.4 9.24 12 5–28 (23) 8/19 0.94 0.69

T 5 61 19.65 66 38–88 (50) 46/67 0.95 0.74

Ana Bonetti and Luka Bonetti Cross-Cultural Adaptation and Validation of the VHI 130.e10

score (Table 2). Nevertheless, basic variability measures givenin Table 2 show that the results of three dysphonic subgroupsoverlap to a certain extent, especially for E subscale and foroverall VHI score.

Table 3 presents the internal consistency and reliability of theCroatian version of VHI. Cronbach alpha for total VHI scorewas .94, and coefficients obtained for the three VHI subscaleswere as follows: a ¼ .87 for functional, a ¼ .88 for physical,and a¼ .85 for emotional subscales. Accordingly, internal con-sistency of three subscales of the Croatian VHI was good, andoverall internal consistency of the Croatian VHI was excellent.ICC estimation was also high, for both total VHI and subscales.The ICC estimation for total score was 0.92, with 95% confi-dence interval (CI) ranging from 0.87 to 0.95. EstimatedICCs for the three subscales were as follows: 0.85 (95% CI,0.77–0.91) for functional, 0.87 (95% CI, 0.80–0.93) for physi-cal, and 0.81 (95% CI, 0.70–0.89) for emotional subscales.

The Kruskal-Wallis test did not show significant differencesbetween dysphonic subgroups on three VHI subscales and over-all VHI scores (P¼ 0.57 for F subscale, P¼ 0.18 for P subscale,P ¼ 0.41 for E subscale, and P ¼ 0.17 for total VHI). The dif-ferences in average functional, physical, emotional, and totalVHI scores between different pairs of groups are displayed inTable 4. Mann-Whitney U test revealed significantly differentaverage scores (P ¼ 0.00) for dysphonic and control subjectson each of the three subscales and overall VHI. Kolmogorov-Smirnov two-sample test showed no significant differences in

TABLE 3.

Internal Consistency (Cronbach Alpha) and Reliability

(ICC With 95% CI) of the Croatian Version of the VHI

VHI

Cronbach

Alpha ICC (95% CI)

Functional (10 items) 0.87 0.85 (0.77–0.91)

Physical (10 items) 0.88 0.87 (0.80–0.93)

Emotional (10 items) 0.85 0.81 (0.70–0.89)

Total (30 items) 0.94 0.92 (0.87–0.95)

the total VHI score or the subscores between male and femalesubjects in the dysphonic group (VHI F: maximum negative�0.46, maximum positive 0.00, P > 0.10; VHI P: maximumnegative�0.22, maximum positive 0.03,P > 0.10; VHI E: max-imum negative �0.50, maximum positive 0.12, P < 0.10; andtotal VHI: maximum negative �0.43, maximum positive0.00, P > 0.10).

As presented in Table 5, positive Spearman rank order coef-ficients were found between age and VHI scores in dysphonicgroup, with the exception of negative coefficient for functionalsubscale score, but their low values indicate that the age of dys-phonic subjects was not significantly correlated to their VHIsubscale and total scores. Significant moderate positive correla-tion was found between the average grade of dysphoniaawarded by two experienced judges and the overall VHI score(r ¼ 0.41) as well as the F subscale (r ¼ 0.40). The obtainedSpearman rank order coefficient for the P subscale was r ¼0.30 and for the E subscale r ¼ 0.31, and both these subscaleswere not significantly correlated with average perceived gradeof dysphonia.

DISCUSSION

As indicated by excellent internal consistency and test-retest re-liability for the overall VHI score, as well as good internal con-sistency and test-retest reliability for the VHI subscalescores,13,15 the Croatian version of VHI reliably measuresvoice handicap and its functional, physical, and emotionaldimensions. Based on high Cronbach alpha coefficients andICCs, it seems that the Croatian translation of VHI has theproperty of producing consistent results in repeatedapplications with the purpose of measuring voice handicap.Obtained results of reliability estimation are in agreementwith those reported for other VHI translations.15–17,19

As in several other transcultural VHI studies,15,17,18,22 thehighest average score in dysphonic group was found forphysical subscale, which supports already offered explanationabout physical symptoms of voice disorder being the prominent

TABLE 4.

The Differences in the Results of VHI Subscales and Total VHI Between Dysphonic and Control Groups; Dysphonic

Subgroups; Dysphonic Subgroups and Control Group; and Female and Male Subjects in Both Groups

Compared Groups/Subgroups

VHI

F P E Total

U P U P U P U P

Dysphonic-control 165.5 0.00* 53.5 0.00* 92 0.00* 26.5 0.00*

Structural-inflammatory 124 0.74 105 0.31 121 0.66 117 0.56

Structural-neurogenic 34 0.34 22.5 0.08 29 0.19 20.5 0.05

Inflammatory-neurogenic 25 0.35 24 0.31 23.5 0.29 20.5 0.18

Structural-control 87 0.00* 43 0.00* 15 0.00* 14 0.00*

Inflammatory-control 63 0.00* 9 0.00* 75 0.00* 12.5 0.00*

Neurogenic-control 15.5 0.00* 1 0.00* 2 0.00* 0 0.00*

Female-male (dysphonic group) 64* 0.04* 97.5 0.42 78.5 0.14 73.5 0.10

Female-male (control group) 46.5 0.37 55 0.68 62 0.99 56.5 0.74

The table shows the significance of U statistic in Mann-Whitney U test, and values which are bolded and marked ‘‘*’’ are significant at P < 0.05.

Journal of Voice, Vol. 27, No. 1, 2013130.e11

perceptual parameters and therefore more easily associated withdysphonia.

The nonparametric tests used to compare the average resultsof dysphonic and control subjects showed that the Croatian ver-sion of the VHI could differentiate voice and nonvoice subjects,which reveals its discriminant potential and validity. Signifi-cantly lower total score and subscale scores in the control groupsupport the thought that the Croatian translation of the VHI issensitive enough to indirectly identify voice problems by esti-mating the voice handicap. Similar findings are reported inother studies of psychometric properties of translated versionsof the VHI.12,15,17,19,23,24 The comparison of VHI scores withperceptual assessment of severity of dysphonia furthersupports the validity assumption: the overall VHI score and Fsubscore were significantly correlated with the degree ofdysphonia perceived by the listeners, suggesting that greaterself-perceived handicap is accompanied by more audible devi-ations in the voice quality. The P and E subscales depend moreheavily on the individual’s perception and experience of voiceproblem, whereas F subscale is more directed toward the effi-ciency of interpersonal communication and mostly representsexperiences derived from the collocutor’s feedback, which isbased on acoustic properties of the voice problem. Therefore,one possible explanation of significant correlation betweenfunctional subscale of the VHI and perceptual assessment of

TABLE 5.

Spearman Rank Order Correlations Between the Results

of VHI Subscales and Total VHI in Dysphonic Group and

Age and Grade of Dysphonia

VHI Age Grade of Dysphonia

Functional �0.12 0.40*

Physical 0.11 0.30

Emotional 0.06 0.31

Total 0.05 0.41*

Values marked ‘‘*’’ are significant at P < 0.05.

severity of dysphonia is that they are both oriented towardaudible deviances in voice quality, with one being indirectassessment of listeners’ experiences (F VHI) and other beingdirect perceptive assessment of voice quality.The differences between dysphonic subgroups in average

overall and subscale VHI scores were not statistically signifi-cant, which is not surprising because the original purpose ofVHI is to measure patient’s perception of the voice-relatedproblems and not to discriminate between various causes ofthese problems,7 but they may still be meaningful and thereforeshould not be overlooked. The groups with different patholo-gies achieved different average VHI scores, with neurogenicvoice patients being the ones with highest self-estimated voicehandicap. The same finding occurred in several earlier studies,where VHI scores of dysphonic groups with different type ofvoice disorders were compared.15–17,27 However, because ofa very small number of subjects, it is only possible toconsider the tendency of the scores on Croatian version ofthe VHI to be affected by different type of voice disordersas preliminary finding, demanding further investigationin Croatian population. One should think the same aboutthe fact that VHI scores and subscores were not affected byage or gender, although this is in agreement with thepreviously reported findings,12,16,17 and is also an importantcue about the appropriateness of the translation. What furtherencourages more detailed investigation of the use of theCroatian VHI in clinical settings is the fact that the subjectsdid not have any objections to the items while answeringthem. Under the condition that the purpose and protocol wereexplained before the questionnaire’s self-administration, thesubjects needed no help to complete the questionnaire in rela-tively short time, which suggests that the VHI’s translationwas adequately governed.

CONCLUSION

Judging by the results of preliminary investigation of its psy-chometric properties, it appears that the Croatian version of

Ana Bonetti and Luka Bonetti Cross-Cultural Adaptation and Validation of the VHI 130.e12

the VHI, in its current form, has the potential to be used for thepurpose of self-assessment of voice handicap. Preliminaryfindings of this research indicate that the Croatian VHIcould provide a reliable and clinically valid measure of patient’scurrent perception of voice problem and its reflection onquality of life. As such, these preliminary results encouragea more comprehensive and rigorous investigation of psycho-metric characteristics of the Croatian VHI, and of its justifiable-ness and usefulness in the initial assessment of dysphonicpatients, as well as treatment evaluation in Croatian clinicalsettings.

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Journal of Voice, Vol. 27, No. 1, 2013130.e13

APPENDIX

Indeks vokalne te�sko�ce

Upute: Ovo su tvrdnje koje su mnogi ljudi upotrijebili kako bi opisali svoj glas i utjecaj toga glasa na njihove �zivote. Zaokru�zite odgo-vor koji pokazuje kako �cesto Vi imate isto iskustvo.

0, NIKADA; 1, GOTOVO NIKADA; 2, PONEKAD; 3, GOTOVO UVIJEK; 4, UVIJEK

DIO I.

F

1. Moj glas je razlog za�sto me ljudi te�sko �cuju. 0 1 2 3 4

2. U bu�cnoj prostoriji ljudi me te�sko razumiju. 0 1 2 3 4

3. �Clanovi obitelji me te�sko �cuju kada ih dozivam odnekud iz ku�ce. 0 1 2 3 4

4. Telefon upotrebljavam rjeCe nego �sto �zelim. 0 1 2 3 4

5. Zbog svoga glasa nastojim izbje�ci ve�ce grupe ljudi. 0 1 2 3 4

6. Zbog svoga glasa rjeCe razgovaram s prijateljima, susjedima ili rodbinom. 0 1 2 3 4

7. Ljudi tra�ze da ponovim kad razgovaram s njima licem u lice. 0 1 2 3 4

8. Te�sko�ce s glasom ograni�cavaju moj osobni i dru�stveni �zivot. 0 1 2 3 4

9. Osje�cam kako sam zbog svoga glasa isklju�cen/-a iz konverzacije. 0 1 2 3 4

10. Problem s glasom mi uzrokuje gubitak u prihodima. 0 1 2 3 4

DIO II.

P

1. Ostajem bez zraka za vrijeme govorenja. 0 1 2 3 4

2. Zvuk moga glasa varira tijekom dana. 0 1 2 3 4

3. Ljudi me pitaju: ‘‘�Sto nije u redu s Va�sim glasom ?’’ 0 1 2 3 4

4. Moj glas zvu�ci ‘‘�skripavo i suho.’’ 0 1 2 3 4

5. Osje�cam kao da se moram naprezati da bih govorio/govorila. 0 1 2 3 4

6. Jasno�ca moga glasa je nepredvidiva. 0 1 2 3 4

7. Poku�savam mijenjati svoj glas da zvu�ci druk�cije. 0 1 2 3 4

8. Upotrebljavam dosta snage da bih govorio/govorila. 0 1 2 3 4

9. Glas mi je lo�siji nave�cer. 0 1 2 3 4

10. Glas me ‘‘izdaje’’ usred govorenja. 0 1 2 3 4

DIO III.

E

1. Zbog svog glasa osje�cam se napet/napeta kad razgovaram s drugima. 0 1 2 3 4

2. Ljudi se doimaju iritirani mojim glasom. 0 1 2 3 4

3. Mislim da drugi ljudi ne razumiju moje probleme s glasom. 0 1 2 3 4

4. Problem s mojim glasom me uzrujava. 0 1 2 3 4

5. Manje izlazim zbog problema s glasom. 0 1 2 3 4

6. Zbog svoga glasa se osje�cam hendikepirano. 0 1 2 3 4

7. Ljutim se kad ljudi tra�ze da ponovim �sto sam rekao/rekla. 0 1 2 3 4

8. Zbunjen sam kad ljudi tra�ze da ponovim �sto sam rekao/rekla. 0 1 2 3 4

9. Moj glas je razlog za�sto se osje�cam nesposobno. 0 1 2 3 4

10. Sramim se svojih problema s glasom. 0 1 2 3 4

Ana Bonetti and Luka Bonetti Cross-Cultural Adaptation and Validation of the VHI 130.e14

Voice handicap index (English Translation)

This index is a way for us to assess how you would describe the way you use your voice. It also allows you to explain to us how yourvoice effects your life. Please circle the response that indicates how frequently you have these experiences.

0, Never; 1, Almost never; 2, Sometimes; 3, Almost always; 4, Always

PART I.

F

1) My voice makes it difficult for people to hear me. 0 1 2 3 4

2) People have difficulty understanding me in a noisy room. 0 1 2 3 4

3) May family has difficulty hearing me when I call them through the house. 0 1 2 3 4

4) I use the phone less often than I would like to. 0 1 2 3 4

5) I tend to avoid groups of people because of my voice. 0 1 2 3 4

6) I speak with friends, neighbors, or relatives less often because of my voice. 0 1 2 3 4

7) People ask me to repeat myself when speaking in person. 0 1 2 3 4

8) My voice difficulties restrict personal and social life. 0 1 2 3 4

9) I feel left out of conversations because of my voice. 0 1 2 3 4

10) My voice problem causes me to lose income. 0 1 2 3 4

PART II.

P

1) I run out of air when I talk. 0 1 2 3 4

2) The sound of my voice varies throughout the day. 0 1 2 3 4

3) People ask, “What’s wrong with your voice?”. 0 1 2 3 4

4) My voice sounds creaky and dry. 0 1 2 3 4

5) I feel as though I have to strain to produce voice. 0 1 2 3 4

6) The clarity of my voice in unpredictable. 0 1 2 3 4

7) I try to change my voice to sound different. 0 1 2 3 4

8) I use a great deal of effort to speak. 0 1 2 3 4

9) My voice is worse in the evening. 0 1 2 3 4

10) My voice “gives out” on me in the middle of speaking. 0 1 2 3 4

PART III.

E

1) I am tense when talking to others because of my voice. 0 1 2 3 4

2) People seem irritated with my voice. 0 1 2 3 4

3) I find other people don’t understand my voice problem. 0 1 2 3 4

4) My voice problem upsets me. 0 1 2 3 4

5) I am less outgoing because of my voice problem. 0 1 2 3 4

6) My voice makes me feel handicapped. 0 1 2 3 4

7) I feel annoyed when people ask me to repeat. 0 1 2 3 4

8) I feel embarrassed when people ask me to repeat. 0 1 2 3 4

9) My voice makes me feel incompetent. 0 1 2 3 4

10) I am ashamed of my voice problem. 0 1 2 3 4