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The Voice Handicap Index (VHI): Development and Validation

Article  in  American Journal of Speech-Language Pathology · August 1997

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 Research

The Voice Handicap Index (VHI):

Development and Validation

Barbara H. Jacobson
Alex Johnson
Cynthia Grywalski
Alice Silbergleit
Gary Jacobson
Michael S. Benninger
Henry Ford Hospital and Health Sciences Center,
Detroit, MI

Craig W. Newman
The Cleveland Clinic Foundation, Cleveland, OH

To date, no instruments exist to quantify the and the initial 85-item version was reduced to a
psychosocial consequences of voice disorders. 30-item final version. This final version was
The aim of the present investigation was the administered to 63 consecutive patients on two
development of a statistically robust Voice occasions in an attempt to assess test-retest
Handicap Index (VHI). An 85-item version of stability, which proved to be strong. The
this instrument was administered to 65 con- findings of the latter analysis demonstrated that
secutive patients seen in the Voice Clinic at a change between two administrations of 18
Henry Ford Hospital. The data were subjected points represents a significant shift in psychoso-
to measures of internal consistency reliability cial function.

M
easuring the severity of a voice disorder is defined as, “a social, economic, or environmental disad-
difficult. Methods have ranged from subjective vantage resulting from an impairment or disability.” Thus,
measures of voice disorder severity including a voice handicap might occur when a person changes jobs
perceptual judgments (e.g., grading of voice quality as because he cannot give presentations as required in his
mild, moderate, or severe) to objective measures of voice present position due to vocal fatigue.
characteristics (e.g., videostroboscopic findings and Self-perceived disability/handicap measures are
physiological measure of voice compared to normative ubiquitous in the field of audiology. That is, several
data). Although these methods can yield valuable data, disability/handicap measures have been developed for the
they do not provide insight into why patients with similar evaluation of the communicative and psychosocial impact
voice disorders experience differing levels of handicap and of hearing loss, dizziness, and tinnitus (Jacobson &
disability. For example, a retired man who lives alone and Newman, 1990; Newman, Jacobson, & Spitzer, 1995;
has few social contacts may view his voice disorder Newman, Jacobson, Weinstein, & Hug, 1990; Newman,
(resulting from unilateral vocal fold paralysis) as less Weinstein, Jacobson, & Hug, 1991; Ventry & Weinstein,
handicapping than a salesperson who has daily contact 1982). These latter measures have been found to be useful
with customers and two small children at home. for quantifying functional outcome following medical
The terms “disability” and “handicap” have specific surgical or rehabilitative interventions.
definitions. For example, the World Health Organization There are few standardized methods for assessing the
(1980) defines disability as “a restriction or lack of ability psychosocial consequences of voice disorders. Llewellyn-
manifested in the performance of daily tasks.” In this Thomas et al. (1984) developed a linear analogue scale that
connection, voice disability would be the inability to was an attempt to quantify self-assessment of voice quality
produce a high pitch or to speak loudly. Handicap is and daily functioning for patients with laryngeal cancer.

66 American Journal
American of Speech-Language
Journal of Speech-Language Pathology •• Vol.
Pathology Vol. 66 •• 1058-0360/97/0603-0066
No. 3 August 1997
© American Speech-Language-Hearing Association
Thirty-four patients who were undergoing radiation groups based on diagnoses made jointly by otolaryngolo-
treatment rated the severity of their voice symptoms and gists and speech-language pathologists. Subjects in the
their ability to communicate in various situations along a mass lesions group had diagnoses such as vocal nodules,
10-cm line. One end of each item’s linear scale was vocal polyps, and vocal cysts. Subjects in the neurogenic
anchored by a statement that indicated no impairment and group had diagnoses such as vocal fold paralysis and
the other end anchored by a statement that indicated severe spasmodic dysphonia. Subjects in the musculoskeletal
impairment. For example, the item “How satisfactory has tension group had demonstrated normal-appearing larynges
your ability to use your voice in work/leisure/social-related but had significant laryngeal area muscle tension without
activities been over the past week?” was anchored by any clear psychological overlay. Subjects in the inflamma-
“Entirely satisfactory, i.e., able to carry out all speech- tory group had acute erythema of the vocal folds. Subjects in
related activities without apparent effort” and “Absolutely the atypical group had normal-appearing larynges and a clear
unsatisfactory, i.e., all speech-related activities are impos- psychogenic etiology with sudden onset for their dysphonias.
sible.” Test-retest reliability for the symptom and function Procedure. An initial pool of 85 items was developed
scales ranged from r = 0.56 to r = 0.93. Although this scale empirically from case history interviews with patients with
was designed for use with a select group of patients, it voice disorder seen in the Voice Clinic over the past 7
represents the first attempt to produce a statistically years. Patients seen in the Clinic have been diagnosed with
validated instrument for assessment of the functional a variety of voice disorders, ranging from benign mass
impact of alteration in voice quality. lesions, vocal fold paralysis, spasmodic dysphonia,
Smith et al. (1994) designed a questionnaire to elicit papilloma, musculoskeletal tension disorders, and atypical
information from patients regarding the functional impact (“psychogenic”) voice disorders. Some items were created
of voice disorders in various aspects of their lives, the by rewording a previous item so that the meaning was
effects of vocal symptoms specifically on employment, similar. This was done to ensure that items were as clear as
symptoms, risk factors, and family history. Data were possible in the final version. Items were grouped a priori
collected from 113 patients. In an initial analysis, work- into three content domains representing functional (25
related effects for patients with voice disorders were items), emotional (31 items), and physical (29 items)
apparent, as were effects on social interaction reported by aspects of voice disorders. The 85 items comprising this
older patients. This was the first study to evaluate the preliminary version of the VHI were selected from
impact of voice disorders on quality of life dimensions and patients’ reports to ensure that the scale had both content
provided direction and impetus for further study. and face validity. The functional subscale included
Although there has been acknowledgment in the statements that described the impact of a person’s voice
literature that voice disorders can have a devastating disorder on his or her daily activities. An example of a
impact on daily functioning and quality of life, there are probe item from the functional content domain was, “My
few instruments that have been developed specifically to voice problem causes me to miss work.” The emotional
address this issue. Accordingly, the purpose of the present subscale consisted of statements representing a patient’s
investigation was to develop a psychometrically robust affective responses to a voice disorder. An example of a
voice disability/handicap inventory that could be used with probe item from the emotional content domain was, “I feel
patients exhibiting a variety of voice disorders. annoyed when people ask me to repeat.” Items comprising
the physical subscale were statements representing self-
perceptions of laryngeal discomfort and voice output
Investigation 1: Scale Development characteristics (e.g., voice pitched too low or high). An
Method example of a probe item from the physical content domain
Subjects. Sixty-five consecutive adult patients seen in was, “I feel as though I have to strain to produce voice.”
the Voice Clinic at Henry Ford Hospital completed the Subjects were asked to read each item and circle one of
preliminary version of the Voice Handicap Inventory five responses comprising an equal-appearing five-point
(VHI) (mean age = 52.3; SD = 16.28; 25 males and 40 scale. The scale had the words “never” and “always”
females). The subjects were diagnosed with a broad range anchoring each end and the words “almost never”, “some-
of voice disorders (Table 1). They were classified into 6 times”, and “almost always” appearing in between. An
“always” response was scored 4 points, a “never” response
was scored 0, and the remaining options were scored
TABLE 1. Diagnoses for patients participating in the develop- between 1 and 3 points.
ment of the VHI.
The instructions to the patients were as follows: “These
are statements that many people have used to describe their
Diagnosis Number of Patients (%)
voices and the effects of their voices on their lives. Circle
Mass lesions 21 (32) the response that indicates how frequently you have the
Neurogenic 17 (26) same experience.”
Laryngectomy 17 (26)
Musculoskeletal tension 5 (8)
Results
Inflammatory 3 (5)
Atypical 2 (3) The internal consistency reliability of the preliminary
version of the VHI was evaluated using Cronbach’s alpha

Jacobson • Johnson • Grywalski • Silbergleit • Jacobson • Benninger • Newman 67

TABLE 2. Correlation matrix for total score and subscale Results
scores for the final version of the Voice Handicap Index (VHI).
A Pearson product-moment correlation coefficient was
Subscale Functional Physical Emotional Total used to determine the test-retest stability of the VHI
subscales and total score. Test-retest stability for subscale
Functional * 0.70 0.79 0.91 and total scores was found to be strong for the functional (r
Physical * * 0.72 0.88 = 0.84), emotional (r = 0.92), physical (r = 0.86) subscales,
Emotional * * * 0.93 and total score (r = 0.92). From this data set, the 95%
Total * * * * confidence intervals (critical difference scores) were
derived for the functional, emotional, and physical
subscales (8 points each) and for the VHI total scale score
coefficient. Items contained within a scale that have high (18 points). Thus, a shift in the total score of 18 points or
item-total correlations contribute to the scale’s overall greater is required in order to be certain that the change is
reliability and are more representative of scale content than not due to unexplained variability inherent in the VHI.
items with low item-total correlations. The item total Cronbach’s alpha coefficient was calculated for the
correlations ranged from r = 0.17 to r = 0.86. Nunnally item-total correlation of the final version of the VHI. The
(1978) has suggested that Cronbach’s alpha coefficient resulting alpha coefficient (r = 0.95) represented little
should be at least r = 0.50 for a single item to demonstrate change from that calculated for the 85-item version of the
acceptable internal consistency. Accordingly, the preliminary VHI (r = 0.97).
version was reduced from 85 items to 57 items by eliminat- Finally, the magnitude of the relationship between the
ing all items with item-total correlations of r < 0.60. We subscales was assessed with data collected from the first
retained an additional four items with item-total correlation administration of the VHI. (The results are shown in Table
coefficients below r = 0.60 because they were judged by the 2). The relationships between the functional, physical, and
authors to have high face validity. These items were: “The emotional subscales of the VHI were moderate-strong with
sound of my voice varies throughout the day,” “My voice Pearson product-moment correlations ranging from r =
sounds creaky and dry,” “My voice problem causes me to 0.70 to r = 0.79.
lose income,” and “I run out of air when I talk.”
Fifteen more items were eliminated because the Investigation 3: Relationship of VHI Score to
observed frequencies of “positive” (i.e., score of “2” to Voice Disorder Severity
“4”) or “negative” (i.e., score of “0” or “1”) scores differed
substantially between men and women. Responses to these Method
items appeared to reflect a dependency on the sex of the Subjects. Subjects used for this investigation were the
patient; therefore, they were removed. same as those in Investigation 2 (Table 3).
An additional 16 items were eliminated because they Procedure. In addition to completing the VHI, subjects
were answered “never” by 50% or more of the subjects or were asked to self-rate the severity of their voice disorder
because the item content was found to be redundant (that on a 0 to 3 point scale with “0” representing a self-
is, the subject matter was present in similarly worded perception of voice as normal, “1” representing mildly
questions with stronger item-total correlations). impaired voice, “2” representing moderately impaired
Through these procedures, the original 85-item prelimi- voice, and a “3” representing self-perception of voice as
nary version of the VHI was reduced to a 30-item (120- severe. Instructions to the subjects were as follows: “Please
point total) final version (see Appendix). The final version rate, in your opinion, how severe your voice problem is on
consisted of a 10-item functional subscale, a 10-item this scale.” No specific instruction was given to the patient
emotional subscale, and a 10-item physical subscale. regarding the meaning of “severity.” It was predicted that
self-perceived voice handicap would increase systemati-
cally with the degree of self-perceived voice abnormality.
Investigation 2: Test-Retest Reliability
Method
Results
Subject. Sixty-three of the adult patients who partici-
Subjects rating their voices as “normal” or “mild” were
pated in the first investigation served as subjects for this
investigation (mean age = 49 years, SD = 18 years; 25 grouped together. Mean VHI total and subscale scores are
males, 38 females). Only two of the original subjects were TABLE 3. Demographics of 63 subjects participating in
lost to follow-up, so the diagnosis mix remained roughly Investigation 3.
the same.
Procedure. The final version of the VHI was administered Severity
to subjects on two occasions. The amount of time between
administrations ranged from 6 to 71 days (M = 29.3 days, SD Mild Moderate Severe
(n = 13) (n = 27) (n = 23)
= 29.26). A pencil and paper format was used. During this
time, subjects did not undergo any intervening medical, Age (years; mean, (SD)) 43.31 (4.70) 55.59 (3.26) 43 (3.53)
surgical, or behavioral treatment. The subjects were given the Sex (male/female) 6/7 12/15 9/14
same instructions as in Investigation 1.

68 American Journal of Speech-Language Pathology • Vol. 6 • No. 3 August 1997

shown in Table 4 as a function of severity groupings. A relative to our judgments of the severity of their voice
Pearson product-moment correlation coefficient was used disorders. The VHI can be of use in evaluating the effective-
to compare subjects’ VHI scores and judgments of sever- ness of specific voice treatment techniques such as Vocal
ity. Results indicated a moderate relationship between the Function Exercises or the Accent Method (Stemple, Glaze, &
two patient self-assessment measures (r = 0.60). Gerdeman, 1995; Kotby, 1995). Data obtained from the VHI
also can be used as a continuing quality measure for accredi-
tation processes (e.g., Joint Commission for the Accreditation
Discussion of Health Organizations). Finally, the VHI can be useful as a
The aim of the present investigation was to develop a component of measuring functional outcomes in behavioral,
psychometrically validated tool for measuring the psycho- medical, and surgical treatments of voice disorders. We
social handicapping effects of voice disorders. We found already use well-established physiologic and perceptual
the VHI to demonstrate strong internal consistency measures toward this purpose and the addition of a patient
reliability and test-retest stability. A 95% confidence self-assessment measure will strengthen our conclusions
interval of 18 points was established that gives users of this about the effectiveness and efficiency of various interven-
scale assurance that changes in total scores between tions for voice disorders.
administrations are not due to inherent variability in the
VHI. The VHI was developed using a diverse sample of References
patients with voice disorders, representing the breadth of
Jacobson, G. P., & Newman, C. W. (1990). The development of
pathology in most clinical settings. This was intentional, as the Dizziness Handicap Inventory (DHI). Archives of
we wanted to create a scale that could be generalized to Otolaryngology–Head and Neck Surgery, 116, 424–427.
other clinics and would have widespread application. Kotby, M. K. (1995). The accent method of voice therapy. San
Construct validity was not fully evaluated in this study, Diego: Singular Publishing Group.
although the relationship between patient self-perceived Llewellyn-Thomas, H. A., Sutherland, H. J., Hogg, S. A.,
severity and VHI scores was determined to be moderately Ciampi, A., Harwood, A., Keane, T., Till, J. E., & Boyd,
strong. This aspect of instrument design is crucial to N. F. (1984). Linear analogue self-assessment of voice
establishing the overall validity of any scale. Since there quality in laryngeal cancer. Journal of Chronic Disease, 37,
are no comparable scales to cross-validate construct 917–924.
Newman, C. W., Jacobson, G. P., & Spitzer, J. (1995).
validity for the VHI, one approach might be to administer
Development of the Tinnitus Handicap Inventory. Archives of
the VHI to a group of persons without voice disorders. In Otolaryngology–Head and Neck Surgery, 122, 143–148.
this way, the presence of handicap and disability as Newman, C. W., Jacobson, G. P., Weinstein, B. E., & Hug,
represented by VHI scores can be confirmed. G. A. (1990). The hearing handicap inventory for adults:
Several interesting observations were made during the Psychometric adequacy and audiometric correlates. Ear and
course of this investigation. Patients mentioned frequently Hearing, 11, 430–433.
that they were unaware of the degree of severity of their Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug,
voice problems until completing the VHI. Thus, measure- G. A. (1991). Test-retest reliability of the hearing handicap
ment of handicap can have significant implications for the inventory for adults. Ear and Hearing, 12, 355–357.
educational component of the treatment process. A crucial Nunnally, J. C. (1978). Psychometric theory (2nd ed.). New
York: McGraw-Hill.
element in a patient’s ability to change behavior is motiva-
Smith, E., Nichols, S., Lemke, J., Verdolini, K., Gray, S. D.,
tion. When patients understand the implications of their voice Barkmeier, J., Dove, H., & Hoffman, H. (1994). Effects of
problems in the context of daily living and functioning, they voice disorders on patient lifestyle: Preliminary results. NCVS
may be more likely to work toward changing factors that Status and Progress Report, 4, 237–248.
contribute to the development of their dysphonias. Stemple, J. C., Glaze, L. E., & Gerdeman, B. K. (1995).
The VHI has several potential uses in the clinical Clinical voice pathology (2nd ed.). San Diego: Singular.
practice of speech-language pathology. In the most basic Ventry, I., & Weinstein, B. (1982). The Hearing Handicap
application, the VHI can be used to assess the patient’s Inventory for the Elderly: A new tool. Ear and Hearing, 3,
judgment about the relative impact of his or her voice 128–134.
disorder upon daily activities. In several instances, we have World Health Organization. (1980). International classification
of impairments, disabilities, and handicaps. Geneva: World
been surprised at how patients have scored on the VHI
Health Organization.

TABLE 4. Mean values (SD) for VHI subscale and total scale Received February 14, 1996
scores as a function of self-perceived voice severity. Accepted February 10, 1997

Group Contact author: Barbara H. Jacobson, PhD, Division of Speech-

Language Sciences and Disorders, Department of Neurology,
Scale Mild Moderate Severe
Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, Michigan
Functional 10.07 (1.99) 12.41 (1.38) 18.30 (1.50) 48202
Physical 15.54 (1.97) 18.63 (1.37) 22.78 (1.48)
Emotional 8.08 (2.31) 13.33 (1.61) 20.30 (1.74)
Total 33.69 (5.60) 44.37 (3.88) 61.39 (4.21) Key Words: voice disorders, assessment, self-perceived
handicap

Jacobson • Johnson • Grywalski • Silbergleit • Jacobson • Benninger • Newman 69

 Appendix
Voice Handicap Index (VHI), Henry Ford Hospital

Instructions: These are statements that many people have used to E15. I find other people don’t understand my voice problem.
describe their voices and the effects of their voices on their lives.
Circle the response that indicates how frequently you have the F16. My voice difficulties restrict my personal and social life.
same experience. P17. The clarity of my voice is unpredictable.

F1. My voice makes it difficult for people to hear me. P18. I try to change my voice to sound different.

P2. I run out of air when I talk. F19. I feel left out of conversations because of my voice.

F3. People have difficulty understanding me in a noisy room. P20. I use a great deal of effort to speak.

P4. The sound of my voice varies throughout the day. P21. My voice is worse in the evening.

F5. My family has difficulty hearing me when I call them F22. My voice problem causes me to lose income.
throughout the house. E23. My voice problem upsets me.
F6. I use the phone less often than I would like. E24. I am less outgoing because of my voice problem.
E7. I’m tense when talking with others because of my voice. E25. My voice makes me feel handicapped.
F8. I tend to avoid groups of people because of my voice. P26. My voice “gives out” on me in the middle of speaking.
E9. People seem irritated with my voice. E27. I feel annoyed when people ask me to repeat.
P10. People ask, “What’s wrong with your voice?” E28. I feel embarrassed when people ask me to repeat.
F11. I speak with friends, neighbors, or relatives less often E29. My voice makes me feel incompetent.
because of my voice.
E30. I’m ashamed of my voice problem.
F12. People ask me to repeat myself when speaking face-to-face.
P13. My voice sounds creaky and dry. Note. The letter preceding each item number corresponds to the
P14. I feel as though I have to strain to produce voice. subscale (E = emotional subscale, F = functional subscale, P =
physical subscale).

70 American Journal of Speech-Language Pathology • Vol. 6 • No. 3 August 1997

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