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Development and validation of the Arabic pediatric voice handicap index
International Journal of Pediatric Otorhinolaryngology 76 (2012) 1297–1303
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Development and validation of the Arabic pediatric voice handicap index Rasha M. Shoeib a,b, Khalid H. Malki a, Tamer A. Mesallam a,c,*, Mohamed Farahat a, Yasser A. Shehata d a
Communication and Swallowing Disorders Unit, ENT Department, King Saud University, Saudi Arabia Unit of Phoniatrics, Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt c Otolaryngology Department, Faculty of Medicine, Al-Menoufiya University, Shebin Alkoum, Egypt d Public Health & Community Medicine, Faculty of Medicine, Al-Menoufiya University, Shebin Alkoum, Egypt b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2012 Received in revised form 22 April 2012 Accepted 25 May 2012 Available online 22 June 2012
Background and objective: Voice problems negatively affect how children are perceived both by adults and by their peers. Although voice disorders are common in the pediatric population, there is still a lack of information available to clinicians regarding evaluation and treatment of pediatric voice disorders. The purpose of the present study was to develop an Arabic version of pediatric VHI and to test its validity and reliability. Subjects and methods: Fifty children with voice disorders were included in the study. The Arabic version of PVHI was derived in the standard way for test translation. The translated version was then administrated to the parents or caregiver of children with voice disorders and parents of 75 children with no history or symptoms of voice problems. Participants’ responses were statistically analyzed to assess the validity, and to compare the pathological group with the control group. Results: The results showed high internal consistency and reliability of the Arabic version of PVHI (Cronbach’s a = 0.93 and r = 0.95, respectively), and high item-domain and domain-total correlation (r = 0.86–0.97). There was a statistically significant difference between the control and the voice disordered groups (P < 0.001). Conclusion: The Arabic version of PVHI is considered to be a valid and reliable assessment tool used by the parents and caregivers of children with voice disorders to assess the severity of voice disorders in Arabic language speaking children. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric voice handicap index (PVHI) Voice disorders in children Dysphonia Arabic version
1. Introduction Pediatric voice disorders typically have been blamed on vocally ‘‘abusive’’ behaviors, and many practitioners have tended not to provide intervention because they believed that children would ‘‘grow out of it.’’ However, changes in pitch, loudness, and overall vocal quality tend to interfere with their communicative abilities and social activities [1]. Several studies have shown that voice disruptions negatively affect how children are perceived both by adults and by their peers [2–4]. Recently, research has focused on pediatric voice disorders and the effects of a voice disorder on a child’s life. It has been reported that children and adolescents felt that their voice disorders resulted in negative attention and limited their participation in activities [5]. The incidence rates of pediatric voice disorders range from 6% to 23% [6]. Although voice disorders
* Corresponding author at: ENT Department, Communication and Swallowing Disorders Unit (CSDU), King Abdulaziz University Hospital, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia. Tel.: +966 14786100. E-mail addresses: [email protected], [email protected] (T.A. Mesallam). 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.05.023
are common in the pediatric population and have recently been gaining more attention, there is still a lack of information available to clinicians regarding evaluation and treatment of pediatric voice disorders. Voice disorders can be evaluated with the use of instrumental as well as perceptual approaches. The traditional endoscopic imaging tools used to evaluate pediatric larynx provide extensive information about vocal fold and supraglottic pathology. The clinical merit of these approaches for voice evaluation has been established previously [7–9]. Although these instruments allow for physiologic evaluation of the causes of a voice disorder or dysphonia, they do not provide information regarding their impact on a child’s life [10]. For several years there have been questionnaires designed to assess the impact of voice problems on the quality of life of adult patients [11–15]. Recently, the Arabic version of the voice handicap index has been validated, both in the extended 30-question format [16] and in the abbreviated 10-question format [17]. The questionnaire quantifies the impact of voice problems on the quality of life of adult patients, in their functional, physical and emotional aspects. However, it has no application for the pediatric population with voice disorder, as it lacks questions that
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explore the parent’s responses about the voice problems of their child. Numerous health related quality of life instruments have been developed to measure the effect of the illness and disability on children’s activities of daily living. These instruments focus mainly on general concepts related to physical abilities, growth and development and general health perception [18]. In 2007, Zur et al. [19], proposed a modification of the adult VHI known as the pediatric voice handicap index (PVHI). This modification involved changing the language of the statement to reflect parent’s/caregivers’ responses to their child and eliminating questions that are not related to pediatric population. The PVHI was modified in content and language and the final 23item form was validated. These items are equally distributed over three domains: functional, physical, and emotional aspects of voice disorders. The functional domain includes statements that describe the ‘‘impact of voice disorders on patient’s daily activities’’. The emotional domain indicates the patient’s ‘‘affective responses to a voice disorder’’. Items comprising the physical domain are statements representing perceptions of laryngeal discomfort and voice output characteristics. PVHI was shown to have a high internal consistency and test– retest reliability. The authors reported that the PVHI stands to become an important tool that should be incorporated into the comprehensive evaluation of any pediatric dysphonia patients and can be used to expand current knowledge regarding the effects of a pediatric voice disorder on a child’s social, emotional and educational well being [19]. Recently, a study was done to evaluate the validity and reliability of the Italian version of the PVHI which revealed that it is easily administrated, highly reproducible, and exhibits excellent clinical validity [20]. To the best of our knowledge, there is no published validated version of the PVHI in Arabic language, neither in the Kingdom of Saudi Arabia nor in other Arabic countries. The validity of the PVHI was never evaluated in Arabic. Thus, a PVHI that reflects Arab standards may be added to the currently available voice assessment tools from which a clinician can obtain an idea about the impact of the voice problem on Arabic speakers’ children. The purpose of the present study was to develop an Arabic version of PVHI and to test its validity and reliability. 2. Materials and methods 2.1. Development of Arabic PVHI The study was approved by the Research Center, Medical College, King Saud University, and its Ethical Committee. The original English version of the PVHI [19] (‘‘Appendix 1’’) was translated into Arabic by four Arabic bilingual experienced Phoniatrician (consultants of communication, voice, and swallowing disorders). Items on the questionnaire were translated into Arabic, back-translated into English, and compared with the original items by a qualified professional translator familiar with American English and Arabic. The back translation was subsequently sent back to the investigators for review and comments. The Arabic version of the PVHI was then pilot-tested on ten consented Arab parents of children with voice disorders. Subsequently, the PVHI was amended culturally according to their suggestions after reviewing the pilot data. The final result was a culturally modified Arabic PVHI as it appears in Appendix 2. 2.2. Subjects The study included 50 dysphonic consecutive Arab children visiting the voice clinics at King Abdulaziz University Hospital, Riyadh, Saudi Arabia between May 2011 and October 2011. All the subjects were invited to participate in the study after having the
consent of their caregivers along with assent of those children who are 15 years old or above. They were 32 (64%) males and 18 (36%) females with a mean age of 10.18 2.99 years (age range 5–15 years). Our study group included 40 patients with Hyperfunctional childhood dysphonia among them there were 18 patients diagnosed with vocal fold nodules, 2 patients with mutational voice disorders, 6 patients with benign vocal folds lesions (2 cysts, and 4 polyps), and 2 patients with unilateral vocal fold paralysis. A control group consisting of 75 Arab normal children participated in the study. Those children were recruited from normal children accompanying patients attending ENT clinics, King Abdulaziz University Hospital, Riyadh, Saudi Arabia. The mean age of the control group was 9.3 (3.03) years (age range 4–15 years). Thirty-three of the control group children (44%) were females and 42 (56%) were males. Parents of children in the control group reported no history of voice complaints or treatment for a voice disorder by their children. None had a complaint about their voices on the day of assessment or for the last one month. The parent of each participant completed the Arabic version of the PVHI independently. 2.3. Validation, testing, and statistical assessment The final Arabic version of PVHI was validated using content validity. Two independent, experienced and bilingual Phoniatrician judged all items of the final Arabic version for language and cultural appropriateness as being completely relevant to the purpose for which it was meant. The Arabic PVHI was then administered to the parents of voice-disordered group and the control group who were given a full chance to fill it up independently without any assistance. Variables of the current study were of both quantitative and qualitative data. Quantitative data were expressed as mean and standard deviation (SD) with 95% confidence interval (CI), while qualitative data were expressed as number (n.), and percentage (%). As a prerequisite for our statistical analysis, a numerical assessment of the normality of data was undertaken. Shapiro– Wilk Test was more appropriate for our study because of its relatively small sample size. All data were not normally distributed. So, non-parametric statistical analyses were applied. The Mann–Whitney test was used as a non-parametric test to examine the null hypothesis with a level of significance at 95%. P value 0.05 was considered a statistically significant, while P value 0.01 was considered a highly statistical significant difference. Cronbach’s a (alpha) was used as a measure of the internal consistency of the Arabic PVHI. Data was converted to rankings, then Spearman rank correlation coefficient was used to measure correlation between the score of each domain and its individual items, as well as between the score of each domain and the total PVHI score. The test–retest reliability was assessed by estimating the intra-class correlation coefficient (ICC) for the total VHI, as well as for the separate domain scores. The Statistical Package for the Social Sciences, Version 16 (SPSS Inc, Chicago, IL, USA) was used for all statistical analysis. 3. Results There was no statistical significant difference between normal children and children with voice disorders in regards to age and gender as shown in Table 1. The mean total PVHI score for the study group was 54.06 (SD = 15.79) with range being from 14 to 82 out of a maximum total score of 92. The mean scores of the three domains (functional, physical, and emotional) are represented in (Table 2). There was very little difference between the average scores of the functional and emotional domains. In the group of children with voice disorders, the average physical domain score was higher than average scores of the functional and emotional domains, with
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Table 1 Comparison between both groups in regards to age and gender. Normal Children (n = 75) Age (year)
9.30 3.03
Gender Male Female
42 (56%) 33 (44%)
Children with voice disorders (n = 50)
P value
Significance
10.18 2.98
0.101
NS
32 (64%) 18 (36%)
0.795
NS
NS = not significant.
Table 2 The mean score of the functional, physical, emotional domains and overall score of the 50 children with voice disorders. Arabic PVHI domain (maximum possible score)
Mean SD
Minimum– maximum score
Functional (28) Physical (36) Emotional (28) PVHI overall (92)
16.6 4.95 21.24 8.01 16.22 5.14 54.06 15.79
4–27 5–36 2–28 14–82
Table 3 Cronbach’s alpha coefficient for each of the three domains and for the overall Arabic PVHI score among patients and control groups. Domain
Number of items
Cronbach’s alpha coefficient for patients (n = 50)
Cronbach’s alpha coefficient for normal children (n = 75)
Functional Physical Emotional PVHI overall
7 9 7 23
0.929 0.925 0.929 0.931
0.782 0.777 0.867 0.856
Domain
Total
Functional
Physical
Total PVHI Functional Physical Emotional
– 0.965* 0.976* 0.933*
– – 0.917* 0.913*
– – – 0.867*
Correlation is significant at the 0.01 level (2-tailed).
mean difference between physical and both functional and emotional domains scores being 5 units (Table 2). There was excellent estimated overall internal consistency (a = 0.93) demonstrated for the Arabic PVHI in the dysphonic group. At the same time excellent internal consistency was demonstrated in the three domains with an average a value of 0.92 (Table 3). There was a significant correlation between the score of each domain and the total PVHI score (Table 4). At the same time,
Table 5 Spearman rank correlation coefficient between the score of each domain and its individual items. Functional items r F1 F2 F3 F4 F5 F6 F7
* **
0.530** 0.810** 0.833** 0.646** 0.428* 0.922** 0.776**
Physical items r P1 P2 P3 P4 P5 P6 P7 P8 P9
0.888** 0.894** 0.781** 0.410* 0.790** 0.909** 0.913** 0.864** 0.909**
Domain
r
P value
Functional Physical Emotional Total PVHI
0.865* 0.962* 0.917* 0.952*
0.000 0.000 0.000 0.000
*
Significant intra-class correlation.
Table 7 Spearman rank correlation coefficient between the age and PVHI (total and domains) scores in both the study and control groups. Domain
r Patients
Functional Physical Emotional Total PVHI *
Table 4 Spearman rank correlation coefficient between the score of each domain and total Arabic PVHI score.
*
Table 6 Test–retest reliability for total Arabic PVHI scores and individual domain scores.
0.380 0.223 0.483 0.367
P value Controls 0.019 0.142 0.076 0.092
Patients *
0.006 0.120 0.000* 0.009*
Controls 0.875 0.226 0.519 0.432
Correlation is significant at the 0.01 level (2-tailed).
there was a significant correlation demonstrated between the score of each domain and its individual item scores (Table 5). Twenty-one caregivers (42%) of the dysphonic group completed the Arabic PVHI twice over a period of 2 weeks. Excellent test– retest reliability was found for the total scores as well as for the three separate domain scores of the Arabic version. The test–retest reliability for the physical domain was slightly higher than both the functional and emotional domains (Table 6). The effect of age was not statistically significant as age was neither correlated to individual domain scores nor the overall PVHI scores (Table 7). The mean PVHI score in male patients was 25.45 26.3, and it was 22.39 27.62 in females. Although males had slightly higher PVHI scores than females, the effect of gender was not statistically significant (Mann–Whitney P values ranged from 0.27 to 0.86). Similarly no statistically significant difference was reported between males and females in the control group when comparing the PVHI scores (Mann–Whitney P values ranged from 0.26 to 0.66). Twenty-six subjects (34.7%) in the control group had an overall VHI score of zero, the range of scores being from 0 to 31. When the three domains were considered, 38 (50.7%), 32 (42.7%), and 44 (58.7%) subjects had a score of zero in the functional, physical, and emotional domains, respectively. In the control group, the internal consistency was good for the overall score (a = 0.85), while it
Emotional items r E1 E2 E3 E4 E5 E6 E7
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
0.769** 0.850** 0.620** 0.374* 0.602** 0.804** 0.600**
Table 8 Comparisons between both groups in regards to domain scores and total PVHI score (Mann–Whitney test).
Functional Physical Emotional Total PVHI *
Significant.
Normal Children (n = 75)
Children with voice disorders (n = 50)
P value
1.41 2.23 1.96 2.7 0.93 1.43 4.3 5.78
16.6 4.95 21.24 8.01 16.22 5.14 54.06 15.79
0.0001* 0.0001* 0.0001* 0.0001*
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ranged from 0.77 to 0.86 for the three domains (Table 3). PVHI scores showed statistically significant difference between normal children and children with voice disorders, for overall PVHI score and each of the functional, physical, and emotional domains scores separately (Table 8). 4. Discussion Currently, no single instrumental measure or value can conclusively quantify or characterize a human voice disorder. Evaluation of voice remains a multifactor process involving expert perceptual judgments, voice signal analysis, air flow measurement, stroboscopic imaging and patient report of the handicapping effects and/or quality of life changes associated with dysphonia [11,14,19–21]. In Arabic countries, there is a lack of a standardized questionnaire addressed to children with voice problems and their caregivers. Therefore, the purpose of this study was to develop, validate and test the reliability of an Arabic version of Pediatric VHI for Arab children with voice disorders. The results of the present study indicate that the Arabic version of the PVHI had strong internal consistency that was clearly demonstrated in both the study and the control groups. Moreover, the Arabic PVHI had excellent test–retest reliability for both the total PVHI scores and the individual domain scores. These findings are similar to the findings of the original study by Zur et al. [19]. They reported in their study that ‘‘test–retest stability was confirmed for the functional (r = 0.95), physical (r = 0.77), emotional (r = 0.79) and total (r = 0.82) components and these correlations was highly significant (P 0.01)’’. At the same time, our results were consistent with that of the Italian versions of the PVHI [20] as they found optimal internal consistency of the Italian PVHI (a = 0.95). Moreover, the test–retest reliability in their study groups of children was high (r = 0.88). The three domains of the Arabic PVHI in the current study had also shown a strong internal consistency. In the group with voice disorders, higher mean physical domain scores were found, in comparison to the functional and emotional domains. The functional and emotional domain scores were close to each other and lower than the physical scores. Similar results have been reported in some of the studies that were done to validate VHI in the past [16,22–25]. 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 [16,22–26]. These findings signify that the physical domain of PVHI is the most prominent self-perceived parameter of voice disorders.In the current study, no gender difference was found regarding the overall PVHI or the three domains (functional, physical, and emotional) in both the voice disordered and the control groups. At the same time, the finding of non-significant correlation that has been demonstrated between age and total PVHI and between the age and the individual domain scores was a common finding in previous studies that were done for VHI [16,22–24]. Furthermore, PVHI maintained a valid construction, being able to discriminate healthy children from those presenting vocal symptoms. The data from the present study indicate that the Arabic version of PVHI may be a sensitive tool when attempting to identify the parent’s perception of the severity of their child’s voice problem. This is indicated by the highly significant difference that
was demonstrated between the voice-disordered group and the control group. These findings are in agreement with the study of Zur et al. [19], and the Italian study [20]. With the development of the Arabic version of PVHI, Arab clinicians who treat Arab children with voice disorders will have a better opportunity to properly address the parents’ impression about voice problem of their children. This facilitates the assessment and management programs of voice disorders and focuses treatment strategies that fit the needs of voice disorders of Arabic speaking children. Similarly, Johnson et al. [27], reported that PVHI in conjunction with auditory perceptual evaluation of voice are useful tools in the measurement of voice outcomes in children with vocal fold lesions. Also, de Alarcon et al. [28], reported that PVHI provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects. Younger children may lack the maturity, cognitive skills, and insight required to complete these questionnaires. Therefore, the parental response is often necessary to determine the effect of voice problems on their child’s quality of life. Parental querying is additionally relevant because it is usually caregivers who are dissatisfied with the child’s vocal status and initiate evaluative consultation [21]. The Arabic PVHI may increase the understanding of the reasons why parents seek help for voice problem of their child. With a valid and reliable questionnaire, the clinician may better address the problems confronting the patient. PVHI should serve as an adjunct to other historical, acoustic, and physical examination findings. The opportunity to add the PVHI to a multidimensional voice assessment for the voice-disordered children empower treatment advocacy in accordance with the patients’ needs and the clinician’s findings. It should be noted that while not all Arabic dialects have the same syntax, grammar, and word meanings, there are more similarities than differences within the Arabic family of these dialects. It remains to be seen if patients from other Arab countries differ in results from the present Arabic (Saudi) PVHI. 5. Conclusion This study is the first research in the kingdom and Arab countries to develop an Arabic version of PVHI. It suggests that the Arabic PVHI can be reliably applied to the Arabic speaking children. The Arabic version of the PVHI appears to be a valid and reliable assessment tool used by the parents of children with voice disorders to assess the impact of voice disorders in Arabic speaking children. It has the advantages of being simple and enables clinicians to assess the voice problems in children and to monitor any improvement or worsening in their voice. Conflict of interest This work was not funded in full or part by any agency and the authors have no conflict of interest to report. Acknowledgement This study has been supervised by the Research Chair of Voice, Swallowing, and Communication Disorders (RCVSCD), King Saud University.
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Appendix A. Pediatric voice handicap index (Original) Subject name: Date: Instructions: 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-F (1) My child’s voice makes it difficult for people to hear him/her (2) People have difficulty understanding my child in a noisy room (3) At home, we have difficulty hearing my when he/she calls throughout the house (4) My child tends to avoid communicating because of his/her voice (5) My child speaks with friends, neighbors, or relatives less often because of his/her voice (6) People ask my child to repeat him/herself when speaking face-to-face (7) My child’s voice difficulties restrict personal, educational and social activities
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
Part II-P (1) My child run out of air when talking (2) The sound of my child’s voice varies throughout the day (3) People ask, ‘‘What’s wrong with your child’s voice?’’ (4) My child’s voice sounds dry, raspy and/or hoarse (5) The quality of my child’s voice is unpredictable (6) My child use a great deal of effort to speak (e.g. straining) (7) My child’s voice is worsen in the evening (8) My child’s voice ‘‘gives out’’ when speaking (9) My child has to yell in order for others to hear him/her
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
Part III-E (1) My child appears tense when talking to others because of his or her voice (2) People seem irritated with my child’s voice (3) I find other people don’t understand my child’s voice problem (4) My child is frustrated with his/her voice problem (5) My child is less outgoing because of his/her voice problem (6) My child is annoyed when people ask him/her to repeat (7) My child is embarrassed when people ask him/her to repeat
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
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Appendix B. Arabic pediatric voice handicap index
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Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Development and validation of the Arabic pediatric voice handicap index Rasha M. Shoeib a,b, Khalid H. Malki a, Tamer A. Mesallam a,c,*, Mohamed Farahat a, Yasser A. Shehata d a
Communication and Swallowing Disorders Unit, ENT Department, King Saud University, Saudi Arabia Unit of Phoniatrics, Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt c Otolaryngology Department, Faculty of Medicine, Al-Menoufiya University, Shebin Alkoum, Egypt d Public Health & Community Medicine, Faculty of Medicine, Al-Menoufiya University, Shebin Alkoum, Egypt b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2012 Received in revised form 22 April 2012 Accepted 25 May 2012 Available online 22 June 2012
Background and objective: Voice problems negatively affect how children are perceived both by adults and by their peers. Although voice disorders are common in the pediatric population, there is still a lack of information available to clinicians regarding evaluation and treatment of pediatric voice disorders. The purpose of the present study was to develop an Arabic version of pediatric VHI and to test its validity and reliability. Subjects and methods: Fifty children with voice disorders were included in the study. The Arabic version of PVHI was derived in the standard way for test translation. The translated version was then administrated to the parents or caregiver of children with voice disorders and parents of 75 children with no history or symptoms of voice problems. Participants’ responses were statistically analyzed to assess the validity, and to compare the pathological group with the control group. Results: The results showed high internal consistency and reliability of the Arabic version of PVHI (Cronbach’s a = 0.93 and r = 0.95, respectively), and high item-domain and domain-total correlation (r = 0.86–0.97). There was a statistically significant difference between the control and the voice disordered groups (P < 0.001). Conclusion: The Arabic version of PVHI is considered to be a valid and reliable assessment tool used by the parents and caregivers of children with voice disorders to assess the severity of voice disorders in Arabic language speaking children. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric voice handicap index (PVHI) Voice disorders in children Dysphonia Arabic version
1. Introduction Pediatric voice disorders typically have been blamed on vocally ‘‘abusive’’ behaviors, and many practitioners have tended not to provide intervention because they believed that children would ‘‘grow out of it.’’ However, changes in pitch, loudness, and overall vocal quality tend to interfere with their communicative abilities and social activities [1]. Several studies have shown that voice disruptions negatively affect how children are perceived both by adults and by their peers [2–4]. Recently, research has focused on pediatric voice disorders and the effects of a voice disorder on a child’s life. It has been reported that children and adolescents felt that their voice disorders resulted in negative attention and limited their participation in activities [5]. The incidence rates of pediatric voice disorders range from 6% to 23% [6]. Although voice disorders
* Corresponding author at: ENT Department, Communication and Swallowing Disorders Unit (CSDU), King Abdulaziz University Hospital, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia. Tel.: +966 14786100. E-mail addresses: [email protected], [email protected] (T.A. Mesallam). 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.05.023
are common in the pediatric population and have recently been gaining more attention, there is still a lack of information available to clinicians regarding evaluation and treatment of pediatric voice disorders. Voice disorders can be evaluated with the use of instrumental as well as perceptual approaches. The traditional endoscopic imaging tools used to evaluate pediatric larynx provide extensive information about vocal fold and supraglottic pathology. The clinical merit of these approaches for voice evaluation has been established previously [7–9]. Although these instruments allow for physiologic evaluation of the causes of a voice disorder or dysphonia, they do not provide information regarding their impact on a child’s life [10]. For several years there have been questionnaires designed to assess the impact of voice problems on the quality of life of adult patients [11–15]. Recently, the Arabic version of the voice handicap index has been validated, both in the extended 30-question format [16] and in the abbreviated 10-question format [17]. The questionnaire quantifies the impact of voice problems on the quality of life of adult patients, in their functional, physical and emotional aspects. However, it has no application for the pediatric population with voice disorder, as it lacks questions that
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explore the parent’s responses about the voice problems of their child. Numerous health related quality of life instruments have been developed to measure the effect of the illness and disability on children’s activities of daily living. These instruments focus mainly on general concepts related to physical abilities, growth and development and general health perception [18]. In 2007, Zur et al. [19], proposed a modification of the adult VHI known as the pediatric voice handicap index (PVHI). This modification involved changing the language of the statement to reflect parent’s/caregivers’ responses to their child and eliminating questions that are not related to pediatric population. The PVHI was modified in content and language and the final 23item form was validated. These items are equally distributed over three domains: functional, physical, and emotional aspects of voice disorders. The functional domain includes statements that describe the ‘‘impact of voice disorders on patient’s daily activities’’. The emotional domain indicates the patient’s ‘‘affective responses to a voice disorder’’. Items comprising the physical domain are statements representing perceptions of laryngeal discomfort and voice output characteristics. PVHI was shown to have a high internal consistency and test– retest reliability. The authors reported that the PVHI stands to become an important tool that should be incorporated into the comprehensive evaluation of any pediatric dysphonia patients and can be used to expand current knowledge regarding the effects of a pediatric voice disorder on a child’s social, emotional and educational well being [19]. Recently, a study was done to evaluate the validity and reliability of the Italian version of the PVHI which revealed that it is easily administrated, highly reproducible, and exhibits excellent clinical validity [20]. To the best of our knowledge, there is no published validated version of the PVHI in Arabic language, neither in the Kingdom of Saudi Arabia nor in other Arabic countries. The validity of the PVHI was never evaluated in Arabic. Thus, a PVHI that reflects Arab standards may be added to the currently available voice assessment tools from which a clinician can obtain an idea about the impact of the voice problem on Arabic speakers’ children. The purpose of the present study was to develop an Arabic version of PVHI and to test its validity and reliability. 2. Materials and methods 2.1. Development of Arabic PVHI The study was approved by the Research Center, Medical College, King Saud University, and its Ethical Committee. The original English version of the PVHI [19] (‘‘Appendix 1’’) was translated into Arabic by four Arabic bilingual experienced Phoniatrician (consultants of communication, voice, and swallowing disorders). Items on the questionnaire were translated into Arabic, back-translated into English, and compared with the original items by a qualified professional translator familiar with American English and Arabic. The back translation was subsequently sent back to the investigators for review and comments. The Arabic version of the PVHI was then pilot-tested on ten consented Arab parents of children with voice disorders. Subsequently, the PVHI was amended culturally according to their suggestions after reviewing the pilot data. The final result was a culturally modified Arabic PVHI as it appears in Appendix 2. 2.2. Subjects The study included 50 dysphonic consecutive Arab children visiting the voice clinics at King Abdulaziz University Hospital, Riyadh, Saudi Arabia between May 2011 and October 2011. All the subjects were invited to participate in the study after having the
consent of their caregivers along with assent of those children who are 15 years old or above. They were 32 (64%) males and 18 (36%) females with a mean age of 10.18 2.99 years (age range 5–15 years). Our study group included 40 patients with Hyperfunctional childhood dysphonia among them there were 18 patients diagnosed with vocal fold nodules, 2 patients with mutational voice disorders, 6 patients with benign vocal folds lesions (2 cysts, and 4 polyps), and 2 patients with unilateral vocal fold paralysis. A control group consisting of 75 Arab normal children participated in the study. Those children were recruited from normal children accompanying patients attending ENT clinics, King Abdulaziz University Hospital, Riyadh, Saudi Arabia. The mean age of the control group was 9.3 (3.03) years (age range 4–15 years). Thirty-three of the control group children (44%) were females and 42 (56%) were males. Parents of children in the control group reported no history of voice complaints or treatment for a voice disorder by their children. None had a complaint about their voices on the day of assessment or for the last one month. The parent of each participant completed the Arabic version of the PVHI independently. 2.3. Validation, testing, and statistical assessment The final Arabic version of PVHI was validated using content validity. Two independent, experienced and bilingual Phoniatrician judged all items of the final Arabic version for language and cultural appropriateness as being completely relevant to the purpose for which it was meant. The Arabic PVHI was then administered to the parents of voice-disordered group and the control group who were given a full chance to fill it up independently without any assistance. Variables of the current study were of both quantitative and qualitative data. Quantitative data were expressed as mean and standard deviation (SD) with 95% confidence interval (CI), while qualitative data were expressed as number (n.), and percentage (%). As a prerequisite for our statistical analysis, a numerical assessment of the normality of data was undertaken. Shapiro– Wilk Test was more appropriate for our study because of its relatively small sample size. All data were not normally distributed. So, non-parametric statistical analyses were applied. The Mann–Whitney test was used as a non-parametric test to examine the null hypothesis with a level of significance at 95%. P value 0.05 was considered a statistically significant, while P value 0.01 was considered a highly statistical significant difference. Cronbach’s a (alpha) was used as a measure of the internal consistency of the Arabic PVHI. Data was converted to rankings, then Spearman rank correlation coefficient was used to measure correlation between the score of each domain and its individual items, as well as between the score of each domain and the total PVHI score. The test–retest reliability was assessed by estimating the intra-class correlation coefficient (ICC) for the total VHI, as well as for the separate domain scores. The Statistical Package for the Social Sciences, Version 16 (SPSS Inc, Chicago, IL, USA) was used for all statistical analysis. 3. Results There was no statistical significant difference between normal children and children with voice disorders in regards to age and gender as shown in Table 1. The mean total PVHI score for the study group was 54.06 (SD = 15.79) with range being from 14 to 82 out of a maximum total score of 92. The mean scores of the three domains (functional, physical, and emotional) are represented in (Table 2). There was very little difference between the average scores of the functional and emotional domains. In the group of children with voice disorders, the average physical domain score was higher than average scores of the functional and emotional domains, with
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Table 1 Comparison between both groups in regards to age and gender. Normal Children (n = 75) Age (year)
9.30 3.03
Gender Male Female
42 (56%) 33 (44%)
Children with voice disorders (n = 50)
P value
Significance
10.18 2.98
0.101
NS
32 (64%) 18 (36%)
0.795
NS
NS = not significant.
Table 2 The mean score of the functional, physical, emotional domains and overall score of the 50 children with voice disorders. Arabic PVHI domain (maximum possible score)
Mean SD
Minimum– maximum score
Functional (28) Physical (36) Emotional (28) PVHI overall (92)
16.6 4.95 21.24 8.01 16.22 5.14 54.06 15.79
4–27 5–36 2–28 14–82
Table 3 Cronbach’s alpha coefficient for each of the three domains and for the overall Arabic PVHI score among patients and control groups. Domain
Number of items
Cronbach’s alpha coefficient for patients (n = 50)
Cronbach’s alpha coefficient for normal children (n = 75)
Functional Physical Emotional PVHI overall
7 9 7 23
0.929 0.925 0.929 0.931
0.782 0.777 0.867 0.856
Domain
Total
Functional
Physical
Total PVHI Functional Physical Emotional
– 0.965* 0.976* 0.933*
– – 0.917* 0.913*
– – – 0.867*
Correlation is significant at the 0.01 level (2-tailed).
mean difference between physical and both functional and emotional domains scores being 5 units (Table 2). There was excellent estimated overall internal consistency (a = 0.93) demonstrated for the Arabic PVHI in the dysphonic group. At the same time excellent internal consistency was demonstrated in the three domains with an average a value of 0.92 (Table 3). There was a significant correlation between the score of each domain and the total PVHI score (Table 4). At the same time,
Table 5 Spearman rank correlation coefficient between the score of each domain and its individual items. Functional items r F1 F2 F3 F4 F5 F6 F7
* **
0.530** 0.810** 0.833** 0.646** 0.428* 0.922** 0.776**
Physical items r P1 P2 P3 P4 P5 P6 P7 P8 P9
0.888** 0.894** 0.781** 0.410* 0.790** 0.909** 0.913** 0.864** 0.909**
Domain
r
P value
Functional Physical Emotional Total PVHI
0.865* 0.962* 0.917* 0.952*
0.000 0.000 0.000 0.000
*
Significant intra-class correlation.
Table 7 Spearman rank correlation coefficient between the age and PVHI (total and domains) scores in both the study and control groups. Domain
r Patients
Functional Physical Emotional Total PVHI *
Table 4 Spearman rank correlation coefficient between the score of each domain and total Arabic PVHI score.
*
Table 6 Test–retest reliability for total Arabic PVHI scores and individual domain scores.
0.380 0.223 0.483 0.367
P value Controls 0.019 0.142 0.076 0.092
Patients *
0.006 0.120 0.000* 0.009*
Controls 0.875 0.226 0.519 0.432
Correlation is significant at the 0.01 level (2-tailed).
there was a significant correlation demonstrated between the score of each domain and its individual item scores (Table 5). Twenty-one caregivers (42%) of the dysphonic group completed the Arabic PVHI twice over a period of 2 weeks. Excellent test– retest reliability was found for the total scores as well as for the three separate domain scores of the Arabic version. The test–retest reliability for the physical domain was slightly higher than both the functional and emotional domains (Table 6). The effect of age was not statistically significant as age was neither correlated to individual domain scores nor the overall PVHI scores (Table 7). The mean PVHI score in male patients was 25.45 26.3, and it was 22.39 27.62 in females. Although males had slightly higher PVHI scores than females, the effect of gender was not statistically significant (Mann–Whitney P values ranged from 0.27 to 0.86). Similarly no statistically significant difference was reported between males and females in the control group when comparing the PVHI scores (Mann–Whitney P values ranged from 0.26 to 0.66). Twenty-six subjects (34.7%) in the control group had an overall VHI score of zero, the range of scores being from 0 to 31. When the three domains were considered, 38 (50.7%), 32 (42.7%), and 44 (58.7%) subjects had a score of zero in the functional, physical, and emotional domains, respectively. In the control group, the internal consistency was good for the overall score (a = 0.85), while it
Emotional items r E1 E2 E3 E4 E5 E6 E7
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
0.769** 0.850** 0.620** 0.374* 0.602** 0.804** 0.600**
Table 8 Comparisons between both groups in regards to domain scores and total PVHI score (Mann–Whitney test).
Functional Physical Emotional Total PVHI *
Significant.
Normal Children (n = 75)
Children with voice disorders (n = 50)
P value
1.41 2.23 1.96 2.7 0.93 1.43 4.3 5.78
16.6 4.95 21.24 8.01 16.22 5.14 54.06 15.79
0.0001* 0.0001* 0.0001* 0.0001*
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ranged from 0.77 to 0.86 for the three domains (Table 3). PVHI scores showed statistically significant difference between normal children and children with voice disorders, for overall PVHI score and each of the functional, physical, and emotional domains scores separately (Table 8). 4. Discussion Currently, no single instrumental measure or value can conclusively quantify or characterize a human voice disorder. Evaluation of voice remains a multifactor process involving expert perceptual judgments, voice signal analysis, air flow measurement, stroboscopic imaging and patient report of the handicapping effects and/or quality of life changes associated with dysphonia [11,14,19–21]. In Arabic countries, there is a lack of a standardized questionnaire addressed to children with voice problems and their caregivers. Therefore, the purpose of this study was to develop, validate and test the reliability of an Arabic version of Pediatric VHI for Arab children with voice disorders. The results of the present study indicate that the Arabic version of the PVHI had strong internal consistency that was clearly demonstrated in both the study and the control groups. Moreover, the Arabic PVHI had excellent test–retest reliability for both the total PVHI scores and the individual domain scores. These findings are similar to the findings of the original study by Zur et al. [19]. They reported in their study that ‘‘test–retest stability was confirmed for the functional (r = 0.95), physical (r = 0.77), emotional (r = 0.79) and total (r = 0.82) components and these correlations was highly significant (P 0.01)’’. At the same time, our results were consistent with that of the Italian versions of the PVHI [20] as they found optimal internal consistency of the Italian PVHI (a = 0.95). Moreover, the test–retest reliability in their study groups of children was high (r = 0.88). The three domains of the Arabic PVHI in the current study had also shown a strong internal consistency. In the group with voice disorders, higher mean physical domain scores were found, in comparison to the functional and emotional domains. The functional and emotional domain scores were close to each other and lower than the physical scores. Similar results have been reported in some of the studies that were done to validate VHI in the past [16,22–25]. 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 [16,22–26]. These findings signify that the physical domain of PVHI is the most prominent self-perceived parameter of voice disorders.In the current study, no gender difference was found regarding the overall PVHI or the three domains (functional, physical, and emotional) in both the voice disordered and the control groups. At the same time, the finding of non-significant correlation that has been demonstrated between age and total PVHI and between the age and the individual domain scores was a common finding in previous studies that were done for VHI [16,22–24]. Furthermore, PVHI maintained a valid construction, being able to discriminate healthy children from those presenting vocal symptoms. The data from the present study indicate that the Arabic version of PVHI may be a sensitive tool when attempting to identify the parent’s perception of the severity of their child’s voice problem. This is indicated by the highly significant difference that
was demonstrated between the voice-disordered group and the control group. These findings are in agreement with the study of Zur et al. [19], and the Italian study [20]. With the development of the Arabic version of PVHI, Arab clinicians who treat Arab children with voice disorders will have a better opportunity to properly address the parents’ impression about voice problem of their children. This facilitates the assessment and management programs of voice disorders and focuses treatment strategies that fit the needs of voice disorders of Arabic speaking children. Similarly, Johnson et al. [27], reported that PVHI in conjunction with auditory perceptual evaluation of voice are useful tools in the measurement of voice outcomes in children with vocal fold lesions. Also, de Alarcon et al. [28], reported that PVHI provided important information regarding the relationship of the severity of voice disturbance to its handicapping effects. Younger children may lack the maturity, cognitive skills, and insight required to complete these questionnaires. Therefore, the parental response is often necessary to determine the effect of voice problems on their child’s quality of life. Parental querying is additionally relevant because it is usually caregivers who are dissatisfied with the child’s vocal status and initiate evaluative consultation [21]. The Arabic PVHI may increase the understanding of the reasons why parents seek help for voice problem of their child. With a valid and reliable questionnaire, the clinician may better address the problems confronting the patient. PVHI should serve as an adjunct to other historical, acoustic, and physical examination findings. The opportunity to add the PVHI to a multidimensional voice assessment for the voice-disordered children empower treatment advocacy in accordance with the patients’ needs and the clinician’s findings. It should be noted that while not all Arabic dialects have the same syntax, grammar, and word meanings, there are more similarities than differences within the Arabic family of these dialects. It remains to be seen if patients from other Arab countries differ in results from the present Arabic (Saudi) PVHI. 5. Conclusion This study is the first research in the kingdom and Arab countries to develop an Arabic version of PVHI. It suggests that the Arabic PVHI can be reliably applied to the Arabic speaking children. The Arabic version of the PVHI appears to be a valid and reliable assessment tool used by the parents of children with voice disorders to assess the impact of voice disorders in Arabic speaking children. It has the advantages of being simple and enables clinicians to assess the voice problems in children and to monitor any improvement or worsening in their voice. Conflict of interest This work was not funded in full or part by any agency and the authors have no conflict of interest to report. Acknowledgement This study has been supervised by the Research Chair of Voice, Swallowing, and Communication Disorders (RCVSCD), King Saud University.
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Appendix A. Pediatric voice handicap index (Original) Subject name: Date: Instructions: 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-F (1) My child’s voice makes it difficult for people to hear him/her (2) People have difficulty understanding my child in a noisy room (3) At home, we have difficulty hearing my when he/she calls throughout the house (4) My child tends to avoid communicating because of his/her voice (5) My child speaks with friends, neighbors, or relatives less often because of his/her voice (6) People ask my child to repeat him/herself when speaking face-to-face (7) My child’s voice difficulties restrict personal, educational and social activities
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
Part II-P (1) My child run out of air when talking (2) The sound of my child’s voice varies throughout the day (3) People ask, ‘‘What’s wrong with your child’s voice?’’ (4) My child’s voice sounds dry, raspy and/or hoarse (5) The quality of my child’s voice is unpredictable (6) My child use a great deal of effort to speak (e.g. straining) (7) My child’s voice is worsen in the evening (8) My child’s voice ‘‘gives out’’ when speaking (9) My child has to yell in order for others to hear him/her
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
Part III-E (1) My child appears tense when talking to others because of his or her voice (2) People seem irritated with my child’s voice (3) I find other people don’t understand my child’s voice problem (4) My child is frustrated with his/her voice problem (5) My child is less outgoing because of his/her voice problem (6) My child is annoyed when people ask him/her to repeat (7) My child is embarrassed when people ask him/her to repeat
0 0 0 0 0 0 0
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
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Appendix B. Arabic pediatric voice handicap index
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