Validity and Reliability of the Turkish SingingVoice Handicap Index-10

ARTICLE IN PRESS

Validity and Reliability of the Turkish Singing Voice Handicap Index-10 €  uz Ku¸sc¸ uD8X X, §D9X XTaner YilmazD10X X, ||Clark 1XD XFatma Esen AydinliD2X X, †D3X XSevtap AkbulutD4X X, *D5X XEsra OzcebeD 6X X, §O D7X X g D1X X A. RosenD12X X, and D13X XJackie Gardner-SchmidtD14X X, *xS{hhiye, and yAta¸sehir, Turkey, ||San Francisco, California, and {Pittsburgh, Pennsylvania

1,* ¶

Summary: Objective. To evaluate the validity and reliability of the Turkish version of the Singing Voice Handicap Index-10 (SVHI-10). Study Design. Cross-sectional study. Methods. Two hundred singers consisting of a control group (n = 136) without voice complaints and a study group (n = 64) diagnosed with a voice disorder served as participants. To detect test-retest reliability, 97 participants (representing a portion of both the control and study group participants) completed the index twice with a minimum of a one-week interval between each completion. Internal consistency was confirmed using Cronbach's alpha coefficient. To complete a clinical validity assessment, scores from the control group participants were compared with scores from the study group participants. To determine content validity, the correlation between the SVHI-10 and the participants’ perceptions of singing voice complaints was researched. The sensitivity and specificity of the SVHI-10/Turkish version were calculated using a receiver operating characteristic curve analysis. Results. Cronbach's alpha coefficient, which was equal to 0.91, proved to have excellent internal consistency. Item-total correlations were found in the range of 0.55 to 0.76. The mean SVHI-10/Turkish score for the control group was 8.14 § 5.4, whereas this value was significantly higher in the study group (20.54 § 6.9, P < 0.001). The Pearson product-moment correlation test indicated that the Turkish SVHI-10 is a reliable tool (r = 0.90, n = 97, P < 0.001). The area under curve of the Turkish SVHI-10 was 0.95. The optimal cut-off point was found to be 11.5, with a sensitivity of 95.8% and a specificity of 83.2%. Conclusions. The Turkish version of the SVHI-10 has proven to be a reliable and valid instrument for evaluating the self-perception of a singer in relation to voice problems. It can also be used as a quick screening tool because a score on the SVHI-10 higher than 11.5 is indicative of an abnormal singer's perceived voice handicap. Key Words: Singing voice−Voice handicap−Dysphonia−Singer−Index.

INTRODUCTION The human voice is one of the most important components of verbal communication; therefore, voice impairments can cause significant handicaps in a person's life. According to the World Health Organization, a handicap is defined as a socially imposed value judgment about a difference or a lack of ability and is described as an environmental barrier.1 To clearly determine the impact of voice impairment on quality of life and the consequent level of handicap for a patient, a comprehensive clinical voice evaluation should include patient-reported outcomes in addition to instrumental and perceptual methods.2 In clinical settings, many patient-reported outcome tools are frequently used to determine treatment outcomes.2 Some of Accepted for publication November 19, 2018. From the *Speech and Language Pathology, Department of Speech and Language Therapy, Faculty of Health Sciences, University of Hacettepe, S{hhiye, Ankara, Turkey; yDepartment of Otolaryngology Head and Neck Surgery, Yeditepe University, Ata¸s ehir, Istanbul, Turkey; xFaculty of Medicine Department of OtolaryngologyHead & Neck Surgery, Division of Laryngology and Phonosurgery, University of Hacettepe, S{hhiye, Ankara, Turkey; ||Department of Otolaryngology—Head and Neck Surgery, Division of Laryngology, UCSF Voice and Swallowing Center, University of California, San Francisco, California; and the {Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania. 1 Mailing Address: Faculty of Health Sciences, Department of Speech and Language Therapy, University of Hacettepe, S{hhiye, Ankara 06100, Turkey. Address correspondence and reprint requests to Fatma Esen Aydinli, Department of Speech and Language Therapy, Faculty of Health Sciences, University of Hacettepe, S{hhiye, Ankara 06100, Turkey. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2018.11.011

them are the Voice Related Quality of Life questionnaire,3 the Voice Activity and Participation Profile,4 the Voice Outcomes Survey,5 the Voice Symptom Scale,6 the Voice Handicap Index (VHI),7 and the VHI-10.8 The VHI and the VHI-10 are the most commonly used questionnaires for patient self-assessment.9 The VHI has been translated into more than 20 languages, while at least nine translations of the shorter version, the VHI-10, have also been published.10 Both questionnaires have proven to be valid and reliable; however, index items are mainly related to the speaking voice. Singers constitute a special population who have unique voice complaints related to their singing voices and who are detrimentally impacted by voice problems.11−13 According to Koufman and Blalock's classification of professional voice users, most singers are considered elite vocal performers. For these performers, any slight deviation in voice quality may result in life-changing consequences, such as a loss of income.12,14−16 Taking these characteristics into consideration, it is not surprising that the VHI and VHI-10 have proven to be insufficient in revealing the true impact of voice disorders on singers.11,12 Consequently, Cohen et al developed a VHI specialized for singers. This original index, the Singing Voice Handicap Index (SVHI), was developed in English in 2007.17 The SVHI consists of 36 questions, and patients are asked to rate their perceptions using a scale from 0 to 4. The questions were primarily related to the physical, emotional, and social aspects of voice impairment.

ARTICLE IN PRESS 2 This reliable tool has been adapted and validated for many languages, including Arabic, German, Turkish, Kannada, Polish, and Italian.18−23 In 2009, it was suggested that the SVHI could increase patients’ cognitive load and perhaps be difficult to apply, particularly when used for repeated measurements.24 Therefore, a shortened version of the SVHI, the SVHI-10, was developed and validated.24 The SVHI-10 provides clinicians with the ability to learn the level of a singing handicap for a singer that is caused by a voice problem in a relatively short time. This index includes only 10 questions. It has a five-point rating scale, wherein zero is equal to never, one is equal to almost never, two is equal to sometimes, three is equal to almost always, and four is equal to always. A higher score indicates a higher self-perception of disability regarding his/her singing voice problem. To the best of our knowledge, the SVHI-10 has been translated into and validated using the Kannada and Tamil languages.25,26 Adaptation and validation of selfadministered questionnaires are not only important for developing reliable and valid tools, but also for creating an index that can be used universally.10 It is also recommended that an index validation study should maintain item consistency and order so the diagnostic instruments can be universally used.10 The Turkish version of the SVHI has proven to be a valid and reliable tool,20 however, it takes a long time to complete the inventory, especially when it is administered along with other questionnaires. Accordingly, the main purpose of this study was to determine the validity and reliability of the Turkish SVHI-10. METHODS Development of the Turkish version of the SVHI-10 The SVHI was translated and adapted to the Turkish language in the study conducted by Denizo glu et al.20 For the present study, the items of the SVHI-10 originated from this source. The items chosen for this study were the same as those found in the English version of the SVHI-10, and the order of these items is also the same. Items numbered 1, 6, 7, 10, 15, 17, 18, 29, 31, and 32 of the SVHI were extracted for use in the Turkish SVHI-1024 (Appendix). This study was approved by the Hacettepe University Ethics Committee (Approval No: GO 15/783-15) on December 16, 2015.

Participants Singers were included from a wide range of experience levels, amateur to professional, and different music genres, such as Turkish folk music, Turkish classical music, Western classical music, pop, arabesque music, and jazz. A total of 200 singers participated in the study, and participants were divided into control and study groups. Participants of at least 16 years old and younger than 65 years old were included in the study. The control group (n = 136) consisted of singers who were vocally healthy individuals; they were evaluated perceptually and examined with a

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videolaryngostroboscope. In both groups, participants with a reported or documented history of systemic or neurological disease, upper respiratory tract infections and/or allergies on the day of evaluation, and current medication usage likely to affect their voices were excluded. The study group (n = 64) consisted of singers who were diagnosed with voice disorders by perceptual evaluation and videolaryngostroboscopic examination. Although participant cohort numbers differed, they were age and gender matched. To determine test-retest reliability, 97 participants, representing a portion of both groups, completed the SVHI-10 twice, with a minimum one-week interval in between each completion.

Administration of the questionnaire Each singer who participated in the study completed a case history form that was related to demographic characteristics, singing style, and years of singing training, and they were questioned regarding a history of voice disorder. Nearly half of all the participants (48.5%) completed the same questionnaire a second time. The duration between the two applications of the questionnaire varied 7−14 days, with a mean of 10 days. Participants did not receive any training or medication during this period of time. In addition, participants were asked to circle the word that most closely matched how serious they felt their singing voice problem was overall. These options included no problem, a mild problem, a moderate problem, or a severe problem.

Videolaryngostroboscopic examination The videolaryngostroboscopic examinations were performed via a rigid endoscope using the Kay Pentax digital strobe (Kay Pentax, Lincoln Park, NJ, USA). The videolaryngostroboscopic examination was based on the visualization of the participants’, at comfortable loudness and modal phonation of the /i/ vowel sound in agreement with the criteria listed by Hirano's book on videostroboscopy.27 The standard evaluation sheet was used. Glottal closure configuration, vocal fold edge, vocal fold vibratory characteristics, and mucosal wave were the main parameters evaluated.27 On the rare occasion, for those participants who could not tolerate the rigid endoscope, a 3.7-mm-diameter flexible fiberoptic laryngoscope (Optim, Sturbridge, MA, USA) was used. The transnasal fiberoptic examination included counting from 1 to 10 and running speech. The larynx was observed in mediolateral and anteroposterior directions. This assessment was not graded; instead it was noted as abnormality absent or present. Laryngeal pathology and supraglottic hyperfunction were assessed.28 Kay Pentax Rls 9100 B equipment (Kay Elemetrics, Lincoln Park, NJ, USA) was used to capture the video and record the voices. Recordings were examined in a separate session by two board-certified laryngologists (SA, TY).

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Validity and Reliability of the Turkish Singing Voice Handicap Index-10

Auditory-perceptual evaluation Auditory-perceptual evaluations were conducted using the grade, roughness, breathiness, asthenia, strain method by one speech and language therapist (FEA) and two laryngologists (SA, OK) to confirm that voices of the participants in the control group were healthy.29,30 If there was a disagreement between the raters; participant excluded from the control group. The speech samples gathered for this purpose included a sustained /a/ phonation and conversational speech recordings that were approximately 1.5 minutes in duration. Recordings were made in a silent room using an iPad Air 2 device. Statistical analysis Statistical analysis was carried out by the Statistical Package for the Social Science Statistics Inc. 20.0. Internal consistency was determined using Cronbach's alpha coefficient. Corrected item-total correlation coefficients were also calculated. The total questionnaire scores obtained in the control and study groups were compared through an independent sample t test. Pearson chi-square test was used to determine differences between the study and control groups in terms of age and gender. Pearson rank correlation coefficient was calculated to evaluate the correlation between the SVHI-10 and the participants’ perceptions of singing voice complaints. Test-retest reliability was determined using the Pearson product-moment correlation test. Sensitivity and specificity of the SVHI-10 were determined using the receiver operating characteristic (ROC) curve analysis.31 RESULTS Demographics of the participants Participants aged 16−65 years were included. The control group consisted of 136 participants whose mean age was 24.07 § 7.88. The study group consisted of 64 participants whose mean age was 25.06 § 8.59. Females made up 73.5% (n = 100) of the control group and 76.56% (n = 49) of the study group. The control and study groups were not significantly different in terms of age and gender characteristics (P = 0.660 and P = 0.668, respectively). In both groups, students constituted the majority; that is 48.43% of the study group and 50.00% of the control group were students. Amateur singers constituted 37.50% of the participants in the study group and 36.76% of the participants in the control group. Professional singers made up 14.06% of the study group and 13.97% of the control group. In both groups, most of the singers were Western classical music genre singers, followed by Turkish folk music and Turkish classical music singers. Table 1 shows the demographics of the participants according to the groups. Diagnoses of the voice disordered participants Table 2 shows the distribution of the study group participants’ diagnoses, which included benign vocal fold lesions,

TABLE 1. Demographics of the Participants According to the Groups Parameter Age (y) Mean § SD Gender n (%) Female Male Singing status n (%) Student Professional Amateur Singing style n (%) Western classical music Turkish folk music Turkish classical music Pop Arabesque Jazz

Study Group

Control Group

25.06 § 8.59

24.07 § 7.88

49 (76.56%) 100 (73.50%)

15 (23.44%) 36 (26.50%)

31 (48.43%) 9 (14.06%) 24 (37.50%)

68 (50.00%) 18 (13.23%) 50 (36.76%)

40 (62.50%) 8 (12.50%) 7 (10.93%) 6 (9.37%) 2 (3.12%) 1 (1.56%)

93 (68.38%) 14 (10.29%) 14 (10.29%) 9 (6.61%) 3 (2.20%) 3 (2.20%)

Abbreviations: SD, standard deviation; n, number.

primary muscle tension dysphonia, vocal fold edema, ectasia, sulcus vocalis, and unilateral vocal fold paralysis. The internal consistency and reliability analysis Cronbach's alpha coefficient for the 10 items of the SVHI-10 for all subjects (n = 200) was 0.91, indicating excellent internal consistency. Item-total correlation coefficients for each item were in the range of 0.552−0.764 (Table 3). All the item-total correlation coefficients were found to be higher than 0.40, which is the suggested minimum level.32 If any item were deleted, Cronbach's alpha coefficients were lower than the overall Cronbach's alpha coefficient (Table 3). This finding indicates that the 10 items of the SVHI-10 were all well-integrated into the questionnaire and that item reduction would decrease the level of internal consistency of the SVHI-10. Pearson's product-moment correlation assessed the testretest reliability for 97 of the participants. Results indicated

TABLE 2. Primary Diagnosis Distribution in the Study Group Primary Diagnosis* †

Benign vocal fold lesion Muscle tension dysphonia Vocal fold edema Ectasia Sulcus vocalis Vocal fold paralysis

n

%

19 14 13 8 7 3

29.69 21.88 20.31 12.50 10.93 4.69

* Classification was based on the primary diagnosis of vocal pathology. † Benign vocal fold lesions included vocal nodules, polyps, cysts, and Reinke’s edema.

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TABLE 3. Item-Total Correlation Coefficients and Cronbach’s Alpha Coefficients for Deleted Items Item (*) € ylemek i¸c in olduk¸c a fazla gayret sarf 1-¸S ark{ so etmem gerekiyor. (It takes a lot of effort to sing.) € yleyeceg  im zaman sesimin nas{l c¸ {kacag  {ndan emin 2-¸S ark{ so olam{yorum. (I am unsure of what will come out when I sing.) € ylerken sesim kesiliyor, tu € keniyor. 3-¸S ark{ so (My voice ‘‘gives out’’ on me while I am singing.)  {na ug  rat{yor. 4-¸S an sesim beni hayal k{r{kl{g (My singing voice upsets me.) € venmiyorum. 5-¸S an sesime gu (I have no confidence in my singing voice.) € ylerken yapmak istediklerimi sesime yapt{rmakta sorun 6-¸S ark{ so ya¸s {yorum. (I have trouble making my voice do what I want it to.) € ylerken ses c¸ {karmak i¸c in sesimi zorlay{p ‘itmek’ zorunda 7-¸S ark{ so kal{yorum. (I have to ‘‘push it’’ to produce my voice when singing.) 8-¸S an sesim c¸ abuk yoruluyor. (My singing voice tires easily.) € ylemekteki yetersizlig  im yu € zu € nden hayat{mda bir s¸ eylerin 9-¸S ark{ so  unu hissediyorum. eksik oldug (I feel something is missing in my life because of my inability to sing.)  im gibi kullanam{yorum. 10-Tiz seslerimi istedig (I am unable to use my ‘‘high voice.’’)

Corrected Item-Total Correlation

Cronbach’s Alpha if Item Deleted

0.552

0.904

0.607

0.901

0.617

0.900

0.756

0.893

0.751

0.893

0.745

0.892

0.764

0.891

0.654

0.898

0.699

0.896

0.568

0.904

* English translations are shown in parentheses.

that the Turkish SVHI-10 had good test-retest reliability (r = 0.90, n = 97, P < 0.001). Clinical validity and content validity analyses The mean SVHI-10 score for the control group was 8.14 § 5.4, with ranges from 0 to 29, whereas it was 20.54 § 6.9 for the study group, with ranges between 4 and 36. The singers with voice complaints had significantly higher values than the singers without voice complaints (t = ¡13.54, degree of freedom (df) = 196, P < 0.001). Retest results of the SVHI-10 also showed that participants with a vocal impairment had significantly higher scores than the control group (t = ¡11.86, df = 95, P < 0.001). The correlation analysis between the SVHI-10 and the self-assessment evaluation indicated a moderately positive relationship. Pearson's correlation coefficient was 0.58 and P < 0.001. Comparison of three SVHI-10s available in different languages In Table 4, a comparison of statistics related to the reliability and validity of the four available SVHI-10s is shown. It can be seen that the total scores of the English and Turkish

SVHI-10 are very similar to each other in both control and study groups and that they are higher than the Kannada version's total scores.25 The Cronbach's alpha coefficients for the SVHI-10 in the four languages were higher than 0.90. Test-retest reliability values of the four indices were in the range 0.86−0.99. Sensitivity and specificity The ROC curve analysis was used to define the cut-off point, specificity, and sensitivity. In Figure 1, the area under curve of the Turkish SVHI-10 was 0.95 (95% confidence interval: 0.92−0.97, P < 0.001). The optimal cut-off point determined by the Youden index31 was 11.5 with a sensitivity of 95.8% and a specificity of 83.2%. DISCUSSION Singers have a higher risk of experiencing voice symptoms and laryngeal pathologies compared to nonsingers.33 Singers are considered elite vocal performers among professional voice users. That is, any slight deviation in voice quality may have detrimental effects on a singer's ability.14 Evaluation and management of singers with voice complaints requires a comprehensive approach. This approach should include patient-reported outcomes along with instrumental analyses

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TABLE 4. Comparison of Four SVHI-10s Available in Different Languages Language

24

English Kannada25 Tamil26 Turkish

Total Score (Mean § SD/SE) Control

Study

8.40 § 0.50 5.88 § 3.39 7.08 § 7.2 8.14 § 5.48

21.4 § 1.05 19.6 § 11.4 22.8 § 4.30 20.5 § 6.93

Internal Consistency (Cronbach’s Alpha)

Test-Retest Reliability p^/r*

0.94 0.91 0.93 0.91

p^ = 0.86 r* = 0.97 r* = 0.99 r* = 0.90

Abbreviations: SD, Standard Deviation; SE, Standard Error; p^, Spearmen Correlation Statistic; r*, Pearson Product Moment Correlation Statistic.

and clinician-based perceptual evaluations.34 The most commonly used patient-reported outcome measures used in the population with voice complaints are the VHI and VHI-10. However, it has been proposed that the VHI and VHI-10 are insufficient to reflect the disability of a singer due to his or her voice problem. For example, Renk et al compared the SVHI-10 and the VHI-10 using a participant group of 50 singers and found that the scores of the SVHI-10 were significantly higher than those of the VHI-10.12 The SVHI and the short form of this questionnaire, the SVHI-10, are specifically designed patient-reported outcome measures used to determine the impact of a voice disorder on the ability of a singer.24 The SVHI-10 has proven to be a valid and reliable tool.24 Compared to the longer form, the SVHI-10 is more advantageous, as it can be completed in a short period of time.24 For a complete clinical voice evaluation that includes instrumental analysis, the audio-perceptual analyses of clinicians, and self-report questionnaires, using the SVHI-10 not only saves time but also helps to get more reliable information, while preventing the

FIGURE 1. ROC curve analysis for the Turkish version of the SVHI-10.

possibility of overburdening the singer. The SVHI has been adapted and validated into many different languages,18−23 however, a valid version of the SVHI-10 is only available in Kannada and Tamil.25,26 To provide reliable and valid tools in different languages, question-validation studies should provide experts with universal measurement tools.10 Thus, the results of these studies should be compared, and large multicenter data sets should be combined from different languages and countries using these universal tools. In the current study, the validity and reliability of the Turkish SVHI-10 was evaluated. For this purpose, internal consistency, test-retest reliability, clinical and content validity, and a ROC analysis were determined using a population of 200 singers. Cronbach's alpha coefficient was 0.91, indicating that the Turkish SVHI-10 has an excellent internal consistency in accordance with the English, Kannada, and Tamil versions of the SVHI-10.24−26,35 In addition, all the item-total correlation coefficients were found to be higher than 0.55 and compatible with the results of the Turkish SVHI.20,32 Cronbach's alpha coefficients obtained when any item was deleted demonstrated that all the items are consistent with the questionnaire, and extraction of one of them will decrease the internal consistency of the instrument. The significant difference of the mean scores between the study and the control groups supports the Turkish version of the SVHI-10 as a valid instrument. Interestingly, the mean SVHI-10 scores of the groups were very similar to the values of the original development study done in English,24 similar to the scores gathered in Tamil,26 and higher than the scores gathered in the Kannada translation study. In the Kannada SVHI-10 study, 115 participants, 25 of whom had voice problems, were included.25 In the Tamil SVHI-10 study, 120 participants, 37 of whom were dysphonic, were included.26 The differences in the participants’ population in terms of numbers and vocal diagnoses and their cultural differences may be possible reasons for the slightly different results between the available SVHI-10 studies.36 According to the test-retest evaluation, the Pearson product-moment correlation test values were similar to the other three SVHI-10 versions. In the original version, the Spearmen correlation value was found to be 0.86.24 In the present study, the Pearson product-moment correlation value was

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0.90, for the Kannada version it was 0.97,25 and for the Tamil version, it was 0.99.26 The content validity of the original SVHI-10 was determined by Cohen et al via searching the correlation between the VHI-10 and the SVHI-10.24 In the study of Renk et al in 2016, the authors reported that the SVHI-10 and VHI-10 were found to be incompatible with each other in a singers’ population.12 So, in the present study, the correlation analysis between the SVHI-10 and a self-rating of dysphonia was searched. This analysis proved to have a moderately positive correlation between the two measurements. In the Tamil SVHI-10 validity study, a positive correlation between the SVHI-10 and Voice Related Quality of Life questionnaire measurements was found.26 In the Kannada SVHI-10 validity study, no content-validity analysis method was used. The sensitivity and specificity of the index was determined by using an ROC curve analysis. The area under the ROC curve, which was greater than 0.9, was interpreted to mean that the index has high accuracy.31 The area under the curve and the high sensitivity and specificity values indicated that the Turkish SVHI-10 has a high capability of reflecting the singers’ self-perceived handicaps. The cut-off point was 11.5, which is a higher value than the 9.5 that was obtained in the validity study conducted for the Kannada SVHI-10.25 In both studies, the cut-off point was determined by using ROC analysis.25 The different optimal cut-off points of the two indices may arise from differences in the participants’ populations and cultural factors.36 CONCLUSIONS In conclusion, the present study proved that the Turkish version of the SVHI-10 is a valid and reliable tool. Items selected from the SVHI and the order of the items in the

SVHI-10/Turkish are identical to the original SVHI-10. The SVHI-10/Turkish can easily be used to evaluate the self-perception of a singer's voice problems. A score of 11.5 can be accepted as the cut-off point of the SVHI-10/Turkish for the assessment of singing voice disorders. Put differently, a score of SVHI-10 higher than 11.5 is indicative of an abnormal singer's perceived voice handicap. In future studies, implementing the SVHI-10/Turkish version as an outcome measure is warranted. PATIENT CONSENT The study was approved by the Hacettepe University Ethics Committee (Approval No: GO 15/783-15) on December 16, 2015. Informed consent was obtained in writing from all of the participants.

Acknowledgments This research received no specific grant from any funding agency in public, commercial, or not-for-profit sectors. The study had been presented orally in the 29th Congress of Union of the European Phoniatricians, 13−16 June, 2018, Helsinki, Finland. SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j. jvoice.2018.11.011. € _ APPENDIX. TURK CE ¸ S ¸ AN SESI_ HANDIKAP _ ENDEKSI-10 (SVHI-10/TURKISH)

Hi¸c bir Zaman (0) Nadiren (1) Bazen (2) S{k S{k (3) Her Zaman (4) € ylemek i¸c in olduk¸c a fazla gayret sarf 1-¸S ark{ so etmem gerekiyor. € yleyeceg  im zaman sesimin nas{l 2-¸S ark{ so  {ndan emin olam{yorum. c¸ {kacag € ylerken sesim kesiliyor, tu € keniyor. 3-¸S ark{ so  {na ug  rat{yor. 4-¸S an sesim beni hayal k{r{kl{g € venmiyorum. 5-¸S an sesime gu € ylerken yapmak istediklerimi sesime 6-¸S ark{ so yapt{rmakta sorun ya¸s {yorum. € ylerken ses c¸ {karmak i¸c in sesimi zorlay{p 7-¸S ark{ so ‘itmek’ zorunda kal{yorum. 8-¸S an sesim c¸ abuk yoruluyor. € ylemekteki yetersizlig  im yu € zu € nden hay9-¸S ark{ so  unu hissediyorum. at{mda bir s¸ eylerin eksik oldug  im gibi kullanam{yorum. 10-Tiz seslerimi istedig

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