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PEDOT-7638; No. of Pages 5 International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI) Lorena Sanz a,1,*, Patricia Bau a,1, Ignacio Arribas b, Teresa Rivera a a b
Department of Otolaryngology, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain Foundation for Biomedical Research, Prı´ncipe de Asturias University Hospital, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 April 2015 Received in revised form 15 June 2015 Accepted 16 June 2015 Available online xxx
Objectives: The voice in childhood is a communication tool and a form of emotional expression. It is estimated that 6 to 23% of children may have voice disorders. There is a test, the Pediatric Voice Handicap Index (P-VHI), validated in English to assess the specific impact on quality of life of children with speech pathology. Spanish is the second most widely used language in the world in terms of number of speakers, with over 500 million native speakers, so it is necessary to have tools that allow us to evaluate the effects of dysphonia in Spanish-speaking children. The aim of our study is the validation of the Spanish version of the P-VHI. Material and methods: We performed a cross-sectional study including patients between 4 and 15 years of age. The English P-VHI validated version was translated into Spanish and this translation was reviewed and modified by three specialists in Otorhinolaryngology. There were two study groups, children who had dysphonia (n = 44) and a control group of children without alterations in voice (n = 44). The questionnaire was always answered by parents. Results: Significant differences were found between the group of children with dysphonia and the control group in the overall P-VHI score and the different subscales (p < 0.001). Optimal internal consistency with a good Cronbach’s alpha (a = 0.81) was found, with high test–retest reliability (Wilcoxon z: 0847, p > 0.05). Conclusions: The Spanish version of the P-VHI is a validated tool that has good internal consistency. It is a reliable test that evaluates the Voice Handicap Index in the pediatric population, with easy application for daily clinical practice. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric dysphonia Voice Handicap Index
1. Introduction The voice in childhood is a communication tool and a form of emotional expression that is part of children’s psychosocial development. The causes of dysphonia in children, like adults, can range from primary organ damage, functional impairment of the larynx or secondary organ damage as a result of altered laryngeal function. Dysphonia studies with children have shown an incidence between 6% and 23% [1,2]. Voice disorders in children are less common than might be expected, given that vocal abuse is so widespread in this age group [3]. To study child dysphonia we have the traditional endoscopic imaging tools that allow assessment the phonatory anatomical structures. This scanning method plays a fundamental role since it
* Corresponding author. Tel.: +34 918878100x2422. E-mail address: [email protected] (L. Sanz). 1 Coauthors.
can be done at any age, does not require sedation, is performed in consultation and allows a direct view of the vocal cords. However, there has been little study of the psychological evaluation of the causes of dysphonia and the impact on the lives of children. An investigation of the importance of voice disorders in children and adolescents showed that dysphonia caused discomfort and limited their participation in activities [4]. There are several instruments to assess disability generated by voice disorders in adults as well as the impact on their quality of life. These include the adult Voice Handicap Index (VHI) [5], the survey on the effects of voice (Voice outcome survey, VOS) [6] and the survey on quality of life related to voice (voice related quality of life, V-RQL) [7]. The VHI in adults is a survey consisting of 30 statements designed to be answered by the patient. A validated tool in many languages, it is used to assess the functional effect of dysphonia at both the physical and emotional level. To assess the effects of dysphonia in children is even more subjective. The survey on the effects of pediatric voice (pediatric voice outcome survey, P-VOS) [8], which consists of five questions
http://dx.doi.org/10.1016/j.ijporl.2015.06.021 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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PEDOT-7638; No. of Pages 5 L. Sanz et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
2
answered by parents, has been validated as an instrument to measure quality of life related to the child’s voice, although it is not helpful in revealing the functional, physical and emotional aspects of voice disorders. Zur et al. developed and validated in English a test adapted from the adult VHI to be applied in children, known as the Pediatric Voice Handicap Index (P-VHI) [9]. The modifications included changes in the language of the questions to be answered by the parents or guardians of dysphonic children and eliminating those that were not related to children. Recently, three studies were designed to evaluate the validity and reliability of the P-VHI versions in Italian, Arabic and Korean, which revealed that the instrument is easy to implement, highly reproducible and consistently shows excellent clinical validity in voice study in pediatrics [10–12]. The Spanish language is the second language in the world by number of speakers with over 500 million native speakers, so it is necessary to have tools that allow us to evaluate the effects of dysphonia in Spanish-speaking children. The aim of our study was to develop a Spanish version of the Pediatric Voice Handicap Index and assess its internal consistency, reliability and clinical validity. 2. Material and methods 2.1. Development of the Spanish version of the P-VHI The original English version of the P-VHI was translated into Spanish, after translated back into English and compared by three specialist in Otolaryngology, independently, in order to adapt a vocabulary more consistent and understandable to the Spanish language. The final questionnaire is presented in Appendix A. The P-VHI consists of 23 statements, divided into three groups, which assess the impact of voice pathology at the functional, physical and emotional level. Each of the statements requires an answer based on how often the respondent experienced each item. Each response is individually scored on a Likert scale of 5 points, ranging from ‘‘never’’ (score 0) to ‘‘always’’ (score of 4), with a range of total score ranging from 0 to 92 [13]. We also added a visual analogue scale at the beginning of the test for classifying the loquacity of the child. The test is designed to be taken by parents or guardians, who should be responsible for assessing a child’s vocal disability in daily life.
2.3. Statistical evaluation The following statistical tests were performed using SPSS 16.0 (SPSS Inc., Chicago, USA). The internal consistency of the questionnaire was determined using Cronbach’s alpha coefficient. An alpha value greater than 0.8 is considered good and greater than 0.9 is considered excellent, whereas any value above 0.7 is considered satisfactory. The Student t-test was used to measure the clinical validity of the variables used in the test analysis. The Wilcoxon test was used to analyze the reliability by test– retest of the second group of randomly selected parents. 3. Results 3.1. Clinical validity All parents participated in the study by answering the survey without any need of help. No significant differences (p > 0.05) were observed when comparing gender and age between the control group and the group of dysphonic children. The demographics of the group of control children and the study group of children with voice disorders are shown in Table 1. The mean score on the visual analogue scale that assessed the child’s talkativeness as subjectively perceived by parents showed no significant differences between the groups, obtaining an average of 5.7 in the control group and 5.5 in the dysphonic group. In the group of dysphonic children, the following pathogenic causes were found: vocal nodules, inclusion cyst, functional dysphonia, recurrent paralysis and laryngeal papillomatosis. The most prevalent disease was laryngeal nodules in 86.36% of cases (Table 2). There were statistically significant differences between the study groups in the mean total P-VHI score and the average score for each functional, physical and emotional item obtained in both groups (Table 3). Analysis of the data using the Student t-test showed that children with dysphonia present a Voice Handicap Index with values 20% higher than the control group (24.52 4.86 11.5 vs. 6.6, p < 0.001). In children with speech disorders, a higher average score on the physical item, comparing the functional and emotional item was found. 3.2. Internal consistency
2.2. Methods A cross-sectional study was conducted in collaboration with the departments of Otolaryngology, Pediatrics and Rehabilitation. All parents were invited to participate freely after signing an informed consent explaining the objectives of our work, in accordance with the rules of the Ethics Committee of our hospital. The questionnaire was answered by a total of 88 parents or guardians of children between 4 and 15 years of age seen from October 2012 through April 2014. The control group answered the survey from pediatric emergency visits. Data were obtained from parents of currently healthy children without acute disease (inflammatory or infectious upper airway) with no history of present or past conditions or voice pathology, or history of language delay or speech problems, hearing loss, neurological diseases or psychomotor retardation. Parents of children with speech disorders were recruited directly from the Otolaryngology voice inventory performed at diagnosis of the child’s dysphonia, and from consultation with vocal rehabilitation in cases that were already engaged in speech therapy. A group of parents selected from the study group were asked to reply to randomly survey a second time with an interval of 2–8 weeks.
The results of the statistical study of internal consistency of the P-VHI showed a statistically significant satisfactory overall coefficient (a = 0.81). The physical item P-VHI was the component Table 1 Demographic characteristics of patients. Patients
n
Male
Female
Mean age
Dysphonic children Control children Total
44 44 88
35 (79.5%) 26 (59%) 61
9 (20.4%) 18 (49.9%) 27
9.1 years (5–14) 7.9 years (4–14) 8.5 years
Table 2 Main diagnoses in the group of children with dysphonia. Patients
n
%
Vocal fold nodules Inclusion cyst Functional dysphonia Recurrent paralysis Laryngeal papillomatosis Total
38 2 2 1 1 44
86.4 4.5 4.5 2.3 2.3 100
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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PEDOT-7638; No. of Pages 5 L. Sanz et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx Table 3 Total P-VHI score and functional, physical and emotional subscales. Dysphonic children
Spanish P-VHI domains (maximum possible score)
Control children
Mean SD
Range
Mean SD
Range
Functional (28) Physical (36) Emotional (28) Total (92)
5.41 4.5 16.11 7.1 2.98 3.0 24.52 11.5
0–16 0–28 0–12 0–44
1.93 2.7 2.3 3.7 0.7 1.6 4.86 6.6
0–12 0–13 0–8 0–29
t-Student
Table 4 Internal consistency assessed by Cronbach’s alpha coefficient. Cronbach’s alpha (a)
Functional Physical Emotional Total
0.612 0.924 0.428 0.811
Table 5 Test–retest reliability for total Spanish PVHI scores and different subscales evaluated by the Wilcoxon test. P-VHI Functional Physical Emotional Total
z
Significance (p) 0.524 0.857 1.473 0.847
significant differences (p > 0.05); which is good agreement since it shows that there was no difference between the scores collected between the first and second measurement survey (Table 5). 4. Discussion
p < 0.001 p < 0.001 p < 0.001 p < 0.001
SD: standard deviation.
Subscale
3
>0.05 >0.05 >0.05 >0.05
that showed the best internal consistency (a = 0.92), in contrast with the emotional subscale of P-VHI which showed the lowest coefficient of 0.42 (Table 4). 3.3. Reliability The test–retest reliability was assessed by determining the level of agreement between the results of the first and second measurement questionnaire of the randomly selected group within the group of dysphonic patients. Statistical analysis of the reliability of the questionnaire was calculated for paired data. For each item and for the total score there were no statistically
From the vocal standpoint, children constitute a unique population because the phonatory function varies from birth up to the adulthood, but it is during childhood and puberty when the most progressive changes in size, shape and laryngeal position take place, culminating in structural maturation of tissues [3]. Given the complexity of phonatory processes at these ages, small variations of development produce significant changes in the voice. Therefore, our study sample comprises children aged 5 to 14 years. We emphasize the particularity of parents or teachers who perceive voice disorders, not the patients who sometimes have gone completely unnoticed. Vocal nodules are the most common acquired lesions of the vocal cords in children of school age, mainly related by vocal abuse. In our study, we found 38 patients with vocal nodules of the 44 selected in the group of dysphonic children. In the literature we can find tools and tests validated to Spanish for self-assessment of vocal disorders of patients for the spoken voice (VHI, Voice Handicap Index) [14] and for the singing voice (SVHI disability index test singing voice) [15], but due to the peculiarities of the pediatric population these would not be useful to assess the vocal problems of children. For this reason we designed and validated a specific questionnaire for self-assessment of pediatric voice disorders in Spanish, as Zur et al. did in 2007 in English [9]. The P-VHI questionnaire translated into Spanish does not lose validity, the original version having been translated into Italian, Arabic and Korean [10–12]. The total mean P-VHI scores of dysphonic patients (24.52 11.5) and subscales are similar to published studies (functional: 5.41 4.5, physical: 16.11 7.1, emotional: 2.98 3.0), and are well above the average score of the control group (Fig. 1). In our study the physical component of the P-VHI is the selfperceived parameter that occurs most frequently in children with voice disorders. These data are consistent with all published studies [9–12] with the highest score (21.24) in the translated Arabic version, followed by the Italian version (18.3), English version (15.48) and finally the Korean version (9.54).
Fig. 1. Comparison of the results of the P-VHI validated in English, Italian, Arabic, Korean and Spanish. Comparative review of results of mean P-VHI scores between control group and group of patients with dysphonia among the different languages in which the P-VHI has been validated (T: total, F: functional, P: physical, E: emotional).
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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The Spanish version of the P-HIV has a high internal consistency with Cronbach’s alpha coefficients with good results in the total score (a = 0.81), excellent in the physical subscale and somewhat lower in the functional and emotional subscales. As with the validity of the physical subscale of the P-VHI, other published studies reveal higher alpha coefficients on this subscale (a = 0.92 Spanish version, a = 0.92 Arabic version, a = 0.93 Italian version, a = 0.89 Korean version) [10–12]. The internal consistency of the test–retest reliability of the Spanish version of the P-VHI is good, with no significant differences found in the Wilcoxon test between the questionnaires evaluated at two different intervals without any therapeutic intervention. These findings are consistent with the correlations made in other studies with Pearson coefficients significant in English version (r = 0.82), Italian version (r = 0.88), Arabic version (r = 0.90) and Korean version (r = 0.97) [9–12]. The main diagnoses in the group of children with altered voice are similar in the Arabic and Italian studies to those in our study [10,11], mostly related to vocal abuse habits; however, in the Korean study all children with dysphonia (n = 41) had bilateral vocal nodules [12] and it is striking that in the original Zur et al. study of patients with dysphonia 33 children had subglottic stenosis secondary to prolonged intubations [9]. Recently, a shortened version of ten items from the Italian translation of P-VHI was published, which has the same value and reliability as the extended version but facilitates completion by the patient’s parents [16]. 5. Conclusion The Spanish version of the P-VHI questionnaire is a validated tool that has good internal consistency.
The P-VHI is a reliable test for completion by parents of children with dysphonia. It is characterized by its easy application in daily clinical practice and gives us additional information to better understand how children perceive dysphonia. We recommend its use and inclusion in the standard protocols for assessing voice in the pediatric population. Conflict of interest statement This work was not funded in full or part by any agency and the authors have no conflict of interest to report. Acknowledgements This study was conducted in collaboration with Cristina Amat (Department of Rehabilitation, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain) and Gloria Lo´pez (Department of Pediatrics, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain), who participated in the selection of patients for the questionnaires.
Appendix A. Scale of talkativeness and Spanish version of the P-VHI The parents of the patients included in the study completed these questionnaires, describing through their scaled agreement with various statements their children’s voices and the effects produced in their children’s daily lives.
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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References [1] P.N. Carding, S. Roulstone, K. Northstone, ALSPAC Study Team, The prevalence of childhood dysphonia: a cross-sectional study, J. Voice 20 (2006) 623–630. [2] E.L. Tavares, A. Brasolotto, M.F. Santana, C.A. Padovan, R.H. Martins, Epidemiological study of dysphonia in 4–12 year-old children, Braz. J. Otorhinolaryngol. 77 (2011) 736–746. [3] F. Nu´n˜ez, M. Morato, Disfonia infantil, in: I. Cobeta, I.F. Nu´n˜ez, S. Ferna´ndez (Eds.), Patologı´a de la voz, Ponencia oficial Sociedad Espan˜ola de Otorrinolaringologı´a y Patologı´a Ce´rvico-Facial 2013, Marge Me´dica Books, Barcelona, 2013, pp. 295–304. [4] N.P. Connor, S.B. Cohen, S.M. Theis, S.L. Thibeault, D.G. Heatley, D.M. Bless, Attitudes of children with dysphonia, J. Voice 22 (2008) 197–209. [5] B.H. Jacobson, A. Johnson, C. Grywalski, A. Silbergleit, G. Jacobson, M.S. Benninger, et al., The Voice Handicap Index: development and validation, Am. J. Speech Lang. Pathol. 6 (1997) 66–70. [6] R.E. Gliklich, R.M. Glovsky, W.W. Montgomery, Validation of a voice outcome survey for unilateral vocal cord paralysis, Otolaryngol. Head Neck Surg. 120 (1999) 153–158. [7] N.D. Hogikyan, G. Sethuraman, Validation of a instrument to measure voicerelated quality of life (V-RQL), J. Voice 13 (1999) 557–569. [8] C.J. Hartnick, Validation of a pediatric voice quality-of-life instrument, Arch. Otolaryngol. Head Neck Surg. 128 (2002) 919–922.
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[9] K.B. Zur, S. Cotton, L. Kelchner, S. Baker, B. Weinrich, L. Lee, Pediatric Voice Handicap Index (pVHI): a new tool for evaluating pediatric dysphonia, Int J. Pediatr. Otorhinolaryngol. 71 (2007) 77–82. [10] A. Schindler, C. Tiddia, C. Ghidelli, V. Nerone, R. Albera, F. Ottaviani, Adaptation and validation of Italian pediatric Voice Handicap Index, Folia Phoniatr. Logop. 63 (2011) 9–14. [11] R.M. Shoeib, K.H. Malki, T.A. Mesallam, M. Farahat, Y.A. Shehata, Development and validation of the Arabic pediatric Voice Handicap Index, Int. J. Pediatr. Otorhinolaryngol. 76 (2012) 1297–1303. [12] S.S. Park, T.K. Kwon, S.H. Choi, W.Y. Lee, Y.H. Hong, N.G. Jeong, et al., Reliability and validity of the Korean version of pediatric Voice Handicap Index: in school age children, Int. J. Pediatr. Otorhinolaryngol. 77 (2013) 107–112. [13] R. Likert, A technique for the measurement of attitudes, Arch. Psychol. 140 (1932) 1–55. [14] F. Nu´n˜ez-Batalla, P. Corte-Santos, B. Sen˜aris-Gonza´lez, J.L. Llorente-Penda´s, C. Go´rriz-Gil, C. Sua´rez-Nieto, Adaptation and validation to the Spanish of the Voice Handicap Index (VHI-30) and its shortened version (VHI-10), Acta Otorrinolaringol. Esp. 58 (2007) 386–392. [15] I. Garcı´a-Lo´pez, F. Nu´n˜ez-Batalla, J. Gavila´n Bouzas, C. Go´rriz-G, Validation of the Spanish version of the Voice Handicap Index for vocal singing (SVHI), Acta Otorrinolaringol. Esp. 61 (2010) 247–254. [16] A. Ricci-Maccarini, V. De Maio, T. Murry, A. Schindler, Development and validation of the Children’s Voice Handicap Index-10 (CVHI-10), J. Voice 27 (2013) 258.e23– 258.e28.
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
PEDOT-7638; No. of Pages 5 International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI) Lorena Sanz a,1,*, Patricia Bau a,1, Ignacio Arribas b, Teresa Rivera a a b
Department of Otolaryngology, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain Foundation for Biomedical Research, Prı´ncipe de Asturias University Hospital, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 April 2015 Received in revised form 15 June 2015 Accepted 16 June 2015 Available online xxx
Objectives: The voice in childhood is a communication tool and a form of emotional expression. It is estimated that 6 to 23% of children may have voice disorders. There is a test, the Pediatric Voice Handicap Index (P-VHI), validated in English to assess the specific impact on quality of life of children with speech pathology. Spanish is the second most widely used language in the world in terms of number of speakers, with over 500 million native speakers, so it is necessary to have tools that allow us to evaluate the effects of dysphonia in Spanish-speaking children. The aim of our study is the validation of the Spanish version of the P-VHI. Material and methods: We performed a cross-sectional study including patients between 4 and 15 years of age. The English P-VHI validated version was translated into Spanish and this translation was reviewed and modified by three specialists in Otorhinolaryngology. There were two study groups, children who had dysphonia (n = 44) and a control group of children without alterations in voice (n = 44). The questionnaire was always answered by parents. Results: Significant differences were found between the group of children with dysphonia and the control group in the overall P-VHI score and the different subscales (p < 0.001). Optimal internal consistency with a good Cronbach’s alpha (a = 0.81) was found, with high test–retest reliability (Wilcoxon z: 0847, p > 0.05). Conclusions: The Spanish version of the P-VHI is a validated tool that has good internal consistency. It is a reliable test that evaluates the Voice Handicap Index in the pediatric population, with easy application for daily clinical practice. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric dysphonia Voice Handicap Index
1. Introduction The voice in childhood is a communication tool and a form of emotional expression that is part of children’s psychosocial development. The causes of dysphonia in children, like adults, can range from primary organ damage, functional impairment of the larynx or secondary organ damage as a result of altered laryngeal function. Dysphonia studies with children have shown an incidence between 6% and 23% [1,2]. Voice disorders in children are less common than might be expected, given that vocal abuse is so widespread in this age group [3]. To study child dysphonia we have the traditional endoscopic imaging tools that allow assessment the phonatory anatomical structures. This scanning method plays a fundamental role since it
* Corresponding author. Tel.: +34 918878100x2422. E-mail address: [email protected] (L. Sanz). 1 Coauthors.
can be done at any age, does not require sedation, is performed in consultation and allows a direct view of the vocal cords. However, there has been little study of the psychological evaluation of the causes of dysphonia and the impact on the lives of children. An investigation of the importance of voice disorders in children and adolescents showed that dysphonia caused discomfort and limited their participation in activities [4]. There are several instruments to assess disability generated by voice disorders in adults as well as the impact on their quality of life. These include the adult Voice Handicap Index (VHI) [5], the survey on the effects of voice (Voice outcome survey, VOS) [6] and the survey on quality of life related to voice (voice related quality of life, V-RQL) [7]. The VHI in adults is a survey consisting of 30 statements designed to be answered by the patient. A validated tool in many languages, it is used to assess the functional effect of dysphonia at both the physical and emotional level. To assess the effects of dysphonia in children is even more subjective. The survey on the effects of pediatric voice (pediatric voice outcome survey, P-VOS) [8], which consists of five questions
http://dx.doi.org/10.1016/j.ijporl.2015.06.021 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
G Model
PEDOT-7638; No. of Pages 5 L. Sanz et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
2
answered by parents, has been validated as an instrument to measure quality of life related to the child’s voice, although it is not helpful in revealing the functional, physical and emotional aspects of voice disorders. Zur et al. developed and validated in English a test adapted from the adult VHI to be applied in children, known as the Pediatric Voice Handicap Index (P-VHI) [9]. The modifications included changes in the language of the questions to be answered by the parents or guardians of dysphonic children and eliminating those that were not related to children. Recently, three studies were designed to evaluate the validity and reliability of the P-VHI versions in Italian, Arabic and Korean, which revealed that the instrument is easy to implement, highly reproducible and consistently shows excellent clinical validity in voice study in pediatrics [10–12]. The Spanish language is the second language in the world by number of speakers with over 500 million native speakers, so it is necessary to have tools that allow us to evaluate the effects of dysphonia in Spanish-speaking children. The aim of our study was to develop a Spanish version of the Pediatric Voice Handicap Index and assess its internal consistency, reliability and clinical validity. 2. Material and methods 2.1. Development of the Spanish version of the P-VHI The original English version of the P-VHI was translated into Spanish, after translated back into English and compared by three specialist in Otolaryngology, independently, in order to adapt a vocabulary more consistent and understandable to the Spanish language. The final questionnaire is presented in Appendix A. The P-VHI consists of 23 statements, divided into three groups, which assess the impact of voice pathology at the functional, physical and emotional level. Each of the statements requires an answer based on how often the respondent experienced each item. Each response is individually scored on a Likert scale of 5 points, ranging from ‘‘never’’ (score 0) to ‘‘always’’ (score of 4), with a range of total score ranging from 0 to 92 [13]. We also added a visual analogue scale at the beginning of the test for classifying the loquacity of the child. The test is designed to be taken by parents or guardians, who should be responsible for assessing a child’s vocal disability in daily life.
2.3. Statistical evaluation The following statistical tests were performed using SPSS 16.0 (SPSS Inc., Chicago, USA). The internal consistency of the questionnaire was determined using Cronbach’s alpha coefficient. An alpha value greater than 0.8 is considered good and greater than 0.9 is considered excellent, whereas any value above 0.7 is considered satisfactory. The Student t-test was used to measure the clinical validity of the variables used in the test analysis. The Wilcoxon test was used to analyze the reliability by test– retest of the second group of randomly selected parents. 3. Results 3.1. Clinical validity All parents participated in the study by answering the survey without any need of help. No significant differences (p > 0.05) were observed when comparing gender and age between the control group and the group of dysphonic children. The demographics of the group of control children and the study group of children with voice disorders are shown in Table 1. The mean score on the visual analogue scale that assessed the child’s talkativeness as subjectively perceived by parents showed no significant differences between the groups, obtaining an average of 5.7 in the control group and 5.5 in the dysphonic group. In the group of dysphonic children, the following pathogenic causes were found: vocal nodules, inclusion cyst, functional dysphonia, recurrent paralysis and laryngeal papillomatosis. The most prevalent disease was laryngeal nodules in 86.36% of cases (Table 2). There were statistically significant differences between the study groups in the mean total P-VHI score and the average score for each functional, physical and emotional item obtained in both groups (Table 3). Analysis of the data using the Student t-test showed that children with dysphonia present a Voice Handicap Index with values 20% higher than the control group (24.52 4.86 11.5 vs. 6.6, p < 0.001). In children with speech disorders, a higher average score on the physical item, comparing the functional and emotional item was found. 3.2. Internal consistency
2.2. Methods A cross-sectional study was conducted in collaboration with the departments of Otolaryngology, Pediatrics and Rehabilitation. All parents were invited to participate freely after signing an informed consent explaining the objectives of our work, in accordance with the rules of the Ethics Committee of our hospital. The questionnaire was answered by a total of 88 parents or guardians of children between 4 and 15 years of age seen from October 2012 through April 2014. The control group answered the survey from pediatric emergency visits. Data were obtained from parents of currently healthy children without acute disease (inflammatory or infectious upper airway) with no history of present or past conditions or voice pathology, or history of language delay or speech problems, hearing loss, neurological diseases or psychomotor retardation. Parents of children with speech disorders were recruited directly from the Otolaryngology voice inventory performed at diagnosis of the child’s dysphonia, and from consultation with vocal rehabilitation in cases that were already engaged in speech therapy. A group of parents selected from the study group were asked to reply to randomly survey a second time with an interval of 2–8 weeks.
The results of the statistical study of internal consistency of the P-VHI showed a statistically significant satisfactory overall coefficient (a = 0.81). The physical item P-VHI was the component Table 1 Demographic characteristics of patients. Patients
n
Male
Female
Mean age
Dysphonic children Control children Total
44 44 88
35 (79.5%) 26 (59%) 61
9 (20.4%) 18 (49.9%) 27
9.1 years (5–14) 7.9 years (4–14) 8.5 years
Table 2 Main diagnoses in the group of children with dysphonia. Patients
n
%
Vocal fold nodules Inclusion cyst Functional dysphonia Recurrent paralysis Laryngeal papillomatosis Total
38 2 2 1 1 44
86.4 4.5 4.5 2.3 2.3 100
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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PEDOT-7638; No. of Pages 5 L. Sanz et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx Table 3 Total P-VHI score and functional, physical and emotional subscales. Dysphonic children
Spanish P-VHI domains (maximum possible score)
Control children
Mean SD
Range
Mean SD
Range
Functional (28) Physical (36) Emotional (28) Total (92)
5.41 4.5 16.11 7.1 2.98 3.0 24.52 11.5
0–16 0–28 0–12 0–44
1.93 2.7 2.3 3.7 0.7 1.6 4.86 6.6
0–12 0–13 0–8 0–29
t-Student
Table 4 Internal consistency assessed by Cronbach’s alpha coefficient. Cronbach’s alpha (a)
Functional Physical Emotional Total
0.612 0.924 0.428 0.811
Table 5 Test–retest reliability for total Spanish PVHI scores and different subscales evaluated by the Wilcoxon test. P-VHI Functional Physical Emotional Total
z
Significance (p) 0.524 0.857 1.473 0.847
significant differences (p > 0.05); which is good agreement since it shows that there was no difference between the scores collected between the first and second measurement survey (Table 5). 4. Discussion
p < 0.001 p < 0.001 p < 0.001 p < 0.001
SD: standard deviation.
Subscale
3
>0.05 >0.05 >0.05 >0.05
that showed the best internal consistency (a = 0.92), in contrast with the emotional subscale of P-VHI which showed the lowest coefficient of 0.42 (Table 4). 3.3. Reliability The test–retest reliability was assessed by determining the level of agreement between the results of the first and second measurement questionnaire of the randomly selected group within the group of dysphonic patients. Statistical analysis of the reliability of the questionnaire was calculated for paired data. For each item and for the total score there were no statistically
From the vocal standpoint, children constitute a unique population because the phonatory function varies from birth up to the adulthood, but it is during childhood and puberty when the most progressive changes in size, shape and laryngeal position take place, culminating in structural maturation of tissues [3]. Given the complexity of phonatory processes at these ages, small variations of development produce significant changes in the voice. Therefore, our study sample comprises children aged 5 to 14 years. We emphasize the particularity of parents or teachers who perceive voice disorders, not the patients who sometimes have gone completely unnoticed. Vocal nodules are the most common acquired lesions of the vocal cords in children of school age, mainly related by vocal abuse. In our study, we found 38 patients with vocal nodules of the 44 selected in the group of dysphonic children. In the literature we can find tools and tests validated to Spanish for self-assessment of vocal disorders of patients for the spoken voice (VHI, Voice Handicap Index) [14] and for the singing voice (SVHI disability index test singing voice) [15], but due to the peculiarities of the pediatric population these would not be useful to assess the vocal problems of children. For this reason we designed and validated a specific questionnaire for self-assessment of pediatric voice disorders in Spanish, as Zur et al. did in 2007 in English [9]. The P-VHI questionnaire translated into Spanish does not lose validity, the original version having been translated into Italian, Arabic and Korean [10–12]. The total mean P-VHI scores of dysphonic patients (24.52 11.5) and subscales are similar to published studies (functional: 5.41 4.5, physical: 16.11 7.1, emotional: 2.98 3.0), and are well above the average score of the control group (Fig. 1). In our study the physical component of the P-VHI is the selfperceived parameter that occurs most frequently in children with voice disorders. These data are consistent with all published studies [9–12] with the highest score (21.24) in the translated Arabic version, followed by the Italian version (18.3), English version (15.48) and finally the Korean version (9.54).
Fig. 1. Comparison of the results of the P-VHI validated in English, Italian, Arabic, Korean and Spanish. Comparative review of results of mean P-VHI scores between control group and group of patients with dysphonia among the different languages in which the P-VHI has been validated (T: total, F: functional, P: physical, E: emotional).
Please cite this article in press as: L. Sanz, et al., Adaptation and validation of Spanish version of the pediatric Voice Handicap Index (P-VHI), Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/10.1016/j.ijporl.2015.06.021
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The Spanish version of the P-HIV has a high internal consistency with Cronbach’s alpha coefficients with good results in the total score (a = 0.81), excellent in the physical subscale and somewhat lower in the functional and emotional subscales. As with the validity of the physical subscale of the P-VHI, other published studies reveal higher alpha coefficients on this subscale (a = 0.92 Spanish version, a = 0.92 Arabic version, a = 0.93 Italian version, a = 0.89 Korean version) [10–12]. The internal consistency of the test–retest reliability of the Spanish version of the P-VHI is good, with no significant differences found in the Wilcoxon test between the questionnaires evaluated at two different intervals without any therapeutic intervention. These findings are consistent with the correlations made in other studies with Pearson coefficients significant in English version (r = 0.82), Italian version (r = 0.88), Arabic version (r = 0.90) and Korean version (r = 0.97) [9–12]. The main diagnoses in the group of children with altered voice are similar in the Arabic and Italian studies to those in our study [10,11], mostly related to vocal abuse habits; however, in the Korean study all children with dysphonia (n = 41) had bilateral vocal nodules [12] and it is striking that in the original Zur et al. study of patients with dysphonia 33 children had subglottic stenosis secondary to prolonged intubations [9]. Recently, a shortened version of ten items from the Italian translation of P-VHI was published, which has the same value and reliability as the extended version but facilitates completion by the patient’s parents [16]. 5. Conclusion The Spanish version of the P-VHI questionnaire is a validated tool that has good internal consistency.
The P-VHI is a reliable test for completion by parents of children with dysphonia. It is characterized by its easy application in daily clinical practice and gives us additional information to better understand how children perceive dysphonia. We recommend its use and inclusion in the standard protocols for assessing voice in the pediatric population. Conflict of interest statement This work was not funded in full or part by any agency and the authors have no conflict of interest to report. Acknowledgements This study was conducted in collaboration with Cristina Amat (Department of Rehabilitation, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain) and Gloria Lo´pez (Department of Pediatrics, Prı´ncipe de Asturias University Hospital, University of Alcala´, Alcala´ de Henares, Madrid, Spain), who participated in the selection of patients for the questionnaires.
Appendix A. Scale of talkativeness and Spanish version of the P-VHI The parents of the patients included in the study completed these questionnaires, describing through their scaled agreement with various statements their children’s voices and the effects produced in their children’s daily lives.
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