ARTICLE IN PRESS

Adaptation and Validation of the Voice Handicap Index

(VHI)-30 into Serbian
*Jelena Sotirović, †Anita Grgurević, ‡Gordana Mumović, *Uglješa Grgurević, *Ljubomir Pavićević,
*Aleksandar Perić, *Milan Erdoglija, and *Milanko Milojević, *†Belgrade, Serbia; and ‡Novi Sad, Serbia

Summary: Objectives. To evaluate the internal consistency, test-retest reliability, and clinical validity of the Serbian
version of the self-administered Voice Handicap Index (VHI)-30.
Study Design. Cross-sectional study.
Methods. The English version of VHI-30 was translated into Serbian and then back-translated into English. The Serbian
VHI-30 was administered to 91 patients divided into four groups according to voice pathology: structural, inflamma-
tory, neurologic, and functional groups. The control group included 90 subjects with no voice problems. The internal
consistency (Cronbach’s alpha coefficient α), test-retest reliability (interclass correlation coefficient) of VHI-30, com-
parison of patient’s and control’s VHI-30 scores (Mann-Whitney U test; Kruskal-Wallis test), and correlation with overall
severity of dysphonia (Spearman correlation coefficient, ρ) were calculated.
Results. In the patient group, we observed excellent internal consistency for the Serbian VHI-30 (α = 0.95) and good
internal consistency for all VHI-30 subscales: physical (α = 0.88), functional (α = 0.88), and emotional (α = 0.88). The
interclass correlation coefficient indicated strong test-retest reliability for patients (0.99) and controls (0.84). The mean
scores of all 30 items in dysphonic participants were significantly higher than in controls (P < 0.001). Good correla-
tion was obtained between the total scores of VHI-30 and patients’ self-perceived overall severity of dysphonia (ρ = 0.748,
P < 0.001). Within the patient group, the female participants displayed significantly higher VHI-30 scores than male
participants (Mann-Whitney U test, P < 0.001). The VHI-30 scores showed strong correlation within different patient
groups and controls (Spearman correlation coefficient: structural, 0.942; inflammatory, 0.756; neurologic, 0.888; func-
tional, 0.982; controls, 0.882).
Conclusions. The Serbian VHI-30 is a useful and valuable tool for the evaluation of patients with vocal disorders
and for making subsequent clinical decisions.
Key Words: Voice Handicap Index–Validity–Serbian version–Quality of life–Questionnaire.

INTRODUCTION
Voice disorders can be evaluated through subjective tests and
through objective acoustic and aerodynamic analyses. Al-
though the objective tests are informative, the same voice disorder
can be perceived differently by different patients. The growing
interest in patients’ quality of life and the importance of human
voice in social engagement make the self-administered ques-
tionnaires for assessing subjective impact of voice disorders
increasingly important. The impact of voice disorders and their
proper evaluation are even more important for vocal professionals.
Because the same voice disorder can result in different handi-
caps, standardized self-perceived measure of vocal disorders
should be included in the clinical assessment, the decision-
making process to determine the type of treatment, and the
evaluation of treatment success, both in malignant and in benign
laryngeal pathology.
Jacobson et al1 introduced a 30-item questionnaire called Voice
Handicap Index (VHI)-30 as an instrument to quantify the psy-
chosocial consequences of voice disorders. Among the numerous
self-administrated questionnaires, including the voice-related
Accepted for publication September 3, 2015.
From the *Clinic for Otorhinolaryngology, Military Medical Academy, Belgrade, Serbia;
†Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia;
and the ‡Department of Ear, Nose and Throat Diseases, Faculty of Medicine, University
of Novi Sad, Clinical Center of Vojvodina, Novi Sad, Serbia.
Address correspondence and reprint requests to Jelena Sotirović, Kaplara Momčila Gavrića
2, Belgrade 11000, Serbia. E-mail address: j.sotirovic@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2015.09.002
quality of life2 and the voice outcome survey,3 the VHI is the
most widely used. The Agency for Healthcare Research and
Quality also reported that the VHI meets the criteria for relia-
bility and validity.4
The VHI-30 is divided into three 10-item subscales: physi-
cal (P), which represents the patient’s perception of his or her
voice; emotional (E), representing the patient’s emotional
experience of his or her problem with his or her voice; and func-
tional (F), which refers to the patient’s problems in
communication.
A shorter version of the VHI containing only 10 items (VHI-
10) was presented by Rosen et al in 2004.5 The same study
showed that VHI-10 is as reliable and as sensitive as VHI-30
for assessing initial patient-based voice handicap and longitu-
dinal follow-up after treatment. Arffa et al6 provided the normative
data showing that a VHI-10 score higher than 11 should be con-
sidered abnormal. The VHI can also be used as a measure of
dysphonia severity in diseases other than those related to the
larynx, such as Parkinson’s disease,7 multiple sclerosis,8 gas-
troesophageal reflux,9,10 and allergic rhinitis,11 as well as after
treatment of benign and malignant vocal fold lesions.12–16
Both VHI-30 and VHI-10 have been translated into numer-
ous languages and subsequently validated.17–25 Adaptation and
validation of the Voice handicap index for a specific language
enable within-language and cross-language comparisons of voice
disorder severity and comparability of treatment results. Cross-
language comparisons are additionally supported by the nine-
item international version (VHI-9i), representing data from more
than one country.26
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2 Journal of Voice, Vol. ■■, No. ■■, 2015
MATERIALS AND METHODS
The original English version of VHI-30 was translated into
Serbian by two professional translators. Voice professionals dis-
cussed each item within the two translations, and if any differences
between the two translations existed, the voice professionals chose
the more appropriate version of the two for each item. Then, the
Serbian translation was back-translated into English, com-
pared with the original by a native English speaker, and found
to be highly consistent with the original English VHI-30. In a
pilot study, the first Serbian version of VHI-30 was adminis-
tered to five patients (two males and three females) with voice
pathology and five healthy subjects (three males and two females).
The feedback from participants of the pilot study was incorpo-
rated into the definitive version of the Serbian VHI-30 (Appendix).
Participants
The Serbian VHI-30 was administered to 91 patients (39 males
and 52 females, mean age 55.99 ± 14.64 years) with voice pa-
thology. Each patient was diagnosed by videostroboscopic
examination of his or her larynx at the Clinic for Otorhinolar-
yngology, Military Medical Academy in Belgrade or at the
Department of Ear, Nose and Throat Diseases, Faculty of Med-
icine, University of Novi Sad, Clinical Center of Vojvodina. The
vocal pathologies were divided into structural (vocal fold polyps,
cysts, nodules, Reinke edemas, tumors), inflammatory (chronic
laryngitis, laryngopharyngeal reflux), neurologic (vocal fold pa-
ralysis), and functional (muscle tension imbalance) abnormalities.
The control group included 90 subjects (46 males and 44
females, mean age 40.60 ± 14.10 years) with no voice prob-
lems and with normal laryngeal findings.
The participants completed the 30-item questionnaire on their
own, including the overall rating of the severity of their voice
change, using 1 for mild dysphonia and 4 for severe dysphonia.
Internal consistency
Cronbach’s alpha coefficient was used to assess the internal con-
sistency of VHI-30. A value >0.9 was considered excellent, >0.8
good, and >0.7 satisfactory.27
Test-retest reliability
Fourteen patients with voice pathology and 14 control subjects
completed the test 2–3 weeks later for test-retest reliability. In-
terclass correlation coefficient (ICC) was used to estimate test-
TABLE 1.
Demographic Parameters of the Participants
Group Number Male
Patient groups 91 39
Structural 65 25
Inflammatory 8 8
Neurologic 11 1 10
Functional 7 5
Control 90 46
Abbreviation: SD, standard deviation.
retest reliability of the total VHI scores and the VHI subscales
(physical, functional, emotional).
Clinical validity assessment
To evaluate the clinical validity of the Serbian VHI-30, the total
VHI-30 scores and the scores from the three VHI-30 subscales
from 91 patients were compared with the scores from the control
group. The comparisons between genders and the estimation of
the overall grade of dysphonia were also done between the two
groups of participants. The mean VHI-30 scores were com-
pared between the patient and control groups using the Mann-
Whitney U test. The Kruskal-Wallis test was used to compare
item scores between groups of patients with different etiolo-
gies. The correlation between the total scores of the VHI-30 and
the patient’s self-perceived overall severity of dysphonia was es-
timated using the Spearman correlation coefficient (ρ). To
compare the total VHI-30 scores between male and female par-
ticipants, we used the Mann-Whitney U test.
Statistical analysis
The statistical analysis was performed using SPSS 21.0 soft-
ware (SPSS Inc., Chicago, Illinois).
RESULTS
Demographic characteristics of participants
Of 91 patients, 65 (71.4%) were diagnosed with structural, eight
(8.8%) with inflammatory, 11 (12.1%) with neurologic, and seven
(7.7%) with functional abnormality.
The demographic characteristics of the patient and control
groups are summarized in Table 1.
Internal consistency
Statistical analysis revealed excellent internal consistency for the
Serbian VHI-30 for the patient group (Cronbach’s α = 0.95) and
the control group (α = 0.91). Good internal consistency was also
obtained for the VHI-30 subscales in the patient group: physi-
cal (α = 0.88), functional (α = 0.88), and emotional (α = 0.88)
subscale. Satisfactory internal consistency was obtained for the
VHI subscales in the control group (physical α = 0.79, func-
tional α = 0.77, and emotional α = 0.78). Table 2 shows
summarized data for internal consistency for both the patient and
control groups.
Mean Age ± SD
Female (Range)
52 55.99 ± 14.64 (18–82)
40 53.09 ± 12.43 (18–75)
0 62.63 ± 16.27 (28–78)
32.81 ± 5.69 (24–39)
2 46.71 ± 18.71 (28–82)
44 40.60 ± 14.10 (17–80)
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Jelena Sotirović et al Adaptation and validation of the VHI-30 into Serbian 3

TABLE 2. TABLE 3.
Internal Consistency of the VHI-30 Subscales Test-retest Reliability of the Serbian VHI-30
Cronbach’s Alpha Cronbach’s Alpha ICC (95% CI) ICC (95% CI)
VHI Subscale (Patients) (Controls) VHI-30 Patients Controls
Physical 0.88 0.79 Physical 0.98 (0.96–0.99) 0.84 (0.51–0.95)
Functional 0.88 0.77 Functional 0.96 (0.89–0.98) 0.82 (0.44–0.94)
Emotional 0.88 0.78 Emotional 0.97 (0.92–0.99) 0.77 (0.27–0.92)
Total 0.95 0.91 Total 0.99 (0.98–0.99) 0.84 (0.50–0.94)
Abbreviation: ICC, interclass correlation coefficient.

Test-retest reliability
ICC indicated strong test-retest reliability for patients (ICC = 0.99)
and controls (ICC = 0.84) for VHI-30, as well as for physical,
functional, and emotional subscales of VHI-30. Summarized
results for test-retest reliability are shown in Table 3.
Validity and VHI item analysis
The mean VHI-30 scores in the patient group were compared
with the scores in the control group. The mean scores for all 30
items in the patient group were significantly higher than that in
the control group (Mann-Whitney U test, P < 0.001, Table 4).
None of the items had a mean difference equal or greater than
2.0, but four of them had a mean difference greater than 1.6.
Comparison of item scores between four patient groups of dif-
ferent etiologies (structural, inflammatory, neurologic, functional)
indicated no statistically significant differences (Table 5). Good
correlation was observed between the total scores of VHI-30 and
patients’ self-perceived overall severity of dysphonia (Spear-
man correlation coefficient ρ = 0.748, P < 0.001). Spearman
correlation coefficient also indicated good correlation between
VHI subscale scores (physical, emotional, and functional) and
self-perceived grade of dysphonia (Table 6). The total VHI-30
scores were also compared between male and female partici-
pants within the patient group. The average total VHI-30 scores
in male and female patients (38.22 and 51.84, respectively) were
statistically significantly different (Mann Whitney U test,
P < 0.001).
DISCUSSION
The VHI represents the degree of a patient’s self-perceived prob-
lems with his/her voice and sometimes does not correlate with
objective voice measures.28 The objective acoustic measures and
VHI give complementary data for pre- and posttreatment
evaluation.29 Principles for process of translation and cultural ad-
aptation for patient-reported outcome measures are summarized
by the Translation and Cultural Adaptation group.30

TABLE 4.
Mean Difference in Item Scores Between Dysphonic and Control Groups
VHI-30 Item Difference VHI-30 Item Difference VHI-30 Item Difference
F1 1.106 F11 0.967 P21 1.591
P2 0.9450 F12 0.995 F22 0.307
F3 1.168 P13 1.754 E23 1.361
P4 1.531 P14 1.633 E24 0.471
F5 1.205 E15 1.230 E25 0.703
F6 0.732 F16 0.933 P26 1.327
E7 1.317 P17 1.611 E27 0.423
F8 0.856 P18 1.118 E28 0.239
E9 0.821 F19 0.537 E29 0.438
P10 1.899 P20 1.525 E30 0.406

TABLE 5.
Mean Value of the VHI-30 Scores in Different Subsets of Patients
Group N Total Physical Functional Emotional
Structural 65 47.68 47.43 48.63 46.87
Inflammatory 8 27.94 28.56 27.19 30.81
Neurologic 11 41.27 41.05 39.45 41.86
Functional 7 58.43 60.43 53.36 61.79
Significance NS (P = 0.116) NS (P = 0.103) NS (P = 0.115) NS (P = 0.138)
Abbreviation: NS, nonsignificant.
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4 Journal of Voice, Vol. ■■, No. ■■, 2015
TABLE 6.
Correlation Between VHI-30 Score and Self-perceived
Grade of Dysphonia
VHI-30 Score ρ P
Total F 0.647 <0.001
Total P 0.771 <0.001
Total E 0.649 <0.001
Total VHI 0.748 <0.001
Abbreviation: ρ, Spearman correlation coefficient.
In the present study, which included 181 participants—91 pa-
tients with voice problems and 90 subjects with no voice
pathology—we evaluated psychometric properties of the Serbian
VHI-30 in detecting the impact of dysphonia on patient’s ev-
eryday life. Following videostroboscopic examination, 91 patients
were divided into four groups according to the etiology of ab-
normality: structural, inflammatory, neurologic, and functional.
Following the translation of English VHI-30 into Serbian and
back-translation into English, the Serbian VHI-30 showed good
test-retest reliability and internal consistency. Authors of the first
VHI-301 showed strong test-retest reliability for the total score
(0.92), as well as for the functional (0.84), emotional (0.92), and
physical (0.86) subscales. Our results also proved excellent test-
retest reliability for the total VHI-30 score (0.99), as well as for
the physical (0.98), functional (0.96), and emotional (0.97)
subscales. The overall Cronbach’s alpha coefficient was 0.95,
and for physical, functional, and emotional subscales was 0.88,
which proved valid internal consistency. Other authors also re-
ported good test-retest reliability and internal consistency of VHI
in different languages.17–20,23,31–34
As expected, the mean total scores of VHI-30 were signifi-
cantly higher in the vocal pathology group than in the control
group, thereby supporting the identification of voice patholo-
gy. This result is in agreement with other studies showing that
VHI offers valuable information in evaluation of patients with
vocal impairment.29,32,35
The most prominent difference between the VHI-30 scores
in the patient and control groups was found in the four state-
ments belonging to the physical domain. Those statements were:
People ask: ″What’s wrong with your voice?″; My voice sounds
creaky and dry; I feel as though I have to strain to produce voice;
The clarity of my voice is unpredictable. In other studies, the
patient group also reported the highest scores of VHI-30 in the
physical domain, while the functional and emotional domains
were less affected.17,18 These results point to the patient’s per-
ception during sound production as the most prominent problem
with voice change. On the other hand, the smallest difference
was found in the emotional domain, showing that although dys-
phonia represents significant handicap in everyday life, it is not
strongly associated with feeling annoyed, embarrassed, incom-
petent, or ashamed (items E27, E28, E29, E30).
While some authors found that the total scores of VHI-30 were
higher in the neurologic etiology group,17,31 our study did not
reveal any statistical differences between four subsets of pa-
tients based on disease etiology (structural, inflammatory,
neurologic, functional). Thus, according to our results, the VHI-
30 is not a valuable tool for the identification of the specific
etiology of dysphonia. Interestingly, while some authors report
VHI-30 scores to be unaffected by gender,17,21 our results show
that voice changes have greater subjective impact on female pa-
tients. Finally, we find that the total scores of VHI-30 show
significant correlation with participant’s self-perceived overall
rating of dysphonia, thereby supporting the validity of VHI-30
use in clinical practice. This is in agreement with another study.22
Various voice-disordered diseases manifest differently among
patients in different professional groups. Singers, teachers, sales
representatives, and other professional users of voice represent
a specific group of patients. Evaluation of dysphonia in every-
day and professional life in this particular subset of patients
demands special approach, bearing in mind significant
handicap.36,37
The Serbian VHI-10, a less time-consuming and therefore less
burdensome instrument for the evaluation of patients’ vocal dis-
ability, could be a subject of future validation.
CONCLUSIONS
The Serbian VHI-30 shows good internal consistency, test-
retest reliability, and clinical validity. This self-administered
questionnaire is a useful tool for evaluating patients’ percep-
tion of voice problems, allowing assessment of need and type
of treatment, as well as evaluation of treatment results. Admin-
istration of the Serbian VHI-30 will help reach a complete clinical
assessment of patients with dysphonia.
Acknowledgements
We sincerely thank Bosiljka Tasić, whose comments and sug-
gestions greatly improved the manuscript.
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Jelena Sotirović et al Adaptation and validation of the VHI-30 into Serbian 5

APPENDIX

Indeks glasovnog oštećenja VHI-30

Naredne izjave se često koriste u opisivanju uticaja izmene glasa na kvalitet života. Molimo Vas da ih pažljivo pročitate i potom što
iskrenije odredite njihovu učestalost u Vašem životu.

TABLE A1.
0—nikad, 1—skoro nikad, 2—ponekad, 3—skoro uvek, 4—uvek
F1 Drugi ljudi imaju poteškoća da me čuju zbog mog glasa. 0 1 2 3 4
P2 Ponestaje mi daha u toku govora. 0 1 2 3 4
F3 Ljudi imaju poteškoća da me razumeju u bučnoj prostoriji. 0 1 2 3 4
P4 Zvuk mog glasa se menja (varira) u toku dana. 0 1 2 3 4
F5 Moja porodica (ukućani) imaju poteškoća da me čuju kada ih dozivam. 0 1 2 3 4
F6 Koristim telefon redje nego što bih želeo/želela. 0 1 2 3 4
E7 Osećam se napeto u razgovoru sa drugim ljudima zbog svog glasa. 0 1 2 3 4
F8 Trudim se da izbegavam grupe ljudi zbog svog glasa. 0 1 2 3 4
E9 Čini mi se da ljude iritira moj glas. 0 1 2 3 4
P10 Ljudi me pitaju: „Šta nije u redu sa tvojim glasom?“ 0 1 2 3 4
F11 Zbog svoj glasa redje razgovaram sa prijateljima, komšijama i rodjacima. 0 1 2 3 4
F12 Ljudi u direktnom razgovoru traže da im ponovim šta sam rekao/rekla. 0 1 2 3 4
P13 Moj glas zvuči hrapavo i suvo. 0 1 2 3 4
P14 Osećam kao da moram da se naprežem da bih govorio/govorila. 0 1 2 3 4
E15 Smatram da drugi ne razumeju moj problem sa glasom. 0 1 2 3 4
F16 Moje teškoće sa glasom ograničavaju moj lični i društveni život. 0 1 2 3 4
P17 Jasnoća mog glasa je nepredvidiva. 0 1 2 3 4
P18 Trudim se da menjam svoj glas da bih zvučao/zvučala drugačije. 0 1 2 3 4
F19 Osećam se izostavljenim/izostavljenom iz razgovora zbog svog glasa. 0 1 2 3 4
P20 Ulažem veliki napor da bih govorio/govorila. 0 1 2 3 4
P21 Moj glas se pogoršava uveče. 0 1 2 3 4
F22 Manje zaradjujem zbog svog problema sa glasom. 0 1 2 3 4
E23 Moj problem sa glasom me uznemirava. 0 1 2 3 4
E24 Redje izlazim zbog svog problema sa glasom. 0 1 2 3 4
E25 Osećam se hendikepirano zbog svog glasa. 0 1 2 3 4
P26 Glas me izdaje usred govora. 0 1 2 3 4
E27 Nervira me kada mi drugi traže da im ponovim šta sam rekao/rekla. 0 1 2 3 4
E28 Stid me je kada mi drugi traže da ponovim šta sam rekao/rekla. 0 1 2 3 4
E29 Osećam se nesposobnim zbog svog glasa. 0 1 2 3 4
E30 Sramota me je zbog mog problema sa glasom. 0 1 2 3 4

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