Development and Standardization of Voice Symptom Scale (Voiss) in Hindi

Development and Standardization of voice symptom scale (VoiSS) in Hindi

Ku Poonam1, Himanshu Kumar2, Indranil chatterjee3, Bibhu Prasad Hota4, Akanksha Kumari5

1(Audiologist and speech language pathologist, Chhattisgarh, India)

2, 3, 4(Lecturer in Speech and Hearing, AYNIHH, ERC, Kolkata, India)

5(Post graduate trainee in speech and hearing, AYJNIHH, ERC, Kolkata, India)

ABSTRACT

Voice Symptom Scale (VoiSS) (Wilson et al., 2004) is a self rating questionnaire for voice evaluation. The objectives of the present study were to develop and standardize voice symptom scale (VoiSS) in Hindi and to measure its validity in clinical population along with test-retest reliability. This study was carried out in 30 participants with age range between 20 to 50 years.

The study included translation of the English version of Voice symptom Scale in Hindi and then comparison of all the parameters of the new developed Hindi (VoiSS) to English Voice symptom scale (VoiSS), GRBAS scale, real voice analysis and voice quality estimates. The results revealed significant correlation between the Hindi and English Voice Symptom Scale (VoiSS) and significantly high correlation between the Hindi Voice Symptom Scale (VoiSS) in test-retest condition (3 weeks after the test condition) on all parameters: emotion, physical, impairment, and total scores. The present study led to the conclusion that the validated versions of Voice

Symptom Scale – VoiSS for Hindi language, have confirmed psychometric properties, and it is specific for evaluation of individuals with voice disorders. It is sensitive enough to reflect the wide range of communication, physical symptoms and emotional responses implicit in adult dysphonia.

Key words: VoiSS, emotion, physical, impairment

INTRODUCTION

Voice is a laryngeal modulation of the pulmonary airstream, which is then further modified by the configuration of the vocal cord (Bracket, 1971). Generally, the mechanism for generating the human voice can be subdivided into three parts: the lungs, the vocal folds within the larynx, and the articulators (Zemlin, 1988). The human voice is capable of conveying not only complex thoughts but also subtle emotions. (Sataloff,1986). Aronson (1971) described the normal voice as one with pleasant quality and absence of noise or atonality, adequate pitch level as per age and sex, appropriate loudness and adequate variation in pitch and loudness that aid in expression of emphasis, meaning or subtleties of feelings of the person.

Unbridled changes in voice is caused by: extensive voice use without enough time for voice rest, to speak in high background noise, prolonged use of voice, age related structural changes in the larynx (presbyphonia), poor room acoustics, poor indoor air quality, poor speaking postures, and lack of appropriate technical aid such as voice amplifiers (Mattiske, Oates, & Greenwood,

1998). These loading factors can also be called “vocoergonomic factors” (Vilkman, 2004).

Other causes include improper dietary habits, medical conditions, stress, anxiety and psychological factors. Deviant voice qualities, inability to sustain phonation, vocal fatigue, pain during phonation and throat irritation are some of the reported voice problems resulting from these causes (Yiu, 2002; Boominathan et al., 2008). Voice Symptom Scale originated in an open-ended questionnaire. It was first developed and standardized in English by Deary, Wilson, Carding, Kenneth and Mackenzie (2003), which was further modified on 2004. Voice symptom scale is a valid and reliable patient based self assessment tool. Its final form consists of 30 items and 3 subscales: impairment (VoiSS-I), physical (VoiSS-P) and emotional (VoiSS-E). Each item had a 5 point, frequency-based response scale: 0 = never, 1 = occasionally, 2 = some of the time, 3 = most of the time, 4 = always (Wilson, Webb, Carding, Steen, MacKenzie, Deary, 2004). Subscale scores range from 0 to 60, 0 to 28 and 0 to 32, for VoiSS-I, VoiSS-P and VoiSS-E subscale respectively and total score ranges from 0 to 120 it measures general voice pathology. VoiSS includes related upper aerodigestive tract symptoms- e.g. throat clearing, blocked nose, phlegm, commonly associated with and also targets for therapeutic intervention (Wilson et al., 2004).

Voice disorder and its symptoms may not be informed though it is evident from clinical observation. Whereas open series questionnaire is important to detect these symptoms detailed by detailed measures with the clinical correlation and therefore is helpful for evaluation of voice disorder (hyperfunctional voice disorder). Most of the instruments that evaluate voice disorders were developed in English and were intended to be used in English speaking countries. There is a need to develop instruments to be used in countries where English is not spoken, because such questionnaires when used with the native speakers of Hindi will not yield exact results. There are widespread cases of hyperfunctional voice disorder in India, correlation between self rating by the patients, perceptual observation of the clinician and the instrument findings needs to be established for standard administration of the questionnaire.

The aim of the study was to develop and standardize a Voice Symptom Scale (VoiSS) in Hindi and to measure its validity in clinical population along with the test retest reliability. METHODOLOGY

Participants:

The study consisted of 30 participants (mean age = 37.06 years, SD = ± 6.35). The participants were further divided into two groups consisting of 15 were males (mean age = 38.2 years, SD =

± 6.84) and 15 were females (mean age = 35.93 years, SD = ± 5.82), between the age ranges of

20 to 50 years.

Inclusion criteria:

1. All of these participants were diagnosed with hyper-functional voice disorder (such as vocal nodule, vocal polyp, thickened vocal cord etc.), by ENT surgeon through clinical examination and Strobovideolaryngoscopy and detailed case history were taken.

2. All the participants were proficient in Hindi and English with a minimum literacy background of graduation, from same socio-economic condition.

3. None of the participants had any history of neurological, cognitive and physical disorders.

4. None of the participants had no any hearing or visual problem.

Tools:

1) Case history questionnaire.

2) Voice symptom scale (VoiSS) (Wilson et al., 2004)

3) GRBAS (Hirano, 1981) scale was used for objective assessment of voice parameters. A specific statistical measurement was used. These scores of 1 and 2 for ‘grade’, ‘roughness’, ‘breathiness’ but only fair agreement for ‘asthenia’ and ‘strain’. Scorers 1 and 3 had moderate agreement for all the components of GRBAS, and scorers 2 and 3 had moderate agreement for grade and breathiness and fair agreement for ‘roughness’, ‘asthenia’ and ‘strain’.

4) Dr. Speech software version 4 (Tiger DRS, Inc., 1998) (Haung, 1995) was used for real voice analysis and voice quality estimates measurement. An omnidirectional microphone (MAX CM-

903 Electret Condenser Microphone) was used for the purpose of recording. The following parameters of real voice analysis were habitual F0 (Habitual Fundamental Frequency), SD F0

(Standard Deviation Fundamental Frequency), Jitter, Shimmer, and NNE (Normalized Noise

Energy), and parameters of voice quality estimates were Hoarse, Harsh and Breathy measured by

Dr. Speech.

Procedure:

This study carried out in four consecutive and explorative phenomenons.

Phase I

Tranadaptation of VoiSS in Hindi by using ITC guideline 2013. The linguistic validation

(Guillemin, Bombardier & Beaton, 1993) of the English version of the Voice Symptom Scale

(VoiSS) (Wilson et al., 2004) into the Hindi version of Voice Symptom Scale (VoiSS) and its psychometric specification which is included the following steps:

(a) Translation :Original version of Voice Symptom Scale was (VoiSS) provided to five native

Hindi Speech Language Pathologists (SLPs) and adequate proficiency in English with at least three years of clinical experience. The five native speakers translated the English version into Hindi language separately. One final formatted version of the scale was compiled by speech language pathologist.

(b) Back Translation: Another five native Hindi Speech Language Pathologists (SLPs) with adequate proficiency in Hindi and English languages were asked for back translation of the pooled Hindi version to English to measure the homogeneity of the English version of VoiSS.

The Newly formed English VoiSS was correlated with English version of VoiSS by Chronbach

-α test which revealed α value of 0.82, thus confirming Hindi VoiSS to be valid.

Phase II

Construct validity

The developed Hindi version of VoiSS questionnaire was administered on subjects with hyperfuntional voice disorder and the test was scored by Likert scale: from 0 to 4 (0 = never, 1 = occasionally, 2 = some of the time, 3 = most of the time, 4 = always) for each parameter

(emotion, physical and impairment). The Hindi Voice Symptom Scale (VoiSS) and English

Voice Symptom Scale (VoiSS) were both administered on the participants and construct validity was achieved by correlating their parameters, which were, Emotion parameter of Hindi Voice

Symptom Scale (VoiSS) and English Voice Symptom Scale (VoiSS), Physical parameter of

Hindi Voice Symptom Scale (VoiSS) and English Voice Symptom Scale (VoiSS) Impairment parameter of Hindi Voice Symptom Scale (VoiSS) and English Voice Symptom Scale (VoiSS).

Phase III

Concurrent validity

Concurrent validity was measured by using Hindi VoiSS and other instrument: 1. GRBAS scores parameter that is Grade, Roughness, Breathiness, Asthenia, and Strain.

2. Real voice analysis measured through Dr. Speech software version 4.0, real voice analysis parameters are Habitual F0, SD, F0, Jitter, Shimmer and NNE.

3. Voice quality estimates measured through Dr. Speech software version 4.0, voice quality estimates parameters are hoarse, harsh and breathy.

Phase IV

Test – retest reliability

In order to evaluate the reproducibility or reliability of the Hindi Voice Symptom Scale (VoiSS),

Pearson’s correlation test was used. To check its test-retest reliability, the participants were again administered with the test, after three weeks from first administration of VoiSS-Hindi. The retest was done without informing the participants of the score of the previous test. There was intervening treatment between test and retest conditions.

RESULT AND DISCUSSION

The present study was aimed to develop and standardize VoiSS in Hindi and to measure its validity in clinical population along with test-retest reliability. The study was aimed to obtain a correlation of: i) Hindi version of VoiSS and English version of VoiSS, ii) Hindi version of

VoiSS and GRBAS scale, iii) Hindi version of VoiSS and real voice analysis using Dr. Speech, iv) Hindi version of VoiSS and voice quality estimates using Dr. Speech and v) Hindi VoiSS in test-retest condition after three weeks of first test condition. Data processing was done on excel spread sheet. Statistical analysis was done using measure of correlation coefficient by Pearson’s two-tailed test using SPSS software (Version 16).The obtained results are as follows: The mean values obtained were 12.23 (SD = ± 1.13) for Emotional VoiSS in Hindi and 12 (SD =

± 1.14) for Emotional VoiSS in English. It can be observed that the mean values for emotional parameter of both Hindi and English version of VoiSS are close to each other.

Table 1. Correlation between parameter of Emotional in both Hindi and English version of

Emotional VoiSS Hindi

Parameter Pearson Correlation(r) Sig. (2-tailed)(t) No.of participants

Emotional VoiSS English 0.876** 0.00 30

** mark showing a high correlation

This finding can be supported by Waaramaa, Palo, & Kankare (2014) where the authors investigated the effect of emotion on voice by EGG findings and concluded emotion affects voice in smaller degree. Females showed fewer significant variations than males. In a study by

Seehausen, Kazzer, Bajbouj, & Prehn (2012) the authors investigated the effect of negative emotion in voice. They found a lower sound intensity of voices, as well as heart rates were increased when answering the questions.

The mean values of scores of the physical parameter of VoiSS in Hindi and English versions for hyper-functional voice disorder population was depicted as 6.1 (SD = ± 0.88) and 6.3 (SD = ±

0.9) respectively. It can be observed that the mean values for physical parameter of both Hindi and English version of VoiSS are near to each other. Table 2. Correlation between parameter of Physical in both Hindi and English version of VoiSS

Physical VoiSS Hindi

Physical VoiSS English 0.659** 0.00 30

This finding can be supported by Stojanovic et al. (2012) where the authors found that the excessive use or misuse of voice by vocal professionals may result in symptoms such are husky voice, hoarse voice, total loss of voice, or even organic changes taking place on vocal folds-- minimal pathological lesions (MAPLs). Milutinovic & Bojic (1996) concluded that functional trauma is caused by excessive and improper use of the voice and may affect the speaking voice of nonprofessionals, but also the speaking and singing voice of vocal professionals. Alipour &

Karnell (2014) suggested that increase in supraglottic compression or excessive use of voice reduced ventricular width affecting voice quality.

The mean values of the impairment parameter of VoiSS in Hindi was obtained as 24.33 (SD = ±

3.69) and the mean value obtained for the same parameter in English VoiSS was found as 24.73

(SD = ± 3.73) for hyper-functional voice disorder population. It can be observed that the mean values for impairment parameter of both Hindi and English VoiSS are again close to each other.

Table 3. Correlation between parameter of Impairment in both Hindi and English version of

Impairment VoiSS Hindi

Impairment VoiSS English 0.881** 0.00 30

**mark showing a high correlation

Similar studies done on smokers by scoring with VHI in which authors concluded that functional and emotional scales of VHI in smokers showed better results (less handicap) than in nonsmokers. Trinite & Sokolovs (2014) investigated the VHI into Latvian language in which high internal consistency was observed among the Lat VHI total scale, functional, physical, and emotional scale in the patient group.

The mean values of the total scores of Hindi and English VoiSS for hyper-functional voice disorder population was depicted as values of mean were found to be: 0.353 (SD = ± 0.029) and

0.354 (SD = ± 0.029) respectively. It can be observed that the mean values for total scores of both Hindi and English version of VoiSS are close to each other.

Table 4. Correlation between total score of Hindi and English version of VoiSS

Total scores of VoiSS

Total score of VoiSS English 0.995** 0.00 30

Similar standardization was done on Validation of the Voice Handicap Index: 10 (VHI-10) into

Brazilian Portuguese (Costa, Oliveira, & Behlau, 2013). The authors achieved appropriate correlation between the total score in VHI. Bonetti & Bonetti (2013) concluded that intraclass correlation coefficient estimation was also high, for both total VHI and subscales (functional subscale, physical subscale, and emotional subscale). Zur et al. (2007) developed pediatric version of VHI, they concluded high correlation between the VHI and the pVHI. The pVHI provides a high internal consistency and test retest reliability for subscales of emotion, physical and impairment.

The mean values of emotional parameter of Hindi VoiSS and GRBAS scale parameter in hyperfunctional voice disorder population has been shown. The mean value were found to be 12.23

(SD = ± 1.13) for emotion parameter. Mean values for Grade, Roughness, Breathiness, Asthenia and Strain in GRBAS scale was found to be: 2.23 (SD = ± 0.43), 2.33 (SD = ± 0.47), 2.06 (SD =

± 0.58), 1.43 (SD = ± 0.72) and 1.66 (SD = ± 0.4) respectively.

Table 5. Correlation between parameter of Emotional of Hindi VoiSS and GRBAS scale parameters (Grade, Roughness, Breathiness, Asthenia, and Strain)

Emotional VoiSS

Parameter Pearson Correlation(r) Sig. (2-tailed)(t) No. of participants

Grade 0.308 0.097 30 Roughness -0.591** 0.001 30

Breathiness 0.231 0.291 30

Asthenia 0.625** 0.000 30

Strain 0.591** 0.001 30

This study can be supported by Nikolaou & Tsaousis (2002). They reported a significant correlation between emotional intelligence and strain. Landa, Lopez-Zafra, Berrios, & Aguilar-

Luzon (2008) found a differential effect of the emotional intelligence on strain. It clearly indicates that Emotional Intelligence, affects strain. The results of studies conducted by Oginska-

Bulik (2005) confirmed the role of emotional intelligence in perceiving occupational stress and preventing employees of human services (Teachers, nurses, probationary officers) from negative health outcomes. Jones, Carding, & Drinnan (2006) were the authors who observed that there was a high significant correlation between perceptual dysphonia severity as assessed by GRBAS and VoiSS questionnaire.

The mean value of physical parameter of Hindi VoiSS in hyperfunctional voice disorder population was depicted. The mean values were found to be: 6.1 (SD = ± 0.88) mean values for

GRBAS (Grade, Roughness, Breathiness, Asthenia and Strain) scale parameters are 2.23 (SD = ±

0.43), 2.33 (SD = ± 0.47), 2.06 (SD = ± 0.58), 1.43 (SD = ± 0.72) and 1.66 (SD = ± 0.4) respectively Table 6. Correlation between parameter of Physical of Hindi VoiSS and GRBAS scale parameters (Grade, Roughness, Breathiness, Asthenia, and Strain

Physical VoiSS

Grade -0.63 0.739 30

Roughness -0.163** 0.391 30

Asthenia 0.625** 0.000 30

Strain -0.325** 0.080 30

Similar standardization was done in factors predicting VHI (Senaris , Nunez, Corte, & Suarez

2006) where authors concluded that no parameter of GRBAS scale were found to predict the physical subscale. This study can also be supported by Gama, Alves, Cerceau, & Teixeira (2009) where the authors concluded that grade, roughness, breathiness are not statistically correlated with the physical V-RQOL.

Obtained scores of impairment parameter of Hindi VoiSS in hyperfunctional voice disorder population has depicted mean value of 24.33 (SD = ± 3.69). Mean values for GRBAS (Grade, Roughness, Asthenia and Strain) scale parameters are 2.23 (SD = ± 0.43), 2.33 (SD = ± 0.47),

2.06 (SD = ± 0.58), 1.43 (SD = ± 0.72) and 1.66 (SD = ± 0.4) respectively.

Table 7. Correlation between parameter of Impairment of Hindi VoiSS and GRBAS scale parameters (Grade, Roughness, Breathiness, Asthenia, and Strain)

Impairment VoiSS

Grade 0.405* 0.739 30

Roughness 0.305 0.391 30

Asthenia -0.235 0.000 30

Strain -0.110 0.080 30

This study supported by Jones, Carding, & Drinnan (2006) where the authors observed that there was a highly significant correlation between perceptual Dysphonia severities as assessed by

Grade and impairment subsets of the VoiSS questionnaire. Karnell et al. (2007) concluded that there was relatively weak agreement between patient-based and clinician-based scales. The mean value of emotional parameter of Hindi VoiSS in hyperfunctional voice disorder population was found to be 12.23 (SD = ± 1.13). Mean values for real voice analysis parameters:

Habitual F0, SD F0, Jitter, Shimmer and NNE are 209.82 (SD = ± 77.85), 0.63 (SD = ± 2.03),

3.62 (SD = ± 2.03), -7.15 (SD = ± 6.55), and 3.03 (SD = ± 1.63) respectively.

Table 8. Correlation between parameter of Emotional of Hindi VoiSS with real voice analysis parameters (Dr. Speech software): habitual F0, SD F0, jitter, shimmer and NNE.

Emotional VoiSS

Habitual F0 0.860** 0.000 30

SD F0 -0.179 0.344 30

Jitter -0.290 0.120 30

Shimmer 0.057 0.763 30

NNE -0.250 0.182 30

** mark showing a high correlation Micheal (1993) concluded that fundamental frequency is affected, by emotion (i.e. anger, fear, joy and disgust).

Emotions like anger will result in an increase of fundamental frequency. Anger affects high - frequency energy and downward - directed F0 contours. So the articulation rate increases. Fear also affects fundamental frequency, due to which mean fundamental frequency and high frequency range increases affecting articulation. Joy and disgust also increases mean fundamental frequency, high frequency also affecting articulation. Whereas the findings can also be supported by Williams & Stevens (1972) who attributed that a given emotional situation are not always consistent from one speaker to another.

The mean value of physical parameter of Hindi VoiSS in hyperfunctional voice disorder population was found to be 6.1 (SD = ± 0.88). Mean values for real voice analysis parameters:

Habitual F0, SD F0, Jitter, Shimmer and NNE are 209.82 (SD = ± 77.85), 0.63 (SD = ± 2.03),

3.62 (SD = ± 2.03), -7.15 (SD = ± 6.55), and 3.03 (SD = ± 1.63) respectively.

Table 9. Correlation between parameter of Physical of Hindi VoiSS with real voice analysis parameters (Dr. Speech software) habitual F0, SD F0, jitter, shimmer and NNE

Physical VoiSS

Habitual F0 -0.40 0.835 30

SD F0 -0.067 0.723 30

Jitter 0.169 0.371 30

Shimmer 0.129 0.496 30

NNE 0.58 0.760 30

Woisard, Bodin, Yardeni, & Puech (2007) observed that acoustic parameter such as jitter is never correlated with the physical subscale. Cho, Yin, Park, & Park (2011) concluded that in men, VHI, VRS, F0 tremor, shimmer, HNR, SNR, and amplitude tremor were related to mental fatigue. In women, only VHI was related to physical fatigue, and none of the acoustic parameters was related to the fatigue score. Perceptual evaluations were not related to fatigue in men or women, which suggests that self-rated symptoms and acoustic parameters related to voice quality are indicative of mental fatigue, and these features are prominent in men.

The mean value of impairment parameter of Hindi VoiSS in hyperfunctional voice disorder population was found to be 24.33 (SD = ± 3.69). Mean values for habitual F0, SD F0, Jitter,

Shimmer and NNE in real voice analysis parameters were carried out as 209.82 (SD = ± 77.85),

0.63 (SD = ± 2.03), 3.62 (SD = ± 2.03), -7.15 (SD = ± 6.55), and 3.03 (SD = ± 1.63) respectively.

Table 10. Correlation between parameter of Impairment of Hindi VoiSS with real voice analysis parameters of (Dr. Speech software): habitual F0, SD F0, jitter, shimmer and NNE.

Impairment VoiSS

Parameter Pearson Correlation(r) Sig. (2-tailed)(t) No. of participants Habitual F0 -0.80 0.674 30

SD F0 -0.011 0.953 30

Jitter -0.80 0.674 30

Shimmer -0.25 0.895 30

NNE 0.221 0.240 30

This study can be supported by Teixeira, Nunes, Coimbra, Lima, & Moutinho (2008) where authors concluded that variations in voice quality are essentially related to modifications of the glottal source parameters, such as: F0, jitter, and shimmer. Voice quality is affected by prosody, emotional state, and vocal pathologies.

The mean value of emotional parameter of VoiSS in Hindi for hyperfunctional voice disorder population was found to be 12.23 (SD = ± 1.13) whereas the mean values for hoarse, harsh and breathy voice were taken out to be 2.3 (SD = ± 0.46), 1.46 (SD = ± 0.62) and 1.73 (SD = ± 0.63) respectively.

Table 11. Correlation between parameter of Emotional of Hindi VoiSS and voice quality estimates parameter (Dr. Speech software version 4) (hoarse, harsh and breathy)

Emotional VoiSS Hindi

Parameter Pearson Correlation(r) Sig. (2-tailed)(t) No.of participants Hoarse 0.059 0.758 30

Harsh 0.180 0.340 30

Breathy 0.231 0.219 30

The mean value of physical parameter of Hindi VoiSS in hyperfunctional voice disorder population was found to be 6.1 (SD = ± 0.88) and mean values for voice quality estimates parameters were obtained for Hoarse was 2.3 (SD = ± 0.46), for Harsh 1.46 (SD = ± 0.62) and for Breathy was obtained as 1.73 (SD = ± 0.63).

Table 12. Correlation between parameter of Physical of Hindi VoiSS and voice quality estimates parameter (Dr. Speech software version 4) (hoarse, harsh and breathy.

Physical VoiSS

Hoarse -0.159 0.402 30

Harsh -0.149 0.433 30

Breathy 0.232 0.218 30

** mark showing a high correlation The mean value of Impairment parameter of Hindi VoiSS for hyperfunctional voice disorder population was carried out to be 24.33 (SD = ± 3.69) whereas the mean values for voice quality estimates parameters are 2.3 (SD = ± 0.46), 1.46 (SD = ± 0.62) and 1.73 (SD = ± 0.63) for

Hoarse, Harsh and Breathy respectively.

Table 13. Correlation between parameter of Impairment of Hindi VoiSS and voice quality estimates parameter (Dr. Speech software version 4) (hoarse, harsh and breathy)

Impairment VoiSS

Hoarse -0.060 0.753 30

Harsh 0.257 0.170 30

Breathy 0.126 0.506 30

The mean values of the emotional parameter of VoiSS in Hindi in first testing and second testing after 3 weeks interval for hyper-functional voice disorder population was found out to be 12.23

(SD = ± 1.13) and 12.2 (SD = ± 1.09) respectively. It can be observed that the mean values for emotional parameter of Hindi VoiSS at first testing and after three week testing are almost the same. Table 14. Correlation between parameter of Emotional of Hindi VoiSS in test-retest condition (3 week after the test condition)

Emotional VoiSS

Emotional VoiSS Hindi 0.765** 0.000 30

Test- retest reliability of Voice Handicap Index in Swedish language was done using singers

(Lamarche, Westerlund, Verduyckt, & Ternstrom, 2010). The author achieved appropriate correlation between the parameters (emotion, physical, impairment and total score) in test-retest condition. Xu et al. (2008) observed that the VHI total scores were significantly higher in dysphonic patients than in control subjects. This is also true for all VHI subscores in the functional, physical and emotional domains.

The mean values of the physical parameter of VoiSS in Hindi of first testing and second testing

(3 weeks after the test condition) for hyper-functional voice disorder population was found 6.1

(SD = ± 0.88) and 6.2 (SD = ± 1.22) respectively. It can be observed that the mean values for physical parameter of Hindi VoiSS at first testing and after three week testing are almost the same.

Table 15. Correlation between parameter of Physical of Hindi VoiSS in test-retest condition (3 week after the test condition) Physical VoiSS

Physical VoiSS Hindi 0.743** 0.000 30

Similar standardization was done in translation and adaptation of voice handicap index in Hindi.

Whereas, validity of Voice Handicap Index in Hindi language was done using voice disorder

(Datta, Sethi, Singh, Nilanketan, & Venkatesh, 2011). The author achieved appropriate correlation between the parameters (emotion, physical, impairment and total score) in both the versions of test in test- retest reliability. Lam et al. (2006) studied VHI in Chinese language, they concluded high test-retest reliability and high item-total correlation for both Chinese VHI-30 and

VHI-10.

The mean values of the impairment parameter of VoiSS in Hindi tested two times in 3 week interval for hyper-functional voice disorder population was found to be 24.33 (SD = ± 3.69) and

23.6 (SD = ± 4.82) for first and second test respectively. It can be observed that the mean values for impairment parameter of Hindi VoiSS at first testing and after three week testing are near to each other.

Table 16. Correlation between parameter of Impairment of Hindi VoiSS in test-retest condition

(3 week after the test condition) Impairment VoiSS

Impairment VoiSS Hindi 0.688** 0.000 30

Validity of Voice Handicap Index in Brazilian language was done using voice disordered population (Behlau, Alves, & Oliveira, 2011). The authors achieved high internal consistency and high test-retest reliability both for the overall VHI score and for the functional, physical, and emotional domains of the VHI in both the versions of test in test- retest reliability. Woisard,

Bodin, & Puech (2004) where the authors validated VHI in French language, they concluded that the test-Retest stability of the pathological subjects was found to be satisfactory for both total score and subscale scores.

The mean values of the total scores of VoiSS in Hindi (3 weeks interval) for hyper-functional voice disorder population was found to be 0.353 (SD = ± 0.029) and 0.354 (SD = ± 0.029) for first test and second test respectively.

Table 17.Correlation between parameter total score of Hindi VoiSS in test-retest condition (3 week after the test condition)

Total VoiSS Hindi

Parameter Pearson Correlation(r) Sig. (2-tailed)(t) No.of participants Total VoiSS Hindi 0.998** 0.000 30

Similar standardization was done in translation and adaptation of voice handicap index in Arabic.

Where, validity of Voice Handicap Index in Arabic language was done using voice disordered population (Saleem & Natour, 2010). The authors obtained strong Test-retest reliability. Malki,

Mesallam, Farahat, Bukhari, & Murry (2010) concluded that, the Arabic VHI showed a significant high internal consistency and reliability, high item-domain and domain-total correlation. Thus the referential attained VoiSS in Hindi is established to be used in the clinical population by speech language pathologist and laryngologist.

SUMMARY AND CONCLUSION

VoiSS is the most rigorously evaluated and psychometrically robust measure currently available for the self assessment of voice quality. Hindi version of Voice Symptom Scale

(VoiSS) developed in this study was a valid and reliable tool that can be applied to the Hindi-

Speaking population in India. This study implicated the use of Voice Symptom Scale (VoiSS) for the self assessment part of voice evaluation on voice disordered population. It can give us an idea of the patient’s perception of their voice disorder, and also help the clinician to understand the degree of emotional, physical and impairment of the patient to act accordingly, and not merely on the basis of the objective findings.

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