Quality of Life: Validation of the Brazilian Version of

the Voice-Related Quality of Life (V-RQOL) Measure

*,†Gisele Gasparini and *,†Mara Behlau São Paulo, Brazil

Summary. The purpose of this prospective study was to perform the Brazilian Voice-Related Quality of Life
(V-RQOL) version and to check its psychometric measurement properties and the relationship between vocal self-
assessment and the instrument’s scores. The translation and validation were performed following the guidelines of
the Scientific Advisory Committee of Medical Outcomes Trust. The instrument was administered to 234 patients,
114 with vocal complaints, and 120 without vocal complaints. The instrument was submitted to validation, reliability,
reproducibility, and responsiveness evaluation. Results showed that internal consistency was demonstrated with high
coefficient values (P < 0.001) and a statistically acceptable level of reliability (functioning 0.700; social-emotional
0.070; and total 0.108). Pre- and posttreatment results showed a significant responsiveness (Functioning 0.026; So-
cial-Emotional 0.006; and Total 0.008). The study concluded that the Brazilian version of the V-RQOL is valid, reliable,
and responsive to change and it can play an important role in the dysphonic patient’s voice evaluation.
Key Words: Voice–Quality of life–Validation–Translation–Dysphonia.

INTRODUCTION
Recently, the World Health Organization (WHO) broadened the
concept of health so that it includes the aspect of quality of life
in its definition of complete physical, mental, and social well
being.1 According to WHO, health and treatment outcome eval-
uation must include not only the indicators of severity and fre-
quency of disease, but also an estimate of well being, which can
be measured by evaluating the individual’s quality of life. This
organization defines ‘‘quality of life’’ as the individual’s percep-
tion of their position in life in the context of the culture and
value systems in which they live and in relation to their goals,
expectations, standards, and concerns.2,3 This is a broad con-
cept that may be affected in many different ways according to
the individual’s physical health, psychological state, level of
independence, social relations, and personal beliefs, as well
as environmentally related characteristics.1
Evaluation of quality of life is primarily conducted by means
of questionnaires, many of which were developed in English
and directed to the population that speaks this language.
Thus, for these instruments to be used in other languages,
they must be translated and adapted based on international
guidelines, and their measuring properties must be demon-
strated in a specific cultural context.4,5 The instrument must
be culturally adapted and carefully translated and tested, avoid-
ing literal translation that excludes cultural and social contexts.5
Instruments must be submitted to tests to prove their validity,
reliability, and responsiveness. Equally, such instruments must
be able to evaluate specific populations, for instance, patients
with cancer, war refugees, or even patients with certain disor-
ders such as dysphonia.6
Among several infirmities, dysphonia represents a difficulty
or deviation in the vocal production that impedes natural
Accepted for publication April 19, 2007.
From the *Human Communication Disorders Department, Universidade Federal de São
Paulo—UNIFESP, São Paulo, Brazil; and the yCEV—Centro de Estudos da Voz, São
Paulo, Brazil.
Address correspondence and reprint requests to Gisele Gasparini, CEV—Centro de Es-
tudos da Voz, Rua Machado Bittencourt, 361 10 andar, Vila Mariana, São Paulo, 04044-
001 Brazil. E-mail: giselegasparini@uol.com.br
Journal of Voice, Vol. 23, No. 1, pp. 76-81
0892-1997/$36.00
Ó 2009 The Voice Foundation
doi:10.1016/j.jvoice.2007.04.005
voicing.7 Most of the time it is a disorder that does not threaten
the individual’s life, and so treatment is elective.
Traditionally, epidemiological and physiological measures
have been used to evaluate treatment outcomes of voice devia-
tion. In ideal conditions, a dysphonic patient evaluation in-
cludes the patient’s history and a complete laryngological and
voice evaluation. However, these evaluations alone are not
able to quantify the patient’s voice problem. Sometimes, objec-
tive evaluation of dysphonia may present normal results,
whereas quality of life instruments and subjective analysis pro-
vide diverse information about the vocal difficulty.8 Even if
a vocal deviation could be precisely quantified, it would not
necessarily reflect the vocal disorder or the effect of its treat-
ment on the patient’s life. More recently, research has shown
the importance of including subjective parameters in voice eval-
uation. Consequently, the concept of voice-related quality of
life was developed.9
The choice of the voice-related quality of life (V-RQOL)
measure was based on the need for a voice-related quality of
life instrument translated into Brazilian Portuguese that was
well designed, with measurement properties such as validity, re-
producibility, and responsiveness to change demonstrated in
other research. Moreover, it is important to point out that the
V-RQOL has been widely used.7–10
Therefore, the purpose of this study was to perform the Bra-
zilian V-RQOL version and to demonstrate its measurement
properties so that it can be used as an instrument to evaluate
the quality of life of Brazilian patients with vocal complaints.
METHODS
The translation and measurement properties’ demonstration
were performed according to the Scientific Advisory Commit-
tee of Medical Outcomes Trust.11
The translation of the V-RQOL was performed by two bilin-
gual speech-language pathologists and English teachers, and
the back-translation was done by an English teacher who had
not participated in the previous stage. The three translators
were informed about the objective and procedure of the re-
search. A committee of five voice specialists revised the final
protocol. To evaluate cultural and linguistic equivalency, the
Gisele Gasparini and Mara Behlau Validation of Brazilian Version of V-RQOL 77

option ‘‘not applicable’’ was introduced to each item of the dysphonia, benign tumors, or laryngeal carcinoma, which are
questionnaire, which was then administered to 38 patients. pathologies caused by a series of processes that do not depend
None of the questions was shown to be invalid. on vocal behavior. A more detailed classification, such as the
After obtaining informed consent, the instrument was admin- CMVD-I proposal13 would probably offer a better clarification
istered to 234 individuals, 114 presenting with vocal complaints of the impact of a voice problem; however, the data were col-
(19 men and 95 women, aged between 18 and 79 years, mean of lected under a previously established academic configuration.
41.3 years) and to 120 individuals presenting with dermatolog- Patients with dermatological complaints were distributed
ical complaints (31 men and 89 women, aged between 16 and according to the dermatological diagnosis: acne, skin cancer,
75 years, mean of 43 years). Each patient also gave a self-rating alopecia, and aging.
of his/her voice quality using a Likert Scale with five items: To determine test-retest reproducibility, voice patients were
poor, fair, good, very good, or excellent. Nineteen patients administered the V-RQOL questionnaire a second time before
who underwent voice rehabilitation were administered a post- treatment. A typical and effective retest interval is usually
treatment V-RQOL questionnaire and also gave a posttreatment between 2 and 14 days. This period should be short enough
self-rating of voice quality. so that not many changes have occurred, but long enough that
The V-RQOL measure is a 10-item, disease-specific out- patients would not remember their answers.8
comes instrument for voice disorders (Appendix). It has Validity was determined by comparing V-RQOL scores to
a Physical Functioning domain (items 1,2,3,6,7,9) and a So- the self-rating of voice quality with the Kruskal-Wallis test. Pa-
cial-Emotional domain (items 4,5,8,10). Domain and total tients were grouped together for this analysis: one group which
scores are calculated using a standard algorithm. Scores may rated their voice as very good or excellent and the other which
vary from 0 to 100, with 0 indicating a very poor V-RQOL rated their voice as poor or fair. To determine internal consis-
and 100 an excellent one. tency, Cronbach’s alpha correlation coefficient was generated
Descriptive statistical analysis was used for clinical and de- and Wilcoxon matched-pairs signed-ranks test was performed
mographic characterization: age, gender, profession, type of de- to determine reproducibility. Responsiveness was evaluated
viation, and presence of vocal complaints. Individuals were by comparing pre- and posttreatment voice-quality ratings
distributed into five groups according to profession,10 accord- and the V-RQOL scores. Statistical Package for Social Sci-
ing to the significance of voice to their work-related or profes- ences, version 10.0, was used to perform all statistical analysis.
sional activities: levels I–V. Level I, elite vocal performer, The level of significance adopted was 5% (0.050).
includes most singers and actors; a slight voice deviation in
this group of professionals may have important consequences.
Level II, professional voice user, includes clergy, teachers, lec- RESULTS
turers, and receptionists; a moderate vocal deviation may im- Demographic characteristics were very similar between groups.
pair adequate professional practice. Level III, nonvocal V-RQOL scores according to the type of dysphonia, profes-
professional, includes lawyers, physicians, businessmen, and sional voice use, and self-assessment of voice quality for the
others; only a severe vocal deviation may compromise job per- voice patients group are shown in Table 1.
formance. Finally, level IV, nonvocal nonprofessional, includes
clerks, laborers, and others; vocal quality is not a prerequisite
for job performance, even in cases of severe vocal deviations. TABLE 1.
Persons from level IV may have important social and emotional Mean Total and Domain V-RQOL Scores by Diagnosis
impacts due to a voice problem, but the quality of their work is Category, Level of Professional Voice Use, and Self-
not affected by it. Another category, level V, was included for Assessment of Voice
retired and unemployed patients, students, and housewives.
Physical Social- V-RQOL
Patients with vocal complaints were also distributed accord- Variables Functioning Emotional Total
ing to the type of dysphonia based on the most widely used clas-
sification of voice problems in Brazil, proposed by Behlau Dysphonia
Functional 65.7 72.5 68.5
et al.12 The authors classify dysphonia in three major cate-
Organic-functional 61.1 70.9 64.9
gories, according to the degree of vocal behavior involvement
Organic 49.7 58.9 53.3
in the development of the voice problem: functional dyspho-
nias, organic-functional dysphonias, and organic dysphonias. Profession
The functional dysphonia category includes patients with a vo- Level I 75.0 56.3 67.5
cal deviation in which the vocal behavior is the basis of the Level II 59.4 75.9 66.2
Level III 59.7 75.0 66.3
voice problem, including purely behavioral cases, minor struc-
Level IV 65.3 72.2 68.0
tural changes, and psychogenic cases. The organic-functional Level V 62.6 68.3 64.8
dysphonia category includes patients with benign lesions de-
rived directly from vocal behavior, or if vocal behavior had Voice self-assessment
an important role in the genesis of the alteration, such as in Excellent/very good 84.2 92.5 87.5
Good 71.3 78.6 74.2
cases of nodules and polyps. Finally, organic dysphonia cate-
Fair/poor 59.4 67.4 62.7
gory includes patients with neurological and endocrinological
78 Journal of Voice, Vol. 23, No. 1, 2009

Validity Emotional domain score changed from 73.7 to 89.2

The domain and total scores of patients according to their self-
assessment of voice quality are shown in Table 2. There was
a highly significant difference in scores across the three cate-
gories. The subjects who rated their voice as either fair or
poor had an average V-RQOL Physical Functioning score of
59.4 (SD ¼ 22.55), an average V-RQOL Social-Emotional
score of 67.42 (SD ¼ 26.16), and an average V-RQOL Total
score of 62.67 (SD ¼ 21.53). Although patients who rated their
voice as good had mean scores around 11 points higher than
those who rated their voice as Fair or Poor, patients who rated
their voice as very good or excellent had an average score of
24 points higher. The two groups of voice and nonvoice patients
presented statistically significant differences according to self-
assessment of voice quality across the three categories of the
questionnaire. The instrument discriminates well between the
two groups, because patients with vocal complaints had scores
statistically lower than patients with dermatological com-
plaints.
Reliability
Reliability data are displayed in Table 3. Internal consistency of
the instrument was determined with a statistically high Cronba-
ch’s alpha coefficient (P < 0.001). The Cronbach’s alpha coeffi-
cient for the Physical Functioning domain was 0.962, for the
Social-Emotional domain was 0.964, and for the Total score
was 0.969. Comparison of test-retest results was done by the
Wilcoxon Matched-Pairs Signed-Ranks Test, which showed
an acceptable level of reproducibility (Physical Functioning do-
main 0.700; Social-Emotional domain 0.070; and Total score
0.108).
Responsiveness
The changes after voice treatment in the scores of the V-RQOL
are shown in Table 4. There were significant differences across
all domains between average V-RQOL scores pre- and post-
treatment. The mean Physical Functioning domain score
changed from 66.5 to 77.2 (P ¼ 0.026), the mean Social-
(P ¼ 0.006), and the mean Total score changed from 69.5 to
81.9 (P ¼ 0.008).
DISCUSSION
Quality of life is an ample and complex concept that involves
subjective and multidimensional aspects, including positive
and negative elements of the individuals’ evaluation accord-
ing to their position in life, their level of job satisfaction,
familial and social life, environment, general health, psy-
cho-emotional and physical conditions, and their functional
competence.1
The term ‘‘quality of life’’ values, in a broad way, aspects that
are not usually considered as health, including income, free-
dom, and environmental quality, and above all, the individual’s
perception of medical and nonmedical aspects of her life and of
the impact of a chronic disease or a specific treatment.3,9,10
Even though epidemiological or physiological measures
have traditionally been used to assess treatment outcomes, re-
cent research has shown the importance of including subjective
parameters in this process. Thus, quality of life assessment is
necessary, not only to set guidelines for medical practice
when evaluating treatment outcomes, but also to demonstrate
the effectiveness and performance of new and emergent ad-
vances, increasing the efficiency of quality monitoring systems
and consequently, enhancing professional practice in the health
field.10,14
The development and validation of instruments that measure
quality of life became an important focus of different areas
within the health field, and during the two last decades, several
instruments of treatment outcome and quality of life measure
have been developed.4,15 Such instruments must be submitted
to evaluation in different situations so that their property mea-
sures may be demonstrated.
The Scientific Advisory Committee of Medical Outcomes
Trust11 conceives and publishes guidelines to aid the develop-
ment and validation of those instruments. The committee is

TABLE 2.
Mean Total and Domain V-RQOL Scores of Voice Group (N ¼ 120) and Nonvoice Group (N ¼ 114) with Respect to Patient
Self-Assessment of Voice Quality for Validity Demonstration
Self-Assessment

Excellent/Very Good Good Fair/Poor

Group and Scores Mean SD Mean SD Mean SD Significance (P)

Voice group
Physical Functioning 84.2 10.8 71.3 21.2 59.4 22.6 0.007
Social-Emotional 92.5 13.5 78.6 25.1 67.4 26.2 0.030
Total 87.5 11.2 74.2 21.2 62.7 21.5 0.008
Nonvoice group
Physical Functioning 97.9 3.5 97.3 4.1 96.1 4.2 0.168
Social-Emotional 99.4 1.9 99.6 1.9 99.0 3.3 0.670
Total 98.5 2.4 98.2 2.8 97.3 2.7 0.091
Note: Kruskal-Wallis Test.
Gisele Gasparini and Mara Behlau Validation of Brazilian Version of V-RQOL 79

ing patients with voice deviation led to the development

TABLE 3.
Reliability Data for V-RQOL Measure: Internal
of voice-related quality of life measurement instruments,
Consistency for Domain and Total Scores and was the primary motivation for the execution of this
study.8,10
Cronbach’s The V-RQOL measure was chosen to be validated in Brazil-
Scores Alpha Coefficient Significance (P)
ian Portuguese because it is an instrument specifically devel-
Physical Functioning 0.962 <0.001 oped to evaluate the impact of a voice disorder on the
Social-Emotional 0.964 <0.001 individual’s life, and it has already demonstrated its validity, re-
Total 0.969 <0.001 liability, and responsiveness. Moreover, it is an instrument that
has been widely used.8–10,12
The population of this study consisted of adults with mean
dedicated to helping research groups around the world analyze age of 41 years, predominantly female (voice group 95%–
new instruments, and its activities played an important role in 83% and nonvoice group 88%–73%). Although the majority
the execution of scientific research on the addressed issue. of the participants of the vocal complaint (61%–51%) and der-
Most instruments of quality of life assessment are almost ex- matological complaint (61%–54%) groups were in the level V
clusively developed in the English language.11 Therefore, the group according to their professional voice use (retired people,
instrument must be translated according to the pre-established housewives, etc), there was a great percentage of the individuals
guidelines provided in the literature for use in other languages. in levels II (15%–13.2%) and III (12%–11%) with voice com-
The instruments must not only be translated, but also have their plaints, among whom a moderate and severe voice deviation,
psychometric measures tested in a specific cultural context.4,11 respectively, would interfere in their professional functioning.
Because quality of life is a representation of social and cul- Generally, women with vocal complaints had lower V-RQOL
tural constructs, it is conveyed by means of language, which scores than men, independent of the type of dysphonia, profes-
is the responsible element of social interaction for its subjective sional voice use, and self-assessment of voice quality (Table 1).
constitution and knowledge source and its human action over Although organic dysphonia showed greater impact on individ-
the world. The human voice is fundamental in oral communica- uals’ quality of life with the lowest scores (Physical Function-
tion and in interpersonal relations and thus, it is part of the ing domain 49.66; Social-Emotional domain 58.88; and Total
constant language movement and human socialization. There- score 53.33), functional (Physical Functioning domain 65.70;
fore, voice problems may create suffering, difficulties, lim- Social-Emotional domain 72.48; and Total score 68.51) and or-
itations, and restriction in the physical, psycho-emotional, ganic-functional (Physical Functioning domain 61.12; Social-
and professional scopes, impacting the individual’s quality of Emotional domain 70.85; and Total score 64.92) dysphonias
life.8 also showed reduced values. The greater impact of the organic
Historically, the evaluation of a voice disorder and the choice dysphonias may be due to the fact that they often present lim-
of a particular treatment has not been a simple and straightfor- ited prognosis, and treatment options are restricted and more
ward task. There is no universal index of vocal function, and aggressive, as in cases of neurological or head and neck cancer
even if the degree of a certain dysphonia could be precisely dysphonias.
measured, it would not necessarily reflect the impact of the The Brazilian version of the V-RQOL performed well in the
disorder or the impact of a specific treatment on the individual’s study patient population that presented a large range of voice
life.12 Hence, general medical issues and difficulties in evaluat- disorders. Tables 3 and 4 show that measures of reliability
and reproducibility are strong for the different V-RQOL scores.
Instrument validity is demonstrated by the robust relationship
between self-assessment of voice and mean V-RQOL scores
TABLE 4. and by the great difference between the results of voice and
Reliability Data for V-RQOL Measure: Test-Retest
nonvoice patients (Table 2).
Reproducibility for Domain and Total Scores
Because one of the purposes of the V-RQOL measure is to
Significance evaluate treatment outcomes, it is important to consider in
Scores Minimum Maximum Mean SD (P) this validation process the responsiveness to change. The Bra-
Physical Functioning zilian V-RQOL version is able to assess treatment outcomes,
Test 8.3 100.0 62.7 22.8 0.700 because it is sensitive to the changes promoted by the proposed
Retest 4.2 100.0 63.0 23.6 voice therapy program. Domain and Total scores showed signif-
Social-Emotional icant differences in answers pre- and posttreatment (Table 5).
Test 0.0 100.0 70.6 26.2 0.070 The pre- and posttreatment results display an evident relation-
Retest 0.0 100.0 72.3 26.5 ship between degree of voice improvement and change in
V-RQOL scores. Although changes after treatment are not dif-
Total
Test 8.0 100.0 65.9 22.0 0.108
ficult to observe, and in fact, are obvious, it is hard to establish
Retest 5.0 100.0 66.9 22.5 minimum values of change, both clinically and psychometri-
cally, in the patient’s quality of life. Larger study populations
Note: Wilcoxon Matched-Pairs Signed-Ranks Test.
are necessary to determine such values.
80 Journal of Voice, Vol. 23, No. 1, 2009

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Gisele Gasparini and Mara Behlau Validation of Brazilian Version of V-RQOL 81

Appendix