See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/6167566

Creation and Validation of the Singing Voice Handicap Index

Article  in  The Annals of otology, rhinology, and laryngology · June 2007

DOI: 10.1177/000348940711600602 · Source: PubMed

CITATIONS READS

148 4,074

8 authors, including:

Seth M Cohen Barbara Jacobson

Duke University Vanderbilt University
108 PUBLICATIONS   3,846 CITATIONS    19 PUBLICATIONS   3,716 CITATIONS   

SEE PROFILE SEE PROFILE

Michael G Stewart Albert Attia

Weill Cornell Medical College Vanderbilt University
66 PUBLICATIONS   3,528 CITATIONS    102 PUBLICATIONS   1,842 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Inverse Problems in Tumor Growth View project

Practical Guides View project

All content following this page was uploaded by Seth M Cohen on 04 June 2014.

The user has requested enhancement of the downloaded file.

Annals of Otology, Rhinology & Laryngology 116(6):402-406.
© 2007 Annals Publishing Company. All rights reserved.

Creation and Validation of the Singing Voice Handicap Index

Seth M. Cohen, MD, MPH; Barbara H. Jacobson, PhD; C. Gaelyn Garrett, MD;
J. Pieter Noordzij, MD; Michael G. Stewart, MD, MPH; Albert Attia;
Robert H. Ossoff, DMD, MD; Thomas F. Cleveland, PhD

Objectives: We developed and validated a disorder-specific health status instrument (Singing Voice Handicap Index;
SVHI) for use in patients with singing problems.
Methods: Prospective instrument validation was performed. Of 81 original items, those with poor statistical validity
were eliminated, resulting in 36 items. The ability to discriminate dysphonic from normal singers, test-retest reliability,
internal consistency, and construct validity were assessed.
Results: We included 112 dysphonic and 129 normal singers, professional and nonprofessional, of classical, country,
rock, choral, and gospel repertoire. Dysphonic singers had worse SVHI scores than normal singers (p <, .001, rank sum
test). Test-retest reliability was high (Spearman correlation, 0.92; p < .001). Internal consistency demonstrated a Cron-
bach's a of .97, and the correlation between the SVHI and self-rated singing voice impairment was .63 (p < .001, Spear-
man correlation).
Conclusions: The SVHI is a reliable and valid tool for assessing self-perceived handicap associated with singing prob-
lems.
Key Words: larynx, quality oflife, singing, voice.

INTRODUCTION population's vocal health needs.

Various health instruments have been designed However, current voice-related health instru-
to measure the impact of voice problems on patient ments do not adequately address the voice prob-
quality of life and the consequent level of handi- lems in the singing population. Because few ques-
cap.'"^ The World Health Organization defines a tions are specifically related to singing, current in-
handicap as a social, economic, or environmental struments may not be sensitive enough to measure
disadvantage resulting from a disability or lack of the impact of voice problems in singers.'-^'^ in addi-
ability to perform a daily task.^ Prior reports have tion, current instruments have not been directly vali-
demonstrated that voice disorders adversely impact dated in the singing population.''^-^ Consequently,
patients' lives, specifically their physical, social, this study's objective was to develop and validate
emotional, and economic function.^"^ a disorder-specific health status instrument (Sing-
ing Voice Handicap Index; SVHI) for use in singers
Singers represent a unique patient population. with voice problems.
Phyland et al'^ found that compared to nonsingers,
singers were at a high risk for voice impairment and METHODS
had more self-reported voice problems and more vo- Approval was obtained from the Institutional Re-
cal disability. Furthermore, voice problems and their view Board of Vanderbilt University Medical Cen-
impact upon the individual may differ between sing- ter. A preliminary questionnaire containing 81 items
ers and nonsingers. Singers may be more sensitive was developed. The items were based upon symp-
to voice changes and more likely to seek medical at- toms reported by. singers presenting to the voice
tention. "^"'^ Thus, measuring the patient-perceived clinic and the experience of laryngologists, speech-
dysfunction resulting from voice problems in sing- language pathoiogists, and a vocal pedagogue. Items
ers is essential to understanding and addressing this were conceptually chosen to address the physical.
From the Division of Otolaryngology-Head and Neck Surgery, Duke Voice Care Center, Duke University Medical Center, Durham,
North Carolina (Cohen); the Vanderbilt Voice Center, Vanderbilt University Medical Center (Jacobson. Garrett. Ossoff. Cleveland),
and the Department of Otolaryngology—Head and Neck Surgery, Vanderbilt University School of Medicine (Attia), Nashville, Ten-
nessee; the Department of Otolaryngology-Head and Neck Surgery, Boston University, Boston, Massachusetts (Noordzij); and the
Department of Otorhinolaryngology, Weill Medical College of Cornell University, New York. New York (Stewart).
Presented at the meeting of the American Laryngological Association, San Diego, California, April 26-27,2007.
Correspondence: Seth M. Cohen, MD, MPH, DUMC Box 3805, Durham, NC 27710.

402
 Cohen et al. Singing Voice Handicap Index 403

TABLE 1. SINGING VOICE HANDICAP INDEX

These are statements that many people have used to describe their singing
iingmg and the effects of their singing on their lives. Circle the re
sponse that indicates how frequently you have had the same experience
;nce in the last month.
1) It takes a lot of effort to sing. never almost never sometimes almost always always
2) My voice cracks and breaks. never almost never sometimes almost always always
3) I am frustrated by my singing. never almost never sometimes almost always always
4) People ask "What is wrong with your voice?" when I sing. never almost never sometimes almost always always
5) My ability to sing varies day to day. never almost never sometimes almost always always
6) My voice "gives out" on me while 1 am singing. never almost never sometimes almost always always
7) My singing voice upsets me. never almost never sometimes almost always always
8) My singing problems make me not want to sing/perform. never almost never sometimes almost always always
9) 1 am embarrassed by my singing. never almost never sometimes almost always always
10) 1 am unable to use my "high voice." never almost never sometimes almost always always
11)1 get nervous before I sing because of my singing problems. never almost never sometimes almost always always
12) My speaking voice is not normal. never almost never sometimes almost always always
13) My throat is dry when I sing. never almost never sometimes almost always always
14) I've had to eliminate certain songs from my never almost never sometimes almost always always
singing/performances.
15) I have no confidence in my singing voice. never almost never sometimes almost always always
16) My singing voice is never normal. never almost never sometimes almost always always
17) 1 have trouble making my voice do what I want it to. never almost never sometimes almost always always
18) 1 have to "push it" to produce my voice when singing. never almost never sometimes almost always always
19) I have trouble controlling the breathiness in my voice. never almost never sometimes almost always always
20) I have trouble controlling the raspiness in my voice. never almost never sometimes almost always always
21)1 have trouble singing loudly. never almost never sometimes almost always always
22) I have difficulty staying on pitch when 1 sing. never almost never sometimes almost always always
23) I feel anxious about my singing. never almost never sometimes almost always always
24) My singing sounds forced. never almost never sometimes almost always always
25) My speaking voice is hoarse after I sing. never almost never sometimes almost always always
26) My voice quality is inconsistent. never almost never sometimes almost always always
27) My singing voice makes it difficult for the audience to never almost never sometimes almost always always
hear me.
28) My singing makes me feel handicapped. never almost never sometimes almost always always
29) My singing voice tires easily. never almost never sometimes almost always always
30) 1 feel pain, tickling, or choking when I sing. never almost never sometimes almost always always
31)1 am unsure of what will come out when I sing. never almost never sometimes almost always always
32) 1 feel something is missing in my life because of my never almost never sometimes almost always always
inability to sing.
33) I am worried my singing problems will cause me to never almost never sometimes almost always always
lose money.
34) I feel left out of the music scene because of my voice. never almost never sometimes almost always always
35) My singing makes me feel incompetent. never almost never sometimes almost always always
36) I have to cancel performances, singing engagements, never almost never sometimes almost always always
rehearsals, or practices because of my singing.

emotional, social, and economic impact of singing
voice problems. Because we wanted to ensure that
items in the final version were as clear as possible,
some of the preliminary items were reworded ver-
sions of other items. Patients were asked to note the
frequency of their experience for each item of the
questionnaire. Each item was individually scored on
a 5-point Likert scale anchored by "never" (score of
0) and "always" (score of 4).
The preliminary questionnaire was administered
to 86 consecutive new patients, all singers. Singing
style and professional status were noted. The inter-
nal consistency of the preliminary questionnaire was
determined by Cronbach's a. The item-total correla-
tions were calculated for all 81 items and, much as in
prior studies, items with low item-total correlations
of less than 0.6 were eliminated, as these items min-
imally contributed to the internal reliability of the
overall questionnaire.'-^ Of redundant items, those
with the lower item-total correlation were also elim-
inated. Associations between sex and item response
was assessed with y} statistics, to compare the fre-
quency of a positive response (2 to 4) versus a nega-
tive response (0 or 1) between men and women.
The final version, the SVHI, had 36 questions
(Table 1). The raw total scores ranged from 0 to 144,
404 Cohen et al, Singing Voice Handicap Index

TABLE 2. CHARACTERISTICS OF INITIAL TABLE 3. CHARACTERISTICS OF FINAL

PATIENT COHORT PATIENT COHORT
Percent Percent
Income Singing primary source 31.4 Income Singing primary source 28.6
Singing secondary source 23.3 Singing secondary source 27.8
Singing not source 46.5 Singing not source 44.6
Singing style* Country 38.4 Singing style* Country 39.3
Classical 38.4 Classical 36.6
Choral 40.7 Choral 50.0
Pop 27.9 Pop 36.6
Rock 34.9 Rock 27.7
Gospel. 47.7 Gospel 50.0
Singing status Professional 50.0 Singing status Professional 53.5
Student 26.7 Student 23.2
Singing teacher 11.6 Singing teacher 13.4
Amateur 34.9 Amateur 30.4
*Patients may have more than one singing style. *Patients may have more than one singing style.

with the higher number representing more self-per-
ceived handicap. The raw scores were scaled from
0 to 100 by multiplying the raw total score by 100
and then dividing by 144 to produce the final SVHI
score. To determine the number of factors or sub-
scales, we performed principal component analysis
by the Quartimax and Varimax methods (SPSS Inc,
Chicago, Illinois).
The SVHI was administered to a second, consec-
utive group of 112 new patients, all singers. Again,
the diagnosis, singing style, and professional status
were determined. This final version was completed
at the initial presentation, and a second copy was
mailed 1 week after the initial patient visit. This tim-
ing was chosen so that the patients' vocal health state
would not have changed and also so they would not
remember their initial answers. The test-retest reli-
ability was determined by a Spearman correlation.
The validity was determined in several ways. In
addition to the SVHI, the 112 patients also self-rat-
ed the severity of their singing problems on a 10-
cm horizontal visual analog scale (VAS) anchored
at 0 by "not a problem" and at 10 by "severe prob-
lem." Correlation between the SVHI and VAS was
assessed with the Spearman correlation. The VAS
scores were also divided into 3 severity categories
(group 1, scores of 0 to the 25th percentile; group 2,
the 25th percentile to the 75th percentile; group 3,
the 75th percentile to the highest score). By an anal-
ysis of variance, the SVHI scores from each severity
category were compared.
Furthermore, singers who denied having any
problems with their voice and had not sought med-
ical care because of a voice problem were identi-
fied from professionals, amateur singing students,
choirs and amateur singing groups, and singing
teachers. This control group consisted of 129 sing-
ers who anonymously completed the SVHI. To de-
termine the ability of the SVHI to discriminate be-
tween singers with voice problems and singers with-
out voice problems, a ^test was used to compare the
SVHI scores of the singing patients and the control
group. Statistical analysis was performed with Sig-
maStat 2.03 (SPSS Inc).
RESULTS
The initial questionnaire of 81 items was com-
pleted by 86 consecutive new singing patients. The
mean age was 34 years with a range of 14 to 66
years; 39.5% were male and 60.5% were female.
The characteristics of this initial cohort are repre-
sented in Table 2.
The Cronbach's a of the preliminary question-
naire was .97. Two items with item-total correla-
tions of less than 0.6 were retained because of face
validity; they concerned performance cancellation
and the economic impact of the singing problem.
Four items for which more than 50% of the patients
answered "never" were eliminated. Three redundant
items were also removed. As a result, the final ver-
sion ofthe SVHI contained 36 items. No association
between item response and sex was identified for
any of the retained items (p > .2, x^).
The final SVHI was completed by a second co-
hort of 112 consecutive new patients, all singers.
The mean age was 35.3 years with a range of 16
to 67 years; 40.2% were male and 59.8% were fe-
male. The patients had had problems with their sing-
ing voice for a mean of 16.4 months (range, 1 week
to 120 months). Patient characteristics are shown in
Table 3, and diagnoses in Table 4.
The principal component analysis found that the
 Cohen et al. Singing Voice Handicap Index
TABLE 4. DIAGNOSES OF FINAL PATIENT COHORT
Diagnosis*
Benign vocal fold lesiont
Muscle tension dysphonia
Chronic laryngitis
Acute laryngitis
Vocal fold edema
Laryngopharyngeal reflux
Spasmodic dysphonia
Superior laryngeal nerve palsy
Recurrent laryngeal nerve palsy
*Patients may have more than one diagnosis.
tincludes polyps, cysts, pseudocysts, nodules, and sulcus.
items loaded on a single factor that explained 51.5%
of the variance. Hence, the SVHI was scored as a
single scale. The test-retest reliability was assessed
by having the patients complete the SVHI at 2 points
in time. Half of the patients completed the second
SVHI a mean of 17.3 days (SD, 9.5 days) after the
first SVHI. The test-retest reliability was .92 (p <
.001, Spearman correlation). The critical difference
score (95% confidence interval for the difference of
the mean SVHI scores at the two time points) was
14. Cronbach's a for the final version of the SVHI
was .97.
The construct validity was evaluated by compar-
ing the SVHI scores to patients' self-rated severity
of singing problems on a VAS. The correlation be-
tween the VAS and SVHI was 0.63 (p < .001, Spear-
man correlation). Additionally, the SVHI scores
from the 3 severity categories (group 1, mean [±SD]
25.7 ± 14.7; group 2, 40.8 ± 17.3; group 3, 64.8 ±
20.5) based upon the VAS were statistically signifi-
cantly different (p < .001, analysis of variance; p <
:.O5, Bonferroni f-test; for all group comparisons).
To determine the discriminant validity, we had
129 singers who denied having a problem with their
singing voice and had not sought medical care for
a voice problem complete the SVHI. Three fourths
of this control group were classical singers, and the
rest were country, choral, pop, rock, or gospel sing-
ers. One third said singing was either a primary or
secondary income source, with one fifth being pro-
fessional singers and the remainder students, sing-
ing teachers, or amateurs. Compared to the 112 sing-
ing patients, the control group of singers had lower
SVHI scores: a median of 22 versus a median of 61
(p < .001, rank sum test). Because the singing pa-
tients were more likely to be professional, more of-
ten used singing as a primary or secondary source
of income, and were less likely to be classical sing-
ers, the SVHI scores were compared within the sub-
groups of professional, income, and classical sing-
ing status. The patients' SVHI scores were twice the
405
control group's SVHI scores regardless of profes-
Percent sional, income, or classical singing status (p < .001,
43.7 rank sum test).
37.5
DISCUSSION
12.5
8.9 Singers have demanding voice needs and are at
8.9 risk for developing voice problems that lead to med-
5.4 ical evaluation and treatment. Measuring the im-
1.8 pact of singing voice problems from the patient's
1.8 perspective will facilitate the evaluation and man-
1.8 agement of patients who sing vocationally or avo-
cationally. Hence, this study's objective was to cre-
ate and validate a health status instrument for use in
singers.
Current knowledge of the impact of singing prob-
lems is limited by the available health status in-
struments. Rosen and Murry" and Behrman et al'^
found that singers had lower Voice Handicap Index
(VHI) scores than nonsingers. Several hypotheses
may explain this finding. Singers' voice problems
may differ from those of nonsingers, and singers
may be more sensitive to voice changes and thus
present earlier." However, the VHI does not ad-
dress limitations that result from singing voice prob-
lems. Because the VHI may not be sensitive enough
for use in singers, important handicaps experienced
by singers may go unmeasured and unnoticed. Ad-
ditionally, the singing voice might be more suscep-
tible to various medical disorders such as reflux or
allergies, but their influence on the singing voice
may not be adequately measured on questionnaires
that primarily focus on the speaking voice.''•'•^ Thus,
having a voice-related instrument that assesses sing-
ing voice impairment and the resultant handicap is
a necessary component of diagnosis for singers with
vocal difficulties.
The SVHI can be a valuable tool for measuring the
handicap resulting from singing voice impairment.
Morsomme et al'^ recognized the lack of an instru-
ment for assessing the singing voice and adapted the
VHI to singers. Their questionnaire was developed
and evaluated in 37 dysphonic classical singers and
has only been published in French. In contrast, our
study used a larger cohort of patients. Moreover, the
SVHI was validated across a diverse group of sing-
ers with various causes of handicap, singing styles,
and professional status. Hence, the SVHI has wide
application to singers with different kinds of train-
ing, styles, and voice disorders.
The SVHI has important psychometric proper-
ties. To ensure the content validity, we selected the
individual items according to patient report and the
expertise of laryngologists, speech pathoiogists, and
a vocal pedagogue experienced in caring for sing-
406 Cohen et al. Singing Voice Handicap Index
ers. Items were chosen to conceptually evaluate the
physical, emotional, economic, and social impact
of singing voice problems. The SVHI demonstrat-
ed high internal consistency and high test-retest re-
liability. Hence, the SVHFs inherent, random vari-
ability is low, enhancing its ability to detect changes
in singing voice-specific health status across treat-
ment.
Additionally, the SVHI serves as a valid, disor-
der-specific health status instrument. As evidenced
by the correlation between self-rated singing voice
problems on the VAS and SVHI and the increased
SVHI scores across the 3 VAS severity categories,
the SVHI does differentiate between different levels
of patient-perceived singing voice impairment. Last,
as evidenced by higher SVHI scores in the singing
patients compared to the control group, the SVHI
discriminates between singers with vocal dysfunc-
tion and singers without voice problems; this find-
ing further supports its validity. This difference per-
sisted regardless of professional, income, or classi-
cal singing status.
Certain methodological issues must be addressed.
Despite the 36 questions, the SVHI's burden ap-
peared minimal. Of all the patients approached, only
1 patient refused to complete the SVHI. Most com-
pleted the questionnaire in 5 to 10 minutes. None-
REFERENCES
1. Jacobson BH, Johnson A, Grywalski CSilbergleit A, Ja-
cobson G, Benninger MS.The Voice Handicap Index (VHI): de-
velopment and validation. Am J Speech Lang Pathol I997;6:66-
70.
2. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Devel-
opment and validation ofthe Voice Handicap Index-IO. Laryn-
goscope 2004; 114:1549-56.
3. Deary IJ, Vk'ilson JA, Carding PN, MacKenzie K. VoiSS:
a patient-derived Voice Symptom Scale. J Psychosom Res 2003;
54:483-9.
4. Gliklich RE, Glovsky TM, Montgomery WW. Validation
of a voice outcome survey for unilateral vocal cord paralysis.
Otolaryngol Head Neck Surg 1999; 120:153-8.
5. Hogikyan ND, Sethuraman G. Validation of an instru-
ment to measure voice-related quality of life (V-RQOL). J Voice
1999; 13:557-69.
6. World Health Organization. International Classification
of Impairments, Disabilities, and Handicaps: a manual of clas-
sification relating to the consequences of disease. Geneva, Swit-
zerland: World Health Organization, 1980:25-43.
7. Cohen SM, Dupont WD,Courey MS. Quality-of-life im-
theless, only 50% ofthe patients completed the sec-
ond SVHI. Whether this second SVHI was lost in
the mail, misplaced by the patient, or not complet-
ed because of the effort and time needed to com-
plete the SVHI a second time is not known. Also,
although our test-retest reliability was high, patients
with more variability in their answers may not have
completed the second SVHI, so our test-retest reli-
ability may have been inflated. Last, the responsive-
ness ofthe SVHI to treatment-related changes in pa-
tients' singing voices was not evaluated and will be
the subject of future investigations. Correlations be-
tween the VHI and SVHI and associations between
singing styles, comorbidities, and the SVHI are im-
portant avenues of study. Further analysis may also
allow f'urther reduction of the number of items.
CONCLUSIONS
The SVHI is a reliable and valid instrument for
measuring the patient-perceived impact of singing
voice problems. Consequently, the SVHI can aid in
the assessment of dysphonic singers. Factors influ-
encing the patient's perception of singing voice im-
pairment, as evidenced by the SVHI, are worthy of
investigation. The SVHI may also serve as a valu-
able tool for the evaluation of treatment outcomes
among singers and for comparing the effectiveness
of different treatments.
pact of non-neoplastic voice disorders: a meta-analysis. Ann
Otol Rhinol Laryngol 2006; 115:128-34.
8. Benninger MS, Ahuja AS, Gardner G, Grywalski C. As-
sessing outcomes for dysphonic patients. J Voice 1998;12:540-
50.
9. Roy N, Merrill RM,Gray SD, Smith EM. Voice disorders
in the general population: prevalence, risk factors, and occupa-
tional impact. Laryngoscope 2005;! 15:1988-95.
10. Phyland DJ, Oates J, Greenwood KM. Self-reported
voice problems among three groups of professional singers. J
Voicel999;13:602-ll.
11. Rosen CA, Murry T. Voice Handicap Index in singers. J
Voice 2000;14:370-7.
12. Behrman A, Sulica L, He T. Factors predicting patient
perception of dysphonia caused by benign vocal fold lesions.
Laryngoscope 2004; 114:1693-700.
13. Morsomme D,Simon C, Jamart J, Remade M, Verduyckt
1. A proposal to adapt the Voice Handicap Index to the sing-
ing voice [in French]. Rev Laryngol Otol Rhinol (Bord) 2005;
126:305-13.
View publication stats