Validation of the Brazilian Version of the Voice

Disability Coping Questionnaire

*,†Gisele Oliveira, ‡Shashivadan P. Hirani, §,kRuth Epstein, {Latife Yazigi, and †,{Mara Behlau, *Brooklyn, NY, y{Sao
Paulo, Brazil, and zxkLondon, UK

Summary: Purpose. To perform the validation of the Brazilian version of the Voice Disability Coping Questionnaire
(B-VDCQ) using procedures according to the Scientific Advisory Committee of Medical Outcomes Trust and psycho-
metric analyses to determine the scales validity and reliability.
Methods. In the preliminary procedures, the VDCQ was administered to 14 patients to determine if items were cultur-
ally valid and propose possible adaptations for a B-VDCQ. The sample of this study consisted of a data set of 178
individuals, 87 with vocal complaint, comprising 19 men and 68 women, with mean age of 34.1 years and 91 without
vocal complaint, comprising 29 men and 62 women, with mean age of 32.4 years. To demonstrate validity, the B-VDCQ
scores were compared to vocal self-assessment and perceptual analysis. To determine the reliability and test-retest
reproducibility, 14 voice patients repeated the measurement between 3 and 14 days after the first administration.
Results. Principal component analyses of the patients with vocal complaint yielded four coping strategies: venting,
support seeking, minimisation, and avoidant acceptance. Subscales of the questionnaire showed acceptable internal con-
sistency and reproducibility values, apart from the minimisation subscale. B-VDCQ validity was demonstrated through
relationships with perceptual analyses and vocal self-assessment and subscale score differences between the two groups.
Conclusions. The B-VDCQ has been submitted to essential steps necessary for cultural adaptation and validation. It
is a simple instrument to administer and shows to be specific for evaluating patients with voice problems. The B-VDCQ
can be an important addition to the voice evaluation of patients with dysphonia.
Key Words: Voice–Dysphonia–Coping behavior–Diagnostic self-evaluation–Questionnaires.

INTRODUCTION health problem produces consequences that will influence the

Dysphonia is an oral communication disorder in which the
voice does not perform its role of carrying the verbal and
emotional message of an individual.1 Usually, voice disorders
indicate benign conditions and may be transitory.2 The Amer-
ican Academy of Otolaryngology–Head and Neck Surgery
Foundation highlights that at least one-third of the American
people will have voice problems at some point in their life.
Approximately, 9% of the US people experience voice diffi-
culties at some point during their lifetime.3 Costs related to
treatment of voice disorders and absenteeism due to voice prob-
lems are estimated in economic losses of billions of dollars in
the United States annually.2 However, a voice deviation may
be extended/chronic and may require diagnosis and treatment.
Furthermore, it may produce several behavioral changes which
would consequently impact quality of life and well-being.4
The effects of a dysphonia are much more than only limita-
tions in the voice production. An individual with a voice prob-
lem may not only face trouble expressing a message intelligibly
but also lose the ability to interact fully, socially, and profes-
sionally.3,5 Adjustments may be necessary for the individual
to deal with a voice disorder and to control the stress
produced by such condition. The way patients deal with their
Accepted for publication January 21, 2015.
From the *Touro College, Brooklyn, New York, USA; yCentro de Estudos da Voz –
CEV, Sao Paulo, Brazil; zHealth Services Research, City University London, UK;
xUniversity College London, UK; kSpeech-Language Pathology Services, Royal National
Throat Nose & Ear Hospital, London, UK; and the {Universidade Federal de S~ao Paulo –
UNIFESP, Sao Paulo, Brazil.
Address correspondence and reprint requests to Gisele Oliveira, 902 Quentin Road,
Brooklyn, NY 11223. E-mail: gisele.oliveira@touro.edu
Journal of Voice, Vol. 30, No. 2, pp. 247.e13-247.e21
0892-1997/$36.00
Ó 2016 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2015.01.004
progress of the condition and treatment outcome.3 Coping re-
fers to the manner in which an individual deals with stressful
situations.6 The literature on coping is ample and controversial,
with different models, classification propositions, and measure-
ment instruments.6–9 Lazarus and Folkman6 spearheaded this
area by describing their cognitive theory of stress and coping.
Although this aspect has been investigated in diverse health
problems, the understanding of it in human communication
and particularly in the area of voice is still scarce.10–12
Several self-assessment measures have been developed; howev-
er, it is questionable whether these instruments are sensitive
enough to identify the type of strategies used by dysphonic peo-
ple to deal with their voice problem.
Although there are some studies available on the effect of
emotions on voice, the effect of vocal deviation on emotions
and on the role of coping has not been deeply studied.13–15
Communication and language have an important impact on
familial, social, and professional adaptation and integration.16
Therefore, it is plausible that the way the individuals cope
with their voice problem may influence treatment outcome.
Currently, there is no clarity as to which strategies the dys-
phonic individuals use to cope with their voice problem.
Furthermore, little is known about the vocal rehabilitation in
changing coping strategies and improving treatment
outcome.10,12
Attempts to measure coping strategies used by patients with
voice disorders have been carried out, and some instruments
were developed to be used both in different contexts and in gen-
eral health, especially in Switzerland, United Kingdom, the
Netherlands, and Belgium.1,3,5,17,18
The initial research that investigated coping with dysphonia
was performed by Epstein et al,10 characterizing coping
247.e14
strategies used by individuals with spasmodic dysphonia and
muscle tension dysphonia. The data from this work were used
to create the only questionnaire that evaluates coping strategies
in voice disorders,3 the Voice Disability Coping Questionnaire
(VDCQ). This was developed using English statements in a UK
population. Its validity and reliability in other populations and
languages need to be established.
The purpose of the present research was to validate the
Brazilian version of the VDCQ (B-VDCQ), by means of per-
forming the cultural and linguistic adaptation and by demon-
strating the psychometric measures of validity and reliability.
METHODS
The sample of this study consisted of a data set of 178 individ-
uals previously used in another study.12 Eighty-seven were in-
dividuals with vocal complaint, who either sought help at the
voice clinic of a university hospital or answered an invitation
placed on printed and audio-visual media in Sao Paulo.
Ninety-one were individuals without vocal complaint from
the general population.
The project of this research was submitted to the Ethics Com-
mittee of Universidade Federal de S~ao Paulo (approval # 1442/
08). Before data collection, all participants agreed to take part
in the study by signing an informed consent.
Procedures
The data set consisted of the following procedures: identifica-
tion and characterization questionnaire developed specifically
for this research, vocal self-assessment, perceptual analysis,
and the B-VDCQ. The exclusion criteria were the diagnosis
of other oral communication disorders, acute upper respiratory
infections, acute hoarseness resulting from phonotrauma, previ-
ous voice rehabilitation, and diagnosis of neurological and psy-
chological disorders.
Voice self-assessment. Each participant rated their own
voice quality using a five-point scale: poor, fair, good, very
good, or excellent.
Perceptual analysis. Speech samples of numbers counting
(1–10) were digitalized in an HP Pavilion ze4900 computer
with a headset microphone (Plantronics H141N DuoSet) at a
fixed microphone-to-mouth distance of 5 cm. Individuals
were asked to carry out the tasks using self-controlled habitual
pitch and loudness. Perceptual analysis consisted of the assess-
ment of overall vocal deviation by means of a 100-unit visual
analog scale. Based on Yamasaki et al,19 the scores of the
analog scale were categorized into normal variability of vocal
quality, mild deviation, moderate deviation, and severe devia-
tion. A speech-language pathologist specializing in voice per-
formed the analysis. This yielded satisfactory reliability
(Cronbach a correlation coefficient for vowel, 0.762; for con-
nected speech, 0.953).
Coping measurement protocol. Coping was assessed by
means of the VDCQ-27. The VDCQ-27 measure is a 27-item,
disease-specific coping instrument for voice disorders. Items
are rated on a six-point scale, ranging from ‘‘never’’ to ‘‘al-
Journal of Voice, Vol. 30, No. 2, 2016
ways.’’ To use a self-assessment instrument in other languages,
the instrument had to be culturally adapted and carefully trans-
lated and tested, avoiding a literal translation that excludes cul-
tural and social contexts. The B-VDCQ-27 was submitted to the
following procedures according to the Scientific Advisory
Committee of Medical Outcomes Trust20: translation, cultural
and linguistic adaptation, cultural equivalency, validity, and
reliability.
The forward translation of the B-VDCQ-27 was performed
by two bilingual speech-language pathologists and English
teachers, and the reversed translation was done by an English
teacher, who had not participated in the previous stage. The
three translators were informed of the research objective and
procedures. A committee of five voice specialists revised the
final questionnaire. To evaluate cultural and linguistic equiva-
lency, the option ‘‘not applicable’’ was introduced in the
response rating scale of each item to enable the identification
of sentences that are not clear or inappropriate to the population
the instrument is intended to address and to have them modified
or excluded afterward. This version was then administered to 14
patients. None of the questions were shown to be invalid; how-
ever, some items still required further adjustments for better un-
derstanding. For instance, the word ‘‘prayer’’ had to be inserted
in item 18, as the word ‘‘religion’’ has a culturally divergent
meaning.
Factor analysis and scale scores. Item responses on the
B-VDCQ questionnaire were subjected to principal component
analysis (PCA) with oblique rotation. Rotation methods are
usually used in factor analyses to relate the calculated factors
to theoretical contents and to reduce the data in an attempt to
achieve simple structures. The rotation methods are either
orthogonal or oblique. The oblique rotation was chosen for
this analysis because the factors of the questionnaire are known
to be correlated, as opposed to the orthogonal rotation which is
used for uncorrelated factors.
The data were analyzed with voice patients only (n ¼ 87).
The factor analyses served to investigate the latent component
structure of the questionnaire in this sample and enabled a com-
parison of the produced components with the original PCA of
the B-VDCQ. It is acknowledged that the participant-per-item
ratio for the questionnaire was relatively small (1:3); however,
the results demonstrate this was not a large problem. Neverthe-
less, results may need to be interpreted with caution.
The sets of data were initially examined by means of Bar-
tlett test of sphericity and the Kaiser-Meyer-Olkin index mea-
sure of sampling adequacy to evaluate whether individual
items should remain in the analysis. Sampling adequacy
with small values indicates that the variables have too little
in common to warrant a factor analysis; therefore, to maxi-
mize the Kaiser-Meyer-Olkin index, the measure of sampling
adequacy was examined item per item on the major diagonal
of the anti-image. Items with measure of sampling adequacy
<0.600 were removed from the analysis and the matrix regen-
erated. This process was repeated until all items had a mea-
sure of sampling adequacy >0.600. The remaining items
were used in the PCA. The scree plot was used to determine
Gisele Oliveira, et al Validation of the B-VDCQ
the number of factors extracted (plus reference was made to
ensure the percentage of variance accounted was >5% and Ei-
genvalues >1.00 per factor). In the final matrix, items with a
loading >0.500 were retained in the factor solution for scale
development.
If the resultant factor solution produced factors that appeared
to contain many items from more than one coping domain, then
the PCA process was rerun on these items to determine lower-
order factors, as per the protocol of the original VDCQ devel-
opment. In the second-order PCA, to be more conservative,
only items with factor loadings >0.600 were considered for
scale formation.
Validity and reliability. Concurrent validity was determined
through patterns of group differences on scores, according to the
perceptual analysis and vocal self-assessments, assessed by
Analysis of Variance (ANOVA). In addition, relationships within
subscales and the perceptual analysis and the vocal self-
assessment were examined using Pearson r statistic, with corre-
lations considered significant at the P > 0.01 level. (The coeffi-
cient of determination [r2] is also reported as an indicator of
the correlation effect size, with r ¼ 0.10 indicating a small effect
size; r ¼ 0.30 indicating a medium-sized effect; and r ¼ 0.50 re-
flecting a large effect size.)
The internal reliability of subscales produced through the
PCA was assessed using Cronbach alpha statistic. Individual
items’ contribution to the reliability index and their removal
statistics were examined. Items were to be removed until no
further valid increment in reliability was achievable. For each
participant, subscale scores were calculated on the basis of
mean item scores (after reversal of scores for appropriate items)
and ranged from 0 to 5.
To determine test-retest reproducibility, scores of the B-
VDCQ administered a second time to 14 voice patients before
treatment were correlated with their earlier scores (between 3
and 14 days after the first administration).
RESULTS
The sample consisted of 178 adults, 87 individuals with vocal
complaint, 19 men and 68 women aged between 20 and 54 years
with a mean of 34.1 (standard deviation [SD] ¼ 9.1) and 91 in-
dividuals without vocal complaint, 29 men and 62 women aged
TABLE 1.
First Principal Component Analysis
Second-Level PCA 1
I cope better with my voice problems by trying to accept it, since nothing can be done.
I find it easier to cope with my voice problem by avoiding being with people in general.
I take the view that there is little I can do about my voice problem.
I keep my frustrations to myself, so few of my friends know I am frustrated.
I try to convince myself that my voice problem is not really that disabling.
I keep any worries I may have about my voice problem to myself.
I find it easier to cope with my voice problem by telling myself not to think about it.
I find it easier to live with my voice problem, if I do not use my voice.
247.e15
between 20 and 55 years with a mean of 32.4 (SD ¼ 8.5). The
two groups did not significantly differ in proportions of each
gender (P ¼ 0.132) or mean age (P ¼ 0.219).
Factor analysis, scale reliability, and scale scores
At the start of the PCA procedures, the item-participant ratio
was relatively low at z1:4. The first anti-image correlation ma-
trix produced four items (16, 21, 24, and 26) with Measure of
sample adequacy (MSA) <0.600. Therefore, the PCA was rerun
after removing these items. This PCA produced all items with
MSA >0.600 (Bartlett test of sphericity: approx.
c2 ¼ 728.617, df ¼ 253, P < 0.001; Kaiser-Meyer-
Olkin ¼ 0.733). The scree plot indicated a two-factor solution,
and PCA produced a factor structure that accounted for 34.3%
of the variance. However, seven items were hyperplane (did not
load strongly on any factor >0.50). The resultant two-factor so-
lution produced factors that appeared to contain many items
from more than one coping domain; therefore, the items of
each factor were subject to further PCAs, which produced a to-
tal of four factors from the original two-factor solution. Each of
the four factors obtained became the four coping strategies that
compose the B-VDCQ.
The first second-level PCA indicated a two-factor solution
(all measure of sampling adequacy of the anti-image correlation
matrix >0.600; Bartlett test of sphericity: approx. c2 ¼ 194.229,
df ¼ 28, P < 0.001; Kaiser-Meyer-Olkin ¼ 0.768). The two fac-
tors accounted for 53.5% of the variance. Two items were hy-
perplane, and each of the remaining items only loaded onto
one factor >0.600. The first factor (2.1) accounted for 40.15%
of variance (Eigenvalue ¼ 3.2) and the second factor (2.2) ac-
counted for 13.3% of variance (Eigenvalue ¼ 1.1) as in Table 1.
The second second-level PCA (Table 2) also indicated a two-
factor solution (all measure of sampling adequacy of the
anti-image correlation matrix >0.600; Bartlett test of sphericity:
approx. c2 ¼ 216.100, df ¼ 28, P < 0.001; Kaiser-Meyer-
Olkin ¼ 0.781). The two factors accounted for 55.3% of the
variance. Two items were hyperplane, and each of the remain-
ing items only loaded onto one factor >0.600. The first factor
(2.3) accounted for 42.0% of variance (Eigenvalue ¼ 3.3) and
the second factor (2.4) accounted for 13.3% of variance
(Eigenvalue ¼ 1.1).
Factor
2.1 2.2
0.807 0.142
0.711 0.047
0.686 0.145
0.556 0.210
0.073 0.819
0.036 0.793
0.095 0.682
0.357 0.423
247.e16 Journal of Voice, Vol. 30, No. 2, 2016

TABLE 2.
Second Principal Component Analysis
Component

Second-Level PCA 2 2.3 2.4

I try to find as much information as possible about my voice problem. 0.879 0.122
I find it easier to cope with my voice problem if I ask the doctor questions about it. 0.717 0.059
It helps me to cope with my voice problem if other people are sympathetic. 0.653 0.046
I ask people to help me with those things I cannot manage because of my voice. 0.530 0.102
I find it easier to cope with my voice problem by finding out as much about it as I can. 0.518 0.352
I find talking with friends and family about my voice problem helpful. 0.176 0.899
I find it easier to cope with my voice problem by expressing my feelings outwardly. 0.170 0.725
Having a voice problem has helped me to find some important truth about my life. 0.181 0.625

The four coping subscales were identified as (1) avoidant
acceptance (four items, Cronbach a ¼ 0.682); (2) minimisation
(three items, ac ¼ 0.679); (3) support seeking (five items,
ac ¼ 0.736); and (4) venting (three items, ac ¼ 0.691).
Validity
Concurrent validity is presented in Tables 3–5. Tables 3 and 4
summarize the comparison between the scores of the
questionnaire and both the perceptual analysis and the vocal
self-assessment. Table 5 summarizes the analysis of subscale
correlations.
Means of overall voice deviation for the individuals with
vocal complaint were greater than those for the individuals
without vocal complaint with statistically significant differ-
ences among all subscales of the B-VDCQ (normal variability
of vocal quality: venting P < 0.001, support seeking P < 0.001,
minimisation P ¼ 0.004, and avoidant acceptance P ¼ 0.002;
mild: venting P ¼ 0.001, support seeking P < 0.001, minimisa-
tion P ¼ 0.006, and avoidant acceptance P ¼ 0.003; moderate:
venting P ¼ 0.001, support seeking P < 0.001, minimisation
P ¼ 0.003, and avoidant acceptance P ¼ 0.020). It is important
to highlight that the reduced number of individuals with
extreme deviation did not allow the performance of this analysis
in these participants.
In regard to the comparison of self-assessment and the B-
VDCQ scores, differences were observed in some of the sub-
scales between the groups, in particular, for the individuals
who classified their voices as ‘‘good’’ (good: venting
P < 0.001, support seeking P < 0.001, and minimisation
P ¼ 0.014). Overall, individuals with vocal complaint had
greater scores than the individuals without vocal complaint.
Subscale correlations. Table 5 presents the correlations of
the subscales. The support seeking subscale was the only one
that significantly correlated with the perceptual analysis
(r ¼ 0.259, P ¼ 0.015). The minimisation and the avoidant
acceptance subscales correlated significantly with the vocal
self-assessment (r ¼ 0.274, P ¼ 0.005 and r ¼ 0.367,
P < 0.001, respectively). The venting subscale was significantly
correlated with the support seeking subscale (r ¼ 0.471,
P < 0.001) and the avoidant acceptance subscale (r ¼ 0.279,
P ¼ 0.009). The avoidant acceptance subscale correlated signif-
icantly with the minimisation subscale (r ¼ 0.549, P < 0.001).

TABLE 3.
Validity: Comparison Between the VDCQ Subscales Perceptual Analysis According to the Groups of Individuals With
(n ¼ 87) and Without (n ¼ 91) Vocal Complaints
Venting Support Seeking Minimisation Avoidant Acceptance

Without With Without With Without With Without With

Rating Complaint Complaint Complaint Complaint Complaint Complaint Complaint Complaint
Normal variability
Mean 1.10 1.91 1.43 2.48 1.12 1.83 0.56 1.09
SD 1.31 1.31 1.48 1.23 1.29 1.34 0.77 1.02
P value 0.001 <0.001 0.004 0.002
Mild
Mean 0.56 2.58 0.42 3.15 0.64 2.54 0.27 1.75
SD 1.09 1.28 1.32 1.14 1.23 1.47 0.50 1.40
P value 0.001 <0.001 0.006 0.003
Moderate
Mean 0.71 2.35 1.00 3.08 0.71 2.03 0.39 0.96
SD 1.05 1.45 1.49 1.02 1.13 1.19 0.69 0.64
P value 0.001 <0.001 0.003 0.020
Gisele Oliveira, et al Validation of the B-VDCQ 247.e17

TABLE 4.
Validity: Comparison Between the VDCQ Subscales Vocal Self-Assessment According to the Groups of Individuals With
(n ¼ 87) and Without (n ¼ 91) Vocal Complaints
Venting Support Seeking Minimisation Avoidant Acceptance

Without With Without With Without With Without With

Rating Complaint Complaint Complaint Complaint Complaint Complaint Complaint Complaint
Fair
Mean 0.65 2.25 1.14 2.65 0.67 0.83 0.46 0.81
SD 1.10 1.87 1.63 1.41 1.03 0.79 0.72 0.68
P value 0.026 0.099 0.765 0.385
Good
Mean 0.88 2.19 1.07 2.49 0.90 1.71 0.52 0.74
SD 1.29 1.12 1.46 1.25 1.26 1.46 0.82 0.71
P value <0.001 <0.001 0.014 0.250
Very good
Mean 1.57 2.17 1.67 2.80 1.45 2.13 0.36 1.31
SD 1.17 1.13 1.36 1.23 1.36 1.24 0.48 1.06
P value 0.198 0.002 0.095 0.002
Notes: ANOVA.

The reliability of the B-VDCQ was demonstrated by the inter-
nal consistency and the test-retest reproducibility (Table 6). In-
ternal consistency of B-VDCQ was determined by the following
Cronbach a coefficients: venting a ¼ 0.691, support seeking
a ¼ 0.736, minimisation a ¼ 0.682, and avoidant acceptance
a ¼ 0.679. The comparison of test-retest values by means of
the intraclass correlation produced the following coefficients:
avoidant acceptance r ¼ 0.813, minimisation r ¼ 0.244, sup-
port seeking r ¼ 0.901, and venting r ¼ 0.701 (Table 6).
The final B-VDCQ ended up having 15 items distributed in
four subscales and is given in the Appendix 1.
DISCUSSION
Coping is considered an important concept of health and in the
context of quality of life. It is deeply associated with the regu-
lation of emotions during a period of stress. Nevertheless, there
is no consensus as to what coping strategies are more efficient
and on how certain coping styles may contribute to problem
solving or to alleviating emotional stress.
Coping is a subject that has been extensively investigated;
however, in the area of communication disorders and particu-
larly in the area of voice, the issue has been little explored.
The pioneer British study of Epstein et al10 called the atten-
tion to the importance of this concept for the design of treat-
ment programs of individuals with dysphonia, indicating how
the nature of the disorder affects the type of coping strategy
used.
The present study describes the validation process of the
B-VDCQ that was designated in Portuguese as Protocolo de Es-
trategias de Enfrentamento nas Disfonias-15 (PEED-15).
The B-VDCQ shows a good performance assessing coping
of individuals with diverse voice complaint. Validity of the

TABLE 5.
Correlation of VDCQ Subscales With Vocal Self-Assessment and Perceptual Analysis in the Group With Voice Complaint
Variable Self-Assessment Perceptual Analysis Venting Support Seeking Minimisation
Venting
Correlation 0.108 0.072
P value 0.280 0.510
Support seeking
Correlation 0.056 0.259 0.471
P value 0.574 0.015 <0.001
Minimisation
Correlation 0.274 0.023 0.022 0.063
P value 0.005 0.832 0.836 0.564
Avoidant acceptance
Correlation 0.367 0.027 0.279 0.180 0.549
P value <0.001 0.807 0.009 0.095 <0.001
Notes: Pearson correlation.
247.e18
TABLE 6.
Internal Consistency (Cronbach Coefficient) and Test-Retest Reliability (Intraclass Correlation [ICC]) of the VDCQ
VDCQ Venting Support Seeking
Cronbach coefficient 0.691 0.736
ICC coefficient 0.701 0.901
instrument was examined by the relationship between the
perceptual analysis and the self-assessment with the subscales
scores. Both groups had very different results showing that the
questionnaire is effective to the population and disorder pro-
posed to measure (Tables 3–5). Individuals with vocal
complaint demonstrated not only higher degree of voice
deviation and lower vocal self-rating compared to the individ-
uals without vocal complaint but also higher scores on the
B-VDCQ as expected. These results confirm that the B-
VDCQ-15 is an instrument that measures what it claims to
measure. Table 6 presents internal consistency and test-retest
reliability values of the B-VDCQ-15.
Correlations between coping subscales help to define the
logical relationships between the subscales. The significant
correlation observed between the venting and support seeking
suggests that individuals with voice problems cope by having
social support and by getting more information through dis-
cussions with friends, family, and professionals. The signifi-
cant correlation between the minimisation and avoidant
acceptance subscales suggests that individuals, who try to
control their emotions, are likely to use denial to cope with
their problems, for instance by avoiding socializing or talking
to people. Similar correlations were found by the study of the
validation of original VDCQ in English.10 The correlation
found between the support seeking subscale and perceptual
analysis suggests that individuals with a more severely devi-
ated voice are prone to use more problem-focused strategies
by looking for social help. The correlation between both the
minimisation and the avoidant acceptance subscales with the
vocal self-assessment tells us that individuals who tend to
use emotion-focused strategies have an impression that their
voices are more deviated.
The internal reliability for a test indicates how similar the
items on the test are to each other in content (homogeneity).
Cronbach alpha coefficients showed that there is an overall ho-
mogeneity among the items within the subscales. It is important
to note that the length of a test can affect internal consistency
reliability. The longer the instrument, the more likely the reli-
ability coefficient will be spuriously inflated.21 Perhaps, if the
subscales of the B-VDCQ-15 had more items, their coefficients
would have been greater; however, the instrument would be
longer. Administration burden is an important attribute for a
self-assessment instrument.
The test-retest reliability of the B-VDCQ-15 showed accept-
able intraclass coefficients for all subscales, except for the min-
imisation (r ¼ 0.244). Reliability is an estimate of the stability
of what is being measured. Some constructs are more stable
than others. Usually, individual skills and abilities are more sta-
ble characteristics to be measured over a particular period
Journal of Voice, Vol. 30, No. 2, 2016
Minimisation Avoidant Acceptance
0.682 0.679
0.244 0.813
compared to psychological-related characteristics such as
coping strategies. For constructs that are expected to vary
over time, an acceptable test-retest reliability coefficient may
be lower than is suggested in the literature. Length of test again
is a variable that can influence in the reliability of a test. On the
whole, tests with a great amount of items provide more reliable
scores than shorter tests.22
Preliminary analysis of 178 individuals with and without
voice complaints generated four coping strategies: support
seeking, venting, minimisation, and avoidant acceptance. The
original VDCQ also yielded four coping strategies (social sup-
port, information seeking, passive coping, and avoidance).10
Although they are slightly different, both questionnaires ended
up having two subscales with problem-focused strategies and
two with emotion-focused strategies.
Venting describes the act of talking about one’s feelings. It is
a process in which the individual look for social support to try
dealing with their stressful situation. The act of venting about
the stressful situation through talking allows the individual to
do a task which helps them focus on the problem.21 During
treatment, clinicians can guide patients by focusing on the prob-
lem to identify actions that can be taken to improve the use of
their voice. Thus, the clinician becomes the facilitator of the pa-
tient’s adjustment process to the stressful situation.
‘‘Support seeking’’ describes a problem-focused strategy
with which the individual uses a range of interpersonal ex-
changes such as information and material assistance and getting
sympathy or help from someone. This type of problem-focused
strategy is characterized by efforts directed at solving or man-
aging the problem that is causing distress, thus promoting adap-
tation of the individual to the voice problem.
‘‘Minimisation’’ describes an effort of the individual to regu-
late his/her feelings and actions. ‘‘Avoidant acceptance’’ refers
to the use of denial or lack of proactive attitude toward changing
the stress source.6 Strategies of minimisation and avoidant
acceptance must be monitored to make sure that the patient
does not develop inadequate behaviors that cause maladaptive
conditions. Although emotion-focused strategies may be useful
during early stages of a disease, in the long-term, the use of such
strategies may produce a new set of problems and affect nega-
tively the patient’s quality of life. In this case, the patient gets
into a vicious cycle in which the voice problem does not
improve because he/she does not try to actively modify the sit-
uation, for instance, by doing exercises or eliminating poor
vocal behaviors and phonotrauma. On the contrary, he/she
may avoid thinking of the voice problem and situations in
which his/her voice problem is evident.
When the mediating role of coping is taken into consider-
ation,6 the diversity of outcomes with voice disorders and the
Gisele Oliveira, et al Validation of the B-VDCQ
importance of approaching the issue during the intervention
course become clearer because it is expected that the coping
process adapts the patient to the situation. This adaptation is
defined as the degree to which the patient deals physiologically,
psychologically, and socially with his/her health condition.23
However, not every coping strategy produces adaptive adjust-
ments that bring the individual’s well-being to a balanced status
because the adaptation to a stressful situation depends on per-
sonal aspects, on specific type of events, on the adaptation
time required, and on treatment outcomes.6 Hence, from the
evaluation session, the clinician should help the patient identify
the strategies that are being used to cope with the voice disorder
and to contribute to the change of those strategies that do not
produce adaptation. At the same time, the clinician should
encourage the use of strategies that are more adequate in
dealing with the problem. Literature shows that there is a rela-
tionship between coping strategies and treatment outcome, and
usually, denial strategies are associated with a worse treatment
effect.24–26
The possibility of identifying maladaptive coping strategies
and the role of coping on treatment outcomes will help clini-
cians to better understand how individuals with dysphonia
cope with their voice limitation. This knowledge will allow
the development of appropriate interventions that address the
change of maladaptive strategies. For this reason, the present
study had the purpose to validate the VDCQ in Brazilian
Portuguese.
The B-VDCQ-15 is a tool that can be used both in the clinical
and research setting to identify aspects that facilitate the out-
comes of a given intervention and help comprehend how the pa-
tient uses coping to deal with the stress produced by a voice
disorder.
Future research should investigate cultural coping differ-
ences used in dealing with specific types of voice disorders
and coping strategies used by professional voice users,
comparing pretreatment and posttreatment results.
CONCLUSIONS
The B-VDCQ-15 has been submitted to essential steps neces-
sary for cultural adaptation and validation. It is a simple instru-
ment to administer and shows to be specific for evaluating
patients with voice problems. The B-VDCQ-15 can be an impor-
tant addition to the voice evaluation of patients with dysphonia.
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