Voice Handicap Index (VHI)

Abstract

The Voice Handicap Index (VHI) is a widely utilized, patient-derived instrument designed to measure the self-perceived severity of the psychosocial and functional consequences associated with a voice disorder. Developed by Jacobson and colleagues in 1997, the VHI is a crucial tool in speech-language pathology for quantifying the impact of dysphonia on a patient’s quality of life, informing treatment planning, and tracking outcomes. It consists of 30 items divided equally into three primary domains: Functional, Physical, and Emotional.

The VHI employs a 5-point Likert scale ranging from 0 (never) to 4 (always), yielding a maximum total score of 120. Higher scores indicate a greater perceived handicap related to the voice problem. Its robust psychometrics have led to its adoption globally, making it a standard measure for assessing the burden of voice issues across various etiologies.

Keywords

Voice Handicap Index, VHI, voice disorder, dysphonia, self-report, functional assessment, speech-language pathology, quality of life, outcome measure, handicap.

Authors

B. H. Jacobson, A. Johnson, C. Grywalski, J. Silbergleit, E. Osborne, K. Abbate.

Purpose

The primary purpose of the Voice Handicap Index (VHI) is to provide a quantitative measure of the impact of a voice disorder from the patient’s perspective. Traditional methods of assessing voice problems often rely solely on objective acoustic or aerodynamic measurements, or subjective clinical ratings. The VHI was developed to capture the subjective experience, which is critical for holistic patient care and evaluation.

In clinical settings, the VHI helps clinicians identify specific areas of difficulty (functional limitations, physical discomfort, or emotional distress) that are most bothersome to the patient. This information guides individualized treatment plans, such as voice therapy or surgical intervention. Furthermore, the VHI serves as an effective outcome measure, allowing both patients and clinicians to monitor changes in the perceived handicap following treatment.

Construct

The VHI measures the multidimensional construct of the self-perceived voice handicap, defined as the disadvantage experienced by an individual as a result of a voice impairment that limits or prevents the fulfillment of a role that is normal for that individual. This construct is operationalized through three distinct subscales, each containing 10 items.

• Functional (F) Subscale: This scale assesses the practical limitations imposed by the voice problem, particularly concerning communication in daily life. Examples include difficulty using the telephone or being understood in noisy environments.
• Physical (P) Subscale: This scale focuses on the patient’s physical sensations related to voice production, such as vocal strain, dryness, fatigue, or perceived changes in voice quality.
• Emotional (E) Subscale: This scale addresses the affective response to the voice disorder, including feelings of shame, embarrassment, frustration, tension, or isolation caused by the voice problem.

Validity

The VHI has demonstrated strong evidence of validity since its initial development. Content validity was established through rigorous item generation and selection processes, ensuring the 30 items adequately represent the full scope of functional, physical, and emotional consequences of voice disorders experienced by patients.

Construct validity has been supported by demonstrating that VHI scores correlate significantly with both objective measures of vocal function and subjective measures of voice quality rated by clinicians. Furthermore, the VHI exhibits discriminant validity, effectively differentiating between individuals with documented voice disorders and those with normal voices, and showing responsiveness to change following successful treatment interventions.

Reliability

The reliability of the VHI is consistently reported as excellent across numerous studies. Internal consistency, which measures the homogeneity of the items within the scale, is very high, typically demonstrating Cronbach’s alpha values above 0.90 for the total score and generally above 0.80 for the individual subscales (Functional, Physical, and Emotional).

Test-retest reliability is also robust, indicating that the VHI yields stable results when administered to the same patient over a short period, assuming no change in the patient’s vocal condition. This stability confirms the instrument’s utility for baseline assessment and reliable monitoring of chronic conditions.

Factor Analysis

The original development of the VHI utilized factor analysis to confirm the intended structure of the instrument. The results strongly supported the hypothesized three-factor model, corresponding precisely to the Functional, Physical, and Emotional dimensions.

Subsequent confirmatory factor analyses performed across various patient populations and languages have generally upheld this three-factor structure, validating the clinical interpretation of the subscale scores. This structural integrity ensures that each subscale measures a distinct aspect of the voice handicap, providing clinically meaningful data beyond the total score alone.

Instrument

Test Type: Self-report questionnaire / Patient-Reported Outcome Measure (PROM)

Format: 30 items scored on a 5-point Likert scale (0=never to 4=always). Total score range: 0 to 120.

Language Available: English (original), and numerous validated translations including Spanish, German, French, Japanese, and Chinese.

Population Group: Individuals experiencing symptoms of a voice disorder (dysphonia).

Age Group: Typically utilized with adults (versions like the VHI-10 and pediatric versions exist for specific populations).

Population Details: Applicable across diverse etiologies of voice disorders, including functional, organic, and neurological causes.

Test Methodology: Paper-and-pencil or digital administration. Requires the respondent to self-rate the frequency of specific experiences related to their voice problem over a specified period (e.g., the last month).

Keywords

Psychometrics, vocal function, dysphonia outcome, self-assessment, voice therapy, quality of life, Functional subscale, Physical subscale, Emotional subscale.

Authors

Author ORCID Identifier: Not publicly standardized for all original authors.

Affiliation Email addresses: Not readily available for correspondence regarding the original 1997 publication.

Correspondence Address: Correspondence is typically directed through current academic affiliations of the authors or the journal publisher.

Permissions & Fee and Test Year

The VHI is widely used and generally considered to be in the public domain for non-commercial clinical and research use, though users should consult the original authors or copyright holders for definitive permission regarding commercial reproduction or modification.

Test Year: 1997

Reference’s

Jacobson BH 1997, ‘The Voice Handicap Index (VHI): development and validation’, American Journal of Speech-Language Pathology, vol. 6, no. 3, pp. 66-70.

The instrument is also available in the Compendium of Clinical Measures for Community Rehabilitation. The original PDF can be downloaded here: http://www.health.qld.gov.au/qhcrwp/docs/clinical_measure.pdf

Items of the Voice Handicap Index (VHI)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

Instructions: These are statements that many people have sued to describe their voices and the effects of their voices on their lives. Circle the response that indicates how frequently you have the same experience. 0 = never 1 = almost never 2 = sometimes 3 = almost always 4 = always

Part I: Functional

1. F1 My voice makes it difficult for people to hear me
2. F2 People have difficulty understanding me in a noisy room
3. F3 My family has difficulty hearing me when I call them throughout the house
4. F4 I use the phone less often than I would like to
5. F5 I tend to avoid groups of people because of my voice
6. F6 I speak with friends‚ neighbours‚ or relatives less often because of my voice
7. F7 People ask me to repeat myself when speaking face-to-face
8. F8 My voice difficulties restrict my personal and social life
9. F9 I feel left out of conversations because of my voice
10. F10 My voice problem causes me to lose income

Part II: Physical

1. P1 I run out of air when I talk
2. P2 The sound of my voice varies throughout the day
3. P3 People ask ”what‟s wrong with your voice?
4. P4 My voice sounds creaky and dry
5. P5 I feel as though I have to strain to produce voice
6. P6 The clarity of my voice is unpredictable
7. P7 I try to change my voice to sound different
8. P8 I use a great deal of effort to speak
9. P9 My voice is worse in the evening
10. P10 My voice “gives out” on me in the middle of speaking

Part III: Emotional

1. E1 I am tense when talking to others because of my voice
2. E2 People seem irritated with my voice
3. E3 I find other people don‟t understand my voice problems
4. E4 My voice problem upsets me
5. E5 I am less outgoing because of my voice problem
6. E6 My voice makes me feel handicapped
7. E7 I feel annoyed when people ask me to repeat
8. E8 I feel embarrassed when people ask me to repeat
9. E9 My voice makes me feel incompetent
10. E10 I am ashamed of my voice problem

Total score_____/120 n