Normative Values for the Voice Handicap Index-10

*Rachel E. Arffa, †Priya Krishna, †,‡Jacqueline Gartner-Schmidt, and †,‡Clark A. Rosen, *yzPittsburgh, Pennsylvania

Summary: Objectives. The objective of this study was to elucidate the normative values for the Voice Handicap
Index-10 (VHI-10) questionnaire.
Methods. VHI questionnaires were completed by 190 subjects without voice complaints. The results were then
analyzed for mean, standard error of the mean (SEM), and standard deviation (SD) for both the original VHI and
VHI-10 subset questionnaires. Outliers were defined as being more than three standard deviations above the mean.
Results. Analysis of 156 VHI questionnaires revealed a mean of 6.86 (SEM ¼ 0.79, SD ¼ 9.88) for the normative
values. One hundred fifty-eight VHI-10 questionnaires were analyzed to show a mean of 2.83 (SEM ¼ 0.31,
SD ¼ 3.93) for the normative values.
Conclusions. This study offers normative data for the VHI-10 that has been missing in the literature. A VHI-10
score >11 should be considered abnormal.
Key Words: VHI–VHI-10–Voice–Quality of life questionnaires.

INTRODUCTION
Voice disorders are complex problems that can affect a patient
in many different ways. Current objective measures of voice
function can only assess one small component of voice produc-
tion (eg, airflow or jitter). Likewise, video perceptual measures,
including magnified and stroboscopic images of the larynx,1
also fail to assess the global handicap presented by a voice dis-
order. Even combined, these measures fail to fully elucidate the
severity of a handicap produced by a voice disorder because of
their subjective nature.2 For example, a teacher may perceive
the handicap caused by a unilateral vocal fold paralysis to be
much larger than would a retired steelworker with few social
contacts, or voice demands.
A handicap, as described by the World Health Organization,
is ‘‘a social, economic, or environmental disadvantage resulting
from an impairment or disability.’’3 Therefore, the handicap
associated with a disorder of the voice must have a subjective
measurement to fully assess its impact on a patient’s life.
Patient-based voice-specific outcome measures can then poten-
tially provide additional information to the anatomic and phys-
iological variable, which can then be used as a component of
assessment of voice handicap longitudinally.
In 1997, Jacobson et al4 proposed a questionnaire that subjec-
tively measured voice handicap, which is the Voice Handicap
Index (VHI) (Table 1). Several studies have shown that the
data provided by the VHI is distinct from the data supplied
by objective voice measures.5,6 Additionally, the VHI was
validated as meeting the criteria for reliability, validity, and
availability of normative data by the Agency for Health Care
Research and Quality in 2002.7 The VHI is, in fact, the only
instrument on voice-related measurements reported to meet
their stringent requirements for good diagnostic tools.
Accepted for publication April 15, 2011.
From the *Division of General Surgery, Department of Surgery, University of Pittsburgh
School of Medicine, Pittsburgh, Pennsylvania; yDepartment of Otolaryngology, University
of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and the zUPMC Voice Center,
Pittsburgh, Pennsylvania.
Address correspondence and reprint requests to Priya Krishna, Department of Otolaryn-
gology, University of Pittsburgh School of Medicine, UPMC Mercy, Ermire Building Suite
11500, 1400 Locust Street, Pittsburgh, PA 15219. E-mail: krishnapd@upmc.edu
Journal of Voice, Vol. 26, No. 4, pp. 462-465
0892-1997/$36.00
Ó 2012 The Voice Foundation
doi:10.1016/j.jvoice.2011.04.006
Although the VHI has been proven to accurately assess the
voice handicap of a patient, it is a long and cumbersome question-
naire for patients to fill out on each visit to a clinic. Therefore, in
2004, Rosen et al8 designed a new shortened VHI-10 question-
naire, including 10 statements from the 30-item VHI form
(Table 2). These 10 statements were selected for having the
highest mean difference between the study and control groups
and/or for significant clinical relevance. On further analysis, the
10 questions included in the VHI-10 were seen to exhibit the
highest mean difference between pre- and posttreatment groups
in comparison to the VHI.
Based on these findings, the VHI-10 may be a more concise
substitute for the VHI. However, no normative data has been
previously published for this new voice assessment tool. As
with quality of life surveys in general, the more important com-
parison would seem to be the pre- to posttreatment change in
scores to evaluate the treatment’s effectiveness. But, the origi-
nal score can also be used to grade the degree of voice handicap.
The goal of this present study is to establish normative data for
the VHI-10.
MATERIALS AND METHODS
The VHI questionnaire was given to 190 family members of
otolaryngology patients without voice complaints. These ques-
tionnaires were only included in the study if the subjects denied
any history of past or present voice problems. All subjects were
asked to complete this questionnaire without assistance. Only
subjects who could read English were included in this study.
The individual item responses of each VHI were recorded
into a computer spreadsheet (Microsoft Office Excel 2003).
They were then separated into separate spreadsheets for full
VHI and VHI-10 questionnaires (the VHI-10 being extracted
from the VHI questionnaire), which were each analyzed for
mean, standard error of the mean (SEM), and standard devia-
tion (SD). Outliers were defined as being more than three stan-
dard deviations from the mean.
RESULTS
After an attrition rate of 9%, the remaining 173 surveys were
analyzed. Only 161 of these had all 30 questions answered.
Rachel E. Arffa, et al Normative Values for the Voice Handicap Index-10 463

TABLE 1.
The VHI, a Validated Voice-Specific Quality of Life Survey Developed in 1997 and Validated in 2002 (Reprinted
With Permission, Rosen et al, 2004)
Voice Handicap Index (VHI)
Instructions: These are statements that many people have used 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 ¼ Never 1 ¼ Almost Never 2 ¼ Sometimes 3 ¼ Almost Always 4 ¼ Always
Part I: Functional
F1 My voice makes it difficult for people to hear me. 0 1 2 3 4
F2 People have difficulty understanding me in a noisy room. 0 1 2 3 4
F3 My family has difficulty hearing me when I call 0 1 2 3 4
throughout the house.
F4 I use the phone less often than I would like to. 0 1 2 3 4
F5 I tend to avoid groups of people because of my voice. 0 1 2 3 4
F6 I speak with friends, neighbors, or relatives less often 0 1 2 3 4
because of my voice.
F7 People ask me to repeat myself when speaking face-to-face. 0 1 2 3 4
F8 My voice difficulties restrict my personal and social life. 0 1 2 3 4
F9 I feel left out of conversation because of my voice. 0 1 2 3 4
F10 My voice problem causes me to lose income. 0 1 2 3 4
Part II: Physical
P1 I run out of air when I talk. 0 1 2 3 4
P2 The sound of my voice varies throughout the day. 0 1 2 3 4
P3 People ask, ‘‘What’s wrong with your voice?’’ 0 1 2 3 4
P4 My voice sounds creaky and dry. 0 1 2 3 4
P5 I feel as though I have to strain to produce voice. 0 1 2 3 4
P6 The clarity of my voice is unpredictable. 0 1 2 3 4
P7 I try to change my voice to sound different. 0 1 2 3 4
P8 I use a great deal of effort to speak. 0 1 2 3 4
P9 My voice is worse in the evening. 0 1 2 3 4
P10 My voice ‘‘gives out’’ on me in the middle of speaking. 0 1 2 3 4
Part III: Emotional
E1 I am tense when talking with others because of my voice. 0 1 2 3 4
E2 People seem irritated with my voice. 0 1 2 3 4
E3 I find other people don’t understand my voice problem. 0 1 2 3 4
E4 My voice problem upsets me. 0 1 2 3 4
E5 I am less outgoing because of my voice problem. 0 1 2 3 4
E6 My voice makes me feel handicapped. 0 1 2 3 4
E7 I feel annoyed when people ask me to repeat. 0 1 2 3 4
E8 I feel embarrassed when people ask me to repeat. 0 1 2 3 4
E9 My voice makes me feel incompetent. 0 1 2 3 4
E10 I am ashamed of my voice problem. 0 1 2 3 4

Five of the 161 VHI of 190 questionnaires were excluded for
being more than three standard deviations above the mean
(>54.9). Of the 156 VHI questionnaires that were included
for analysis, 50 were completed by men and 106 by women.
The results of these questionnaires had a mean of 6.86
(SEM ¼ 0.79, SD ¼ 9.88).
For the VHI-10 portion of the VHI, 163 subjects answered all
10 questions while five questionnaires were eliminated for being
more than three standard deviations above the mean (>20.8). Of
the remaining 158 questionnaires, 48 were completed by men
and 110 by women. The results of these questionnaires had
a mean of 2.83 (SEM ¼ 0.31, SD ¼ 3.93).
DISCUSSION
In 2004, Rosen et al8 designed a new shortened version of the
first and broadly used global handicap assessment tool for voice
disorders, the VHI.4,8 This new questionnaire comprises 10
questions from the original 30 questions of the VHI and was
called the VHI-10; this group of questions was seen to exhibit
the highest mean difference between pre- and posttreatment
groups in comparison to the VHI. As this distinction is the
most important factor in determining the effectiveness of differ-
ent treatments, no normative comparisons were done for the
original creation of the VHI-10. Therefore, this study deter-
mined the normative values of the VHI-10 for a control group.
464
TABLE 2.
The VHI-10, a Voice-Specific Quality of Life Survey Developed Through Factor Analysis of the VHI, Which was
Independently Validated (Reprinted With Permission, Rosen et al, 2004)
Voice Handicap Index-10
F1 My voice makes it difficult for people to hear me.
F2 People have difficulty understanding me in a noisy room.
F8 My voice difficulties restrict my personal and social life.
F9 I feel left out of conversation because of my voice.
F10 My voice problem causes me to lose income.
P5 I feel as though I have to strain to produce voice.
P6 The clarity of my voice is unpredictable.
E4 My voice problem upsets me.
E6 My voice makes me feel handicapped.
P3 People ask, ‘‘What’s wrong with your voice?’’
Based on this present study, the results of the VHI-10 in a patient
with a voice complaint should be compared with the normative
value of 2.83 (SEM ¼ 0.31, SD ¼ 3.93).
In both the VHI and VHI-10 analyses, the same five subjects
were eliminated in the calculation of the mean and standard
deviation as being more than three standard deviations above
the mean. It is possible that these forms were filled out by
patients who had a voice disorder but were visiting an eye
and ear institute at that time for a separate complaint. Con-
versely, these outliers could represent human error, where the
subjects believed that the larger numbers actually referred to
higher function rather than higher handicap. Reporting errors
such as this example are not uncommon in Likert-type scales.
Of note, in this subject sample, the mean of the data from the
original VHI (6.86 ± 9.88) was slightly higher than what has
been reported in the previous literature (Table 3). The differ-
ence in these means may be because of random difference in
patient population. Another source of this difference may be
a higher score related to increased awareness of the voice and
anxiety about it because the subjects were family members of
patients with voice complaints. We acknowledge that the
extraction of questions from the VHI-30 to use as the VHI-10
is not the same as actually giving the patients the VHI-10 ques-
tionnaires; however, the subjects used were part of the original
group used in development and validation of the VHI-10 itself
so there was not a formal VHI-10 available at that time.
TABLE 3.
Extraction of Norms From Various Voice-Related Quality
of Life Questionnaires, Which in Most Cases, Were Not
Expressly Published
Normative Values for VHI
Rasch et al9 5.7 ± 8.7
Pribuisiene et al10 5.39 ± 7.6
Madeira and Tomita11 4.0 ± 6.0
Krouse et al12 4.15 ± 5.64
Present study 6.86 ± 9.88
The standard deviations listed represent one standard deviation from the
mean.
Journal of Voice, Vol. 26, No. 4, 2012
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
Several other patient-based subjective analyses for the dys-
phonic population have been developed.13 Some of these have
normative values, but they are largely limited and some have
only been tested on a few select subsets of voice disorders or
in other countries. Gliklich et al14 developed the Voice Outcome
Survey, which is a five-item form that is a reliable and sensitive
tool for unilateral vocal fold paralysis and in issues related to
dysphagia. In 2005, Bach et al15 developed the Glottal Function
Index, which is a reliable and valid four-item self-administered
symptom index for glottal insufficiency, vocal fold nodules, ad-
ductor spasmodic dysphonia, and glottic granulomas. Hogikyan
et al16 developed the voice-related quality of life (V-RQOL)
instrument in 2000, which is another 10-question survey that
was studied in patients with wide range of disorders in the initial
validation process,17 with significant changes from pre- to post-
treatment. Also, it has been validated in multiple age groups.18 Of
these instruments, only the V-RQOL has expressly reported
normative values for comparison,18,19 though values can be
inferred from other studies based on their control populations
(Table 3). The VHI-10 has also been shown to be reliable, valid,
and sensitive in a wide range of voice disorders and now has a re-
ported normative value for a control group.8 The most compara-
ble instrument to the VHI-10 is the V-RQOL, however, the
control group used for determining normative values was much
smaller in the V-RQOL (21 as compared with 158 in the VHI-
10 validation). There have been some questions raised, however,
in general, about the robustness of these questionnaires as a whole
because of questionnaire development processes, which do not
strictly adhere to the Scientific Advisory Committee of the
Medical Outcomes Trust and the Food and Drug Administration.
At the present time, there is no patient-related outcome measure
for dysphonia that does adhere to all of these guidelines.13
Currently, there are no studies evaluating whether the change
in pre/post absolute values or percentage change best reflects
patient’s satisfaction and subjective improvement (a concept
defined as responsiveness).13 This study provides normative
values to better establish the responsiveness of the VHI-10.
Because standard analysis in reporting normative data includes
two SDs from the mean, the normative data for the VHI-10 is up
to 10.69 (2.83 + (3.93 3 2)). Individuals with a VHI-10 above
11 should be considered as having an abnormal VHI-10 score.
Rachel E. Arffa, et al Normative Values for the Voice Handicap Index-10
Outliers may have occurred because of normal patients not
being satisfied with their baseline voice or difficulty in interpre-
tation of questions as described previously.20 One avenue of
future research may be to evaluate the optimal way to compare
pre- and posttreatment scores and stratify responses by age.
CONCLUSIONS
The normative control group value for the VHI-10 found in this
study was 2.83 (SEM ¼ 0.31, SD ¼ 3.93). These values could
potentially help stratify voice disorder patients in the future.
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