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308 International Journal of Therapy and Rehabilitation, June 2013, Vol 20, No 6
© 2013 MA Healthcare Ltd
Review
Quality of life in persons with
voice disorders: A review
of patient-reported
outcome measures
This article provides concise reviews of widely-used quality of life (QOL) instruments for use with
persons with voice disorders. Designed primarily for English-speaking persons, the reviewed
instruments are delineated by title and population served, i.e. adult or paediatric. Each review reports
the purpose of the QOL instrument as well as its psychometric soundness. Future voice-related QOL
instruments are briey considered. Finally, the appendices include tables with currently-available
translations and known readability information. This article will serve as a reference for physicians and
speech-language pathologists seeking to assess the voice-related QOL of their patients.
Key words: n Quality of life n Patient-reported outcome measures n Voice disorder n Assessment
Submitted 9 February 2013, sent back for revisions 10 May 2013; accepted for publication following double-blind peer
review 22 May 2013
Bonnie Slavych, Amy Engelhoven, Richard Zraick
The American Speech-Language-
Hearing Association (2005: http://
tinyurl.com/ntnbrpm) broadly denes
dysphonia as ‘… an impairment of
the speaking or singing voice.’ More narrowly,
dysphonia has been dened as ‘… a voice that
differs in pitch, loudness, quality, or exibility
from that of others of similar age, gender, and
cultural group’ (Aronson, 1990: 6). Dysphonia
can cause bodily pain, and can result in activity
limitations and participation restrictions (Ma et
al, 2007). Chronic and acute variables may pre-
cipitate dysphonia. These include occupational
vocal demands, medications, health problems,
the environment, physical trauma, and lifestyle
choices (Roy et al, 2005).
Only a handful of epidemiologic studies
have looked into the prevalence and risk fac-
tors of voice disorders in the general popula-
tion, as Best and Fakhry (2011) discuss in their
review. There has been substantial variability in
reported prevalence estimates across the stud-
ies. A conservative estimate suggests dysphonia
in the general population has a point prevalence
rate of approximately 7%, with a lifetime prev-
alence of 29% (Cohen et al, 2012). However,
prevalence of dysphonia is likely to be as much
as double or triple these estimates in high-risk
populations (Carding et al, 2006; Gottliebson
et al, 2007; Munier and Kinsella, 2008; Cohen
and Turley, 2009; Van Houtte et al, 2010). For
example, children are at risk for developing
dysphonia due to development of the larynx
and related structures (Sapienza et al, 2004).
The elderly are at risk for developing dyspho-
nia due to age-related changes and disease-
related changes (Kendall, 2007). Occupational
or professional voice users (Titze et al, 1997;
Vilkman, 2004) are at risk of developing dys-
phonia due to heavy voice use (Sodersten and
Lindhe, 2007); this is particularly true for
teachers, who are among the highest at risk
(Roy et al, 2004; Simberg et al, 2004; Ahlander
et al, 2011). Regardless of the cause, Cohen et
al (2012) estimate that the total annual direct
costs of caring for persons with dysphonia in
the US runs into the hundreds of millions of
dollars, which is comparable to other chronic
disease states.
Two basic approaches to quality of life meas-
urement in persons with voice disorders are
available: generic assessments that provide a
summary of overall health-related quality of
life, and assessments that focus on specific
voice-related quality of life. In a survey of
diagnostic practices of experienced voice cli-
nicians (Behrman, 2005), 94% responded that
voice-related quality of life instruments are
important for assessing treatment outcomes,
and 81% considered the data from such instru-
ments important in defining overall therapy
goals (Behrman, 2005).
Bonnie Slavych is a
doctoral student in the
AR Consortium for the
PhD in Communication
Sciences and Disorders,
University of Arkansas
at Little Rock and
University of Arkansas
for Medical Sciences,
US; Amy Engelhoven
is doctoral student in the
AR Consortium for the
PhD in Communication
Sciences and Disorders,
University of Arkansas
at Little Rock and
University of Arkansas
for Medical Sciences,
US; Richard Zraick
is a Professor in the
Department of Audiology
and Speech Pathology at
the consortium program
of the University of
Arkansas for Medical
Sciences and the
University of Arkansas
at Little Rock and
University of Arkansas
for Medical Sciences,
US.
Correspondence to:
Richard Zraick
E-mail: rizraick@uams.
edu
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International Journal of Therapy and Rehabilitation, June 2013, Vol 20, No 6 309
© 2013 MA Healthcare Ltd
In general, voice-disordered patients report
poor overall health-related and voice-related
quality of life (Cohen, 2010). The choice of
which voice-related quality of life instrument
to administer is often driven by the clinician’s
personal preferences and the dynamics of clini-
cal practice. Regardless of which instrument is
used, the clinician should be aware that vari-
ables such as life events and experiences, per-
sonality factors, and the effects of adaptation
may influence reported subjective wellbeing
(O’Connor, 2004).
Zraick and Risner (2008) provide a compre-
hensive review of instruments for assessing
quality of life in persons with voice disor-
ders (see Table 1). Most of the instruments
are psychometrically sound (Agency for
Healthcare Research and Quality, 2002; Franic
et al, 2005; Branski et al, 2010). The avail-
able scales can be grouped and categorized
using criteria such as patient age, e.g. adult
vs. child; rater, e.g. patient vs. parent or other
proxy; and patient population, e.g. singer vs.
nonsinger. One important consideration in
choosing an instrument is the ability of the
patient to read and comprehend its contents.
A recent analysis by Zraick and Atcherson
(2012) of the readability of the scales in Table
1 revealed that all are at a reading grade level
too high for the average adult to read with
ease and to comprehend.
In the following sections, we describe the
most prominent voice-disordered QOL instru-
ments available. Many of these available instru-
ments were rst developed in English and later
subjected to rigorous translation processes for
use around the world (Amir et al, 2006; Behlau
et al, 2009) (Table 2).
Voice Handicap Index
Jacobson et al (1997) developed the Voice
Handicap Index (VHI), which is a 30-item
questionnaire assessing voice handicap. The
VHI assesses three domains: functional, physi-
cal, and emotional, using a 5-point Likert
scale (0=never; 1=almost never; 2=sometimes;
3=almost always; 4=always). VHI total scores
range from 0 to 120, with 120 being the most
severe. Generally, a score of 10 or less reects
minimal voice handicap. A self-perceived
reduction in voice handicap correlates with a
lowering of the total VHI score by 18 points
or more, and/or a lowering of any VHI sub-
scale score by 8 points or more (Jacobson et al,
1997). The VHI is a psychometrically-sound
instrument (Agency for Healthcare Research
and Quality, 2002; Franic et al, 2005; Bogaardt
et al, 2007), which may be used for both clini-
cal and research purposes.
The Voice Handicap Index-10
Rosen et al (2004) developed the VHI-10,
which measures self-perception of voice prob-
lems in the emotional, functional, and physical
domains. Drawn directly from the VHI, the 10
items of the VHI-10 represent the most dis-
criminative items on the full VHI. To determine
the most salient items, researchers compared:
responses recorded on the VHI by patients
with and individuals without voice disorders;
and results of pre- and post-treatment. The
VHI-10 strongly represents the VHI, offering
good internal consistency (Deary et al, 2004).
A statistical analysis of responses compared
between the VHI-10 and VHI of 819 patients
with a wide spectrum of voice disorders
revealed no statistically signicant difference
and proved the VHI-10’s validity to be strong.
Paediatric Voice Handicap Index
Zur et al (2007) developed the Pediatric Voice
Handicap Index (pVHI), which measures
parental perception of the social, emotional,
and academic impact of a voice disorder on
their child. This adaptation of the VHI to meet
a child’s needs involved changing the language
of the items to reect a parent’s responses, and
eliminating questions that would not relate to
a child. Researchers tabulated responses, and
modified the VHI’s content and language,
resulting in a nal pVHI with functional, physi-
cal, and emotional subscales.
Validity proved good as statistical analysis
of responses on the pVHI compared between
33 caregivers of children with pre- and post-
laryngotracheal reconstructions and 45caregiv-
ers of children without voice disorders differed
greatly for each subscale and total scores (Zur
et al, 2007). Further, pVHI subscale and total
scores correlated similarly with those reported in
the original VHI validation study. The pVHI also
offers good internal consistency and reliability.
Voice Handicap Index-Partner
Zraick et al (2007) developed the Voice
Handicap Index-Partner (VHI-P) to measure
partner perception of the physical, functional,
and emotional impact of a voice disorder on the
patient. The process adaptating the VHI to meet
the needs of the partner involved rewriting the
items from the patient’s primary communica-
tion partner’s viewpoint.
Zraick et al (2007) compared the responses on
the VHI of 20patients with moderate dysphonia
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310 International Journal of Therapy and Rehabilitation, June 2013, Vol 20, No 6
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and the VHI-P by their communication partners;
this revealed a close agreement between patients
and their communication partners regarding the
patient’s degree of voice handicap. This close
agreement extended to each of the three VHI
subscales: physical, functional, and emotional,
with partners perceiving the physical domain as
representing the most handicapped. Of particular
note is the nding that partners tended to under-
estimate the emotional handicap experienced by
the patient with dysphonia.
Singing Voice Handicap Index
(SVHI-10)
Cohen et al (2007) developed the Singing Voice
Handicap Index (SVHI-10), which measures
the physical, emotional, social, and economic
effects of voice difculties on singers. Singers
are a population with more self-reported voice
problems and vocal disability than non-singers
(Rosen and Murry, 2000).
Cohen et al (2007) reported that the correla-
tion between the SVHI-10 and self-rated sing-
ing voice impairment proved to be moderate,
and that responsiveness proved good as the
SVHI captured less handicap post-treatment
(Cohen et al, 2008). As one would expect, the
SVHI-10 and SVHI were highly correlated.
Singing Voice Handicap Index
Developed by Cohen et al (2009), the Singing
Voice Handicap Index-10 (SVHI-10) measures
the physical, emotional, social, and economic
effects of voice difculties on singers. Drawn
directly from the SVHI, the SVHI-10 provides
necessary information regarding voice difcul-
ties while reducing patient burden. Cohen et al
(2009) declared that the SVHI-10 was appro-
priate for ‘broad utilization’ as they found
that its validity proved good. Additionally, the
SVHI-10 and SVHI were highly correlated.
Vocal Performance Questionnaire
Carding et al (1999) developed the Vocal
Performance Questionnaire (VPQ), which
enables patients to rate the severity of certain
voice aspects to their normal voice usage. The
VPQ contains 12 items, each of which holds a
numerical value of 1 to 5, with a total sever-
ity score calculated. Possible total scores
range from 12 (normal vocal function) to 60
(severely-limited vocal function).
Following comparison of the VPQ and VHI-
10, Deary et al (2004) reported that internal
consistency and reliability proved to be good.
Deary et al (2004) concluded that the VPQ
might be useful in clinical settings in which
time constraints limit the ability to administer
longer instruments such as the VHI.
Voice Symptom Scale
Deary et al (2003) also developed the Voice
Symptom Scale (VoiSS), which measures
impairment, emotion, and physical symptoms.
Stanton et al (2009) reported that VoiSS scores
were worse for patients with functional or
structural laryngeal abnormalities than for indi-
viduals with normal larynges in their study of
perceived vocal morbidity.
Deary et al (2010) used the Mokken scale
to investigate item relationship within
the VoiSS. They aimed to identify: the
patient’s perspective of voice disorder;
and the relationship between dysphonia and
psychosocial impairment. The authors con-
cluded that a hierarchy of self-perception exists
and reported a vocal severity ranging from
‘least difcult’ to ‘most difcult’. Additionally,
Deary et al (2010) stated that items at the mild
end of the continuum reflected the ‘practi-
cal consequences’ of a voice disorder, while
those at the severe end reected ‘emotional and
social consequences’.
Voice Activity and Participation Prole
Ma and Yiu (2001) developed the Voice
Activity and Participation Profile (VAPP), a
28-item self-report instrument. As Ma and Yiu
describe, the VAPP evaluates the perception of
voice problems, activity limitations, and partic-
ipation restriction using the WHO International
Classication of Impairments, Disabilities and
Handicaps concept (WHO, 1980; 1997).
The VAPP attempts to quantify the following
domains: the self-perceived severity of voice
problems, effect on a person’s job, effect on
daily communication, effect on social commu-
nication, and effect on their emotions. In the
authors’ initial study, they showed that dys-
phonic patients’ perceptions of their voice
problem correlated positively with their per-
ceived limitations in voice activities and
restricted participation (Ma and Yiu, 2001). The
self-perceived voice problem had little correla-
tion with the degree of voice quality impair-
ment measured acoustically and perceptually.
Voice-Related Quality of Life
Hogikyan and Sethuraman (1999) developed
the Voice-Related Quality of Life (V-RQOL)
tool, which measures the impact of a voice
disorder on the patient’s life. The V-RQOL
contains 10 items and provides a stand-
ard score. Using the V-RQOL and the Center
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International Journal of Therapy and Rehabilitation, June 2013, Vol 20, No 6 311
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for Epidemiology Studies Depression Scale
(CES-D), Cohen (2010) assessed the effect
of dysphonia on QOL. He reported an inverse
relationship between V-RQOL and CES-D
scores. Analysis identified clinically-signifi-
cant predictors that signicantly lower one’s
V-RQOL score.
Morzaria and Damrose (2012) compared
the VHI, VHI-10, and the V-RQOL to deter-
mine responsiveness when treating adductor
spasmodic dysphonia with botox. The authors
concluded that all three instruments correlated
highly, suggesting that the V-RQOL is well
suited to capturing the morbidity of spasmodic
dysphonia, and reecting the effects of treat-
ment with botox.
Paediatric Voice-Related Quality of
Life Survey
Bosely et al (2006) developed the Paediatric
Voice-Related Quality of Life survey
(PVRQOL), to measure voice changes over
time in the paediatric population. Drawn
directly from the V-RQOL, the authors altered
the structure of each of the 10 items of the
PVRQOL to reect parent proxy administration
rather than self-administration.
Hartnick (2002) jointly administered the
V-RQOL and the Paediatric Voice Outcomes
Survey (PVOS) to 104 caregivers of children
with various causes of dysphonia. He repored
that the physical-functional scores on the
PVRQOL agreed most closely with the PVOS,
while the social-emotional scores correlated
to a lesser degree but were still significant.
Blumin et al (2008) established normative data
for the PVRQOL, nding that a minimum score
of 86 reected normal voice-related QOL for
this population.
Voice Outcome Survey
In order to measure QOL in patients with uni-
lateral vocal fold paralysis, Glicklich et al
(1999) developed the Voice Outcome Survey
(VOS). This is a brief, 5-item, valid, reliable,
and highly-sensitive outcome measure, the
raw scores on the VOS transform to a scale of
0 (worst) to 100 (best) for ease of interpreta-
tion. Low scores describe a poor QOL and high
scores describe a better QOL.
In a study of 56 patients, Glicklich et al
(1999) found a high correlation between the
VOS and subscales of the Short-Form 36v2
and with select acoustic voice parameters.
Nevertheless, Jacobson et al (1997) questioned
the reliability of the VOS assessment tool and
its limited applicability.
Paediatric Voice Outcomes Survey
Hartnick (2002) developed the PVOS to
measure QOL in the paediatric population.
Adaptation of the VOS involved modifying item
structure to reect parent-proxy administration.
Using the PVOS as well as the Reflux
Symptom Index (RSI), the Reux Finding Score
(RFS), and oesophageal biopsy results, Simons et
al (2008) obtained scores of the three measures,
measured PVOS and RSI internal consistency,
RFS intrarater and interrater reliability, and cor-
relations between all four measures (P=<0.05).
They found a statistically significant correla-
tion between the PVOS and RSI scores; how-
ever, they did not find statistically significant
correlations between RFS and PVOS scores or
PVOS scores and esophageal biopsy results. The
authors suggested that the RSI could be used as
a parent-proxy in addition to the PVOS, but that
this tool requires further validation.
Paediatric Voice Symptom
Questionnaire
Ingrid et al (2012) developed the Pediatric
Voice Symptom Questionnaire (PVSQ), which
measures QOL from the perspective of the
patient and the patient’s parent. The PVSQ con-
sists of two forms, each with parallel sets of
questions, e.g. ‘Do you have to strain when
you speak?’ and ‘Does your child have to strain
when he/she speaks?’.
Table 1. Currently available voice-related qol instruments and translations
QOL
Instrument
Developer Translations available
VHI Jacobson et al (1997) Arabica, Brazilian-Portugueseb, Chinesec,
Croatiand, Dutche, Filipinof, Frenchg,
Germanh, Greeki, HebrewJ, Hindik, Italianl,
Japanesem, Norwegiann, Persiano, Polishp,
Portugueseq, Spanishr, Swedishs, Turkisht
VHI-10 Rosen et al (2004) Chinesec, Hebrewu, Spanishr
pVHI Zur et al (2007) Arabicv, Italianw, Koreany
VHI-P Zraick et al (2007) None
SVHI Cohen et al (2007) Frenchy, Swedishz
SVHI-10 Cohen et al (2009) None
VPQ Carding et al (1999) None
VoiSS Deary et al (2003) Brazilianaa
V-RQOL Hogikyan and
Sethuraman (1999) Brazilianbb, Norwegiancc
PVRQOL Bosely et al (2006) None
PVOS Hartnick (2002) None
PVSQ Ingrid et al (2012) None
VAPP Ma and Yiu (2001) Finnishdd
CVHI-10 Ricci-Maccarini et al (2012) None
VOS Glicklich et al (1999) Chineseee
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A pilot study revealed that children 6 years of
age or older are able to comprehend the assess-
ment procedures and most of the items as well as
concentrate during administration. Validity and
test-retest reliability proved excellent (Ingrid et al,
2012). Additionally, the tool appeared to be able
to adequately discriminate between normal and
dysphonic speakers at both parent and child levels.
Children’s Voice Handicap Index-10
Ricci-Maccarini et al (2012) developed
the Children’s Voice Handicap Index-10
(CVHI-10), which measures the paediatric
voice patient’s perception of his or her voice
handicap. Drawn from the VHI-10, adaptation
of the CVHI-10 involved: rephrasing words
that would be unfamiliar or inapplicable to
children; and modifying items according to
language and cultural differences. Correlation
proved weak to moderate between clinical and
self-reported perceptions of participants’ voice
disorders (Ricci-Maccarini et al, 2012). Ricci-
Maccarini et al (2012) acknowledged the need
for future research so that their ndings may be
duplicated in a more diverse sample of children
where literacy levels are controlled. Further,
they reported the need to establish validity and
reliability according to age range.
Voice Disability Coping Questionnaire
Developed by Epstein et al (2009), the Voice
Disability Coping Questionnaire (VDCQ)
measures how patients cope with voice prob-
lems. The 28-item VDCQ measures four
subscales: social support, passive coping,
avoidance, and information seeking.
Epstein et al (2009) validated the VDCQ
on 80 patients who had adductor spasmodic
dysphonia (ADDSD) as well as muscle ten-
sion dysphonia (MTD). They concluded that
the VDCQ represents a valid and reliable
instrument, which differentiates between clin-
ical groups and facilitates a patient-centered
approach, therefore enhancing understanding of
voice disorders.
International versions
Simple survey translation of voice disor-
der quality of life tools may not be sufcient
for these tools to serve as international ver-
sions (Berkanovic, 1980). Values and norms
as well as the perception of QOL and the ways
in which health problems are expressed vary
from culture to culture (Kleinmann et al, 1978).
For the survey to be useful in another culture,
it must prove valid and reliable (Cook and
Beckman, 2006) in the language into which it
is translated.
In translating surveys, three key consid-
erations exist: semantic equivalence across
languages, conceptual equivalence across cul-
tures, and normative equivalence to the origi-
nal survey (Measurement and Methods Core of
the Center for Aging in Diverse Communities,
University of California San Francisco, 2007).
Semantic equivalence refers to the meaning
of the translated text compared with the origi-
nal text. Does the item in the translated sur-
vey mean the exact same thing as the item in
Table 2. Readability results for voice-related pro questionnaires
PRO Instrument FRE* aFOG bFORCAST c
VHI 86 7.6 7.7
VHI-10 81 7.5 8.4
VHI-P 86 7.2 7.8
pVHI 77 8.7 8.4
SVHI 56 8.4 13.3
VPQ 84 6.5 9.5
VoiSS 89 7.4 7.3
VAPP 66 8.1 10.0
V-RQOL 73 8.0 8.6
PVRQOL 88 5.4 8.3
VOS 82 5.8 9.4
PVOS 81 5.6 8.9
SVHI-10 **
CVHI-10 **
PVSQ **
Mean 79.1 7.2 9.0
Median 81.5 7.5 8.5
SD 3.5 1.4 0.8
Range 56–89 5.4–9.0 7.3–13.3
Abbreviations: VHI, Voice Handicap Index; VHI-10, Voice Handicap Index-10; VHI-P, Voice
Handicap Index-Partner; pVHI, Paediatric Voice Handicap Index; SVHI, Singing Voice Handicap
Index; VPQ, Vocal Performance Questionnaire; VoiSS, Voice Symptom Scale; VAPP, Voice Activity
and Participation Prole; V-RQOL, Voice-Related Quality of Life; PVRQOL, Paediatric Voice-Related
Quality of Life; VOS, Voice Outcomes Survey; PVOS, Pediatric Voice Outcomes Survey; SVHI-10,
Singing Voice Handicap Index-10; CVHI-10, Children’s Voice Handicap Index-10; PVSQ, Paediatric
Voice Symptom Questionnaire.
* Conversion to grade level: 90–100=5th grade; 80–90=6th grade; 70–80=7th grade;
60–70=8th and 9th grade; 50–60=10th through 12th grade.
** Newer questionnaires not yet analyzed for readability.
a The Flesch Reading Ease readability formula: RE=206.835 - (1.015 x ASL) - (84.63 x SW),
where RE=readability ease; ASL=average sentence length (i.e. the number of words divided by
the number of sentences); and ASW=average number of syllables per word (i.e. the number of
syllables divided by the number of words). The output is a number ranging from 0 to 100. The
higher the number, the easier the text is to read.
b The Gunning’s Fog Index (or FOG) readability formula: Grade level=0.4 (ASL + PHW), where
ASL=average sentence length (i.e. number of words divided by the number of sentences) and
PHW=percentage of hard words. Short sentences written in Plain English achieve a better score
than long sentences written in complicated language. Requires a minimum of 100 sample words.
c The FORCAST readability formula: GL=20 - (n/10), where GL=grade level and n=number of
monosyllabic words in the sample text.
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the original survey? Conceptual equivalence
refers to the concept being measured as the
same across groups, even though the word-
ing to describe it may be different. Normative
equivalence refers to the ability of the trans-
lated text to address social norms that may dif-
fer across cultures. For example, some cultures
are less willing to share personal information
or discuss certain topics than other cultures.
In translating a self-report questionnaire, the
researcher must consider linguistic and cul-
tural differences.
Currently, the original English version of
the VHI is the most frequently-translated QOL
voice survey with more than 20translations
available (Table 1). Additional QOL voice sur-
veys that have been translated include the VHI-
10, pVHI, V-RQOL, and SVHI (Table 1).
DISCUSSION
Psychometric considerations
Franic et al (2005) published a compara-
tive study to determine which instru-
ments had the appropriate psychometric
properties — the properties that the Social
Security Administration’s Evidence Practice
Center Team (EPC) established. Not only are
the current instruments lacking in the breadth
and depth of the health they measure, but
also in their reliability for either individual
patient decision making or clinical decision
making, and convergent and/or discriminant
validity. The authors compared the psycho-
metric properties of the VAPP, VHI, V-RQOL
and VOS quality of life assessment tools. The
authors concluded that the VHI and V-RQOL
were favourable over the VOS. In particular,
the VHI was rated as favorable for individual
decision-making, while the V-RQOL was rated
favourably for group decision making. The
authors indicated that further research on the
psychometric evaluation of voice-related QOL
instruments should be conducted.
Branski et al (2010) reviewed the content
development of nine currently available voice-
related QOL questionnaires. As stated by the
U.S. Food and Drug Administration (FDA),
instrument content development should
include patient input to ensure the question-
naire reects patient concerns (FDA, 2006).
However, Branski et al (2010) discovered that
only ve of the nine voice-related QOL ques-
tionnaires contained patient interviews and
only the VoiSS provided data regarding patient
input. The VHI, V-RQOL, VOS, and the VoiSS
fullled standard criteria for item reduction.
The remaining questionnaire developers used
expert opinion for item reduction and none
of the developers used scaling assumptions.
Branski et al (2010) also state that modifying
instruments to apply to dysphonic subgroups
‘violates the fundamental tenets of instrument
development’ and that translation of instru-
ments without proper linguistic validation
may not ‘capture culturally relevant patient
perspectives’. Finally, Branski identied the
need for use of more contemporary psycho-
metric methods, e.g. Rasch measurement, Item
Response Theory.
Several voice-related QOL instruments exist
that provide qualitative and quantitative infor-
mation regarding patient self-perceptions of
dysphonia. Until recently, however, no infor-
mation on patient accessibility with regards to
literacy level existed. Further, no consensus
existed on the literacy level at which a QOL
instrument should be written. The Scientific
Advisory Committee of the Medical Outcomes
Trust (SACMOT) considers respondent and
administrative burden a principal focus for
instrument review. One third of the QOL
instruments studied by Zraick and Atcherson
(2012) exceeded a ninth grade reading level
(Table 2). Zraick and Atcherson suggested
making readability a consideration in stand-
ardization of QOL instruments. Additionally,
as experts in communication, speech-language
pathologists should be mindful of the literacy
burden of these instruments on patients or oth-
ers completing them.
DIRECTIONS FOR FUTURE RESEARCH
Many voice-related QOL instruments are used
across patient populations. The advisability of
doing so, however, is questionable (Schindler
et al, 2012), as the lived experience of patients
across populations may be very different
(Boone et al, 2013). In a study by Detmar et al
(2002), both physicians and patients suggested
the increased need for voice-related QOL
instruments for specic patient populations.
Future research should focus on develop-
ing voice-related QOL instruments for patients
with specic diseases or conditions, for exam-
ple: neurologic-based voice disorders such as
essential vocal tremor (Barkmeier-Kraemer et
al, 2011) and spasmodic dysphonia (Simonyan
and Ludlow, 2012); age-related voice disorders
such as presbyphonia (Etter et al, 2012); and
laryngeal cancer (Blood, 1993). Additionally,
there is a need for voice-related QOL instru-
ments for adolescents with voice disorders, as
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314 International Journal of Therapy and Rehabilitation, June 2013, Vol 20, No 6
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well as other heavy occupational users of voice
such as teachers (Roy et al, 2004).
CONCLUSION
QOL is a subjective and multidimensional con-
struct that encompasses virtually any aspect of
life contributing to an individual’s perception
of his or her life position. Researchers have
designed several QOL instruments to measure
the impact of voice disorders on QOL. The pur-
pose of these tools is to understand the manner
and extent to which a voice disorder impacts
a patient’s life. Armed with this knowledge, a
clinician will be able to better serve the patient,
and the patient will more likely nd satisfaction
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ISBN-13: 978-1-85642-334-2; 234 x 156 mm; paperback; 112 pages; publication 2007
Promote independence in older people
Visit www.quaybooks.co.uk or call 01722 716 935
Promoting
independence
and activity
in older people
Julie I Swann
9 781856423342
ISBN 978-1-85642-334-2
www.quaybooks.co.uk
Promoting independence and activity in older people Julie I Swan
This book is centred upon articles published in the practical
series of Nursing and Residential Care since 2004.
The author focuses on empowering care assistants to make
a positive difference to the lives of residents in care homes.
The aim is to facilitate independence by utilising different
techniques and assistive devices, and by ensuring that the
environment promotes independence to maximise residual
skills, making tasks easier for residents and carers alike.
Several chapters expand on knowledge evidence for
S/NVQ levels 2 & 3 in care, providing activity organisers,
care assistants and managers with new resources and
practical ideas.
Julie I Swann is an Independent Occupational Therapist
IndActiv fullcover.indd 1 13/4/07 10:17:54
Julie I Swann
n Essential reading for S/NVQ levels 2 and 3
n Chapters based upon articles published in
the series of Nursing and Residential Care
since 2004
n Aims to facilitate independence by using
different techniques and assistive devices
n Aims to ensure the environment promotes
independence to maximise residual skills
n A practical resource for practitioners,
providing activity organisers, care assistants
and managers with resources
and new ideas
