Otolaryngology (ENT)

The Voice Handicap Index (VHI): A Full Guide for Researchers and Clinicians

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Introduction

The Voice Handicap Index (VHI) is a cornerstone instrument in the field of speech-language pathology and laryngology, meticulously designed to assess the self-perceived handicap associated with voice disorders. Developed in 1997 by Barbara H. Jacobson, Alex Johnson, and colleagues, and published by the American Speech-Language-Hearing Association (ASHA), the VHI was created to provide a psychometrically robust inventory for patients with a wide variety of voice disorders. Its widespread adoption and authority are reflected in its extraordinary citation count, with over 3,700 citations on Google Scholar.

This article explores the VHI’s features, comprehensive scoring, diverse applications, and psychometric properties, offering a definitive resource for experts.

Key Features of the Voice Handicap Index (VHI)

Purpose and Use

The primary purpose of the VHI is to measure the multifaceted impact of a voice disorder on an individual’s quality of life. It is not merely a symptom checker; rather, it quantifies the functional, physical, and emotional dimensions of voice-related disability. In clinical settings, it is invaluable for baseline assessments and for tracking outcomes. Furthermore, its sensitivity makes it a powerful tool for evaluating the effectiveness of specific voice treatment techniques, such as Vocal Function Exercises or the Accent Method

Target Population

The VHI is specifically designed and validated for adult patients aged 18 and older. Its normative data applies to a broad spectrum of the adult population, including:

Young Adults (18-24 years)
Middle-Aged Adults (25-44 years)
Older Adults (45-64 years)
Seniors (65+ years)

While this tool is not intended for pediatric populations, specific adaptations (like the Pediatric VHI) exist for that purpose.

Structure

The VHI comprises 30 items organized into three distinct 10-item subscales:

Functional (VHI-F): This subscale (10 items) gauges the impact of the voice disorder on daily communication activities, such as using the telephone or talking in social settings.
Physical (VHI-P): This subscale (10 items) addresses the patient’s perceptions of laryngeal discomfort, vocal effort, and specific voice output characteristics.
Emotional (VHI-E): This subscale (10 items) measures the patient’s affective responses to their voice disorder, including feelings of frustration, anxiety, or depression.

Scoring Method

The VHI employs a 5-point Likert scale for its 30 items, where patients rate the frequency of an experience. The scoring is straightforward and weighted as follows:

Never = 0 points
Almost Never = 1 point
Sometimes = 2 points
Almost Always = 3 points
Always = 4 points

To calculate the scores:

Total Score: The sum of all 30 item scores, ranging from 0 to 120. A higher score reflects a more significant self-perceived voice handicap.
Subscale Scores: The sum of the 10 items within each subscale (Functional, Physical, Emotional), with each subscale score ranging from 0 to 40.

For clinical interpretation, the total score provides clear cut-offs for severity:

0–30: Mild voice handicap
31–60: Moderate voice handicap
61–120: Severe voice handicap

Administration Format

The VHI is designed for maximum practicality in busy research and clinical environments. It takes only 5–10 minutes to administer. As a self-administered questionnaire, it requires no special training for the patient or administrator. Moreover, it is highly versatile and can be administered through virtually all formats, including:

Paper-based forms.
Digital (online) platforms.
Interviews (in-person, phone, or video call).

Applications of the Voice Handicap Index (VHI)

The VHI serves multiple critical roles in both clinical practice and academic research:

Screening: It quickly identifies patients experiencing significant quality-of-life impairments due to their voice disorder, flagging them for more intensive intervention.
Monitoring: The tool is highly sensitive to change, making it ideal for tracking a patient’s progress over time and quantifying their response to therapy.
Treatment Planning: By revealing which domain (functional, physical, or emotional) is most affected, the VHI subscales help clinicians tailor therapies to the patient’s specific needs.
Research: As its 3,700+ citations demonstrate, the VHI is a gold-standard outcome measure in clinical trials for evaluating the efficacy of phonosurgery, voice therapy, and other novel treatments.

Language and availability

A major strength of the VHI is its extensive cross-cultural validation and availability. It has been translated into a multitude of languages, facilitating global, multi-center research. Available languages include:

Arabic
English
Mandarin Chinese
Spanish
French
Russian
German
Others.

The VHI is free for non-commercial clinical and research use. However, it is published under a Proprietary license, and any commercial use requires contacting the publisher, the American Speech-Language-Hearing Association.

Reliability and Validity

The VHI is internationally recognized as a highly reliable and valid instrument. Its psychometric properties are exceptionally strong. The original validation study demonstrated outstanding internal consistency, with a Cronbach’s alpha of 0.95. Subsequent validation studies across numerous languages have consistently reaffirmed its high reliability, test-retest reliability, and construct validity, solidifying its status as a robust tool for measuring voice handicap.
- Validation Studies:
- The original validation study link.
- The French validation study link.
- The Russian validation study link.
- The Hindi validation study link.
- The Chinese validation study link.
- The German validation study link.
- The Dutch validation study link.
- The Italian validation study link.
- The Arabic validation study link.

Limitations and Considerations

As with any self-report questionnaire, clinicians and researchers should consider that patient responses may be influenced by recall bias or individual interpretation of the questions. Despite this general consideration, the VHI’s extensive validation and strong psychometric properties mean it remains one of the most trusted instruments in the field.

Additional Resources

For researchers and clinicians interested in utilizing the VHI, the following resources are essential:
- Original Validation Study link.
- Questionnaire Access: A PDF of the questionnaire can be accessed through this link.
- Author Inquiries: For specific inquiries, you can contact the original author: Barbara H. Jacobson, PhD, at the Division of Speech-Language Sciences and Disorders, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, Michigan 48202.

Frequently Asked Questions (FAQ)

1. Who can use the VHI?
  Clinicians, researchers, and healthcare providers use the VHI for patients aged 18 and older with voice disorders.
1. How long does it take to complete the VHI?
  Patients typically take 5 to 10 minutes to complete the VHI, making it highly feasible for use in busy clinical and research settings.
1. How is the VHI administered?
  Healthcare teams can administer the VHI via paper-based forms, digital (online) platforms, interviews (in-person), or phone/video call formats, offering significant flexibility.
1. Is there any cost to using the VHI?
  The VHI is free for non-commercial clinical and research use. For commercial or for-profit applications, permission from the American Speech-Language-Hearing Association may be necessary.

A word from ResRef about Voice Handicap Index (VHI)

The VHI-30 remains a gold-standard instrument for assessing self-perceived voice handicap. Its robust psychometric properties and extensive cross-cultural adaptations make it a reliable choice for clinicians and researchers worldwide. ResRef highlights its versatility across all adult populations, its practical 5-10 minute administration, and its immense value in both clinical decision-making and the evaluation of treatment outcomes.

References

Johnson, Alex & Jacobson, Barbara & Grywalski, Cynthia & Silbergleit, Alice & Jacobson, Gary & Benninger, Michael. (1997). The Voice Handicap Index (VHI): Development and Validation. American Journal of Speech-Language Pathology. 6. 66-70. Link.
Gaëlle Degroote, Jézabelle Simon, Stéphanie Borel, Lise Crevier-Buchman; The French Version of Speech Handicap Index: Validation and Comparison with the Voice Handicap Index. Folia Phoniatr Logop1 December 2011; 64 (1): 20–25. Link.
Krishtopova MA, Semenov SA, Petrova LG. Lingvisticheskaya adaptatsiya i podtverzhdenie primeneniya russkoi versii oprosnika Indeks izmeneniya golosa-30 (Voice Handicap Index (VHI)-30) u patsientov s disfoniei [Linguistic adaptation and validation of the voice handicap index (VHI)-30 in patients with dysphonia into Russian]. Vestn Otorinolaringol. 2021;86(3):20-27. Link.
Singh P, Dhakar JS, Singh T. Development and Validation of the Voice Handicap Index-10 (VHI-10) in Hindi. Indian J Otolaryngol Head Neck Surg. 2025 Mar;77(3):1256-1264. Link.
Lam PK, Chan KM, Ho WK, Kwong E, Yiu EM, Wei WI. Cross-cultural adaptation and validation of the Chinese Voice Handicap Index-10. Laryngoscope. 2006 Jul;116(7):1192-8. Link.
Nawka T, Wiesmann U, Gonnermann U. Validierung des Voice Handicap Index (VHI) in der deutschen Fassung [Validation of the German version of the Voice Handicap Index]. HNO. 2003 Nov;51(11):921-30. Link.
Hakkesteegt MM, Wieringa MH, Gerritsma EJ, Feenstra L. Reproducibility of the Dutch version of the Voice Handicap Index. Folia Phoniatr Logop. 2006;58(2):132-8. Link.
Schindler A, Ottaviani F, Mozzanica F, Bachmann C, Favero E, Schettino I, Ruoppolo G. Cross-cultural adaptation and validation of the Voice Handicap Index into Italian. J Voice. 2010 Nov;24(6):708-14. Link.
Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T. Validation and cultural modification of Arabic voice handicap index. Eur Arch Otorhinolaryngol. 2010 Nov;267(11):1743-51. Link.