First report on the reliability and validity of speech handicap index in ...

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HEAD AND NECK
The definitive version is available at:
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Published text:
R C Dwivedi, S St Rose, J W Roe, E Chisholm, B Elmiyeh, C
M Nutting, P M Clarke, C J Kerawala, P H Rhys-Evans, K J
Harrington, R Kazi (2010) <strong>First</strong> <strong>report</strong> on the reliability and
validity of speech handicap index in native English-speaking
patients with head and neck cancer, Head and Neck
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<strong>First</strong> <strong>report</strong> on the Reliability and Validity of Speech Handicap Index (SHI) in
Native English-speaking Head and Neck Cancer Patients
Authors:
Raghav C. Dwivedi, MRCS, DOHNS, MS 1,2 ; Suzanne St. Rose, PhD 1,3 ; Justin W.G.
Roe, MSc. Cert. MRCSLT 1,2 ; Edward Chisholm, MRCS, MD 1 ; Behrad Elmiyeh, MRCS,
DOHNS 1 ; Christopher M. Nutting, FRCR 1,2 ; Peter M. Clarke, FRCS 1 ; Cyrus J. Kerawala,
FRCS, FDSRCS 1,2 ; Peter H. Rhys-Evans, FRCS 1,2 ; Kevin J. Harrington, FRCR, PhD 1,2 ;
Rehan Kazi, MS, FRCS 1,2
Affiliations:
1
Head and Neck Unit, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.
2
The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK.
3
Department of Statistics, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
Address for correspondence:
Dr. Raghav Dwivedi
Head and Neck Unit
Royal Marsden Hospital
Fulham Road, London, SW3 6JJ, UK
Ph: 0044 207 808 2202; E-mail: raghav_dwivedi@rediffmail.com
Funding and financial support
Dr. Raghav Dwivedi, Dr. Rehan Kazi and Mr. Justin Roe are supported by Research
Grants from the Head and Neck Cancer Research Trust/ The Oracle Cancer Trust.
Acknowledgement:
The authors would like to thank Mr. Rico N. Rinkel, Department of Otolaryngology-
Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands
and Prof. Adrian Fourcin, Department of Phoniatrics and Linguistics, University College
London, UK for their continuous support and encouragement for this study.
Running title:
Validation of English Version of Speech Handicap Index
Key words: Speech Handicap Index (SHI); Head and neck cancer; Oral cancer;
Oropharyngeal cancer; Quality of life.
1

Abstract:
Background
Post-treatment speech problems are seen in nearly half of head and neck cancer patients.
Although there are many voice-specific scales, surprisingly there is no speech-specific
questionnaire for English-speaking head-neck cancer patients. The aim of this study was
to validate the Speech Handicap Index (SHI) as the first speech-specific questionnaire in
the English language.
Method
Fifty-five consecutive patients in follow-up for oral and oropharyngeal cancer completed
the SHI and University of Washington Quality of Life Questionnaire (UWQOL V.04).
Thirty-two patients completed both questionnaires again four weeks later to address testretest
reliability.
Results
Internal consistency, test-retest reliability, construct validity and group validity of the
SHI were found to be highly significant (P

Introduction:
Head and neck cancer per se and its treatment may negatively affect patient's functional
status and quality of life. 1-6
Patients often <strong>report</strong> speech deterioration, swallowing
difficulties and facial appearance changes which may ultimately result in psycho-social
problems. 7-10 Nowhere else is this more obvious than in cancers involving the oral cavity
and oropharynx. 1,2 The presence of post-treatment speech problems in patients with oral
and oropharyngeal cancers has been well documented in the literature by both
prospective and retrospective studies. 11-29 According to recent estimates, nearly 50% of
oral and oropharyngeal cancer patients encounter speech problems in their day-to-day
life, 2 which is not surprising as the tumor and its treatment often has a detrimental impact
on the functioning of important speech articulators (tongue, alveolar ridge, hard and soft
palate and floor of mouth) in the oral cavity and the oropharynx. 1 Timely detection of
post-treatment speech problems and their appropriate rehabilitation is vital in providing a
good functional QOL to these patients. 1,13
Evaluation of patient’s speech can be undertaken by either subjective methods or
objective speech analysis techniques. 1,30 Easiest and most commonly used methods are
subjective speech evaluation by using patient self-rated health-related QOL
questionnaires (HRQOL). 1,31 These can be general, disease-specific or
symptom/function-specific QOL questionnaires. 1,31 To date, there are over 1000
instruments available for measuring health-related QOL in patients. 31 Some commonly
used head-neck cancer -specific questionnaires are University of Washington QOL
(UWQOL), European Organization for Research and Treatment of Cancer head-neck
3

module (EORTC-HN) and Functional Assessment of Cancer Therapy head–neck module
(FACT-HN). 1,31 Examples of symptom/function-specific questionnaires commonly used
in HNC patients are Performance Status Scale (PSS), MD Anderson Dysphagia Inventory
(MDADI) and Swallowing Quality of Life Questionnaire (SWAL-QOL) for swallow
assessment and Voice Handicap Index (VHI) and Voice Related QOL (VRQOL) for
voice assessment. 1,31
Although numerous voice-specific scales exist for use in the
literature, there is no speech-specific questionnaire available for English-speaking headneck
cancer patients 1 . It is important to distinguish between voice and speech; voice is a
laryngeal function while speech is the final end-product of complex interplay between
vocal tract articulators, hence requires specific assessment tools. 1
The first speechspecific
questionnaire, the Speech Handicap Index (SHI) was developed and validated in
the Dutch language by Rinkel et al 2 in the latter half of 2008. Our work aims at filling
this gap by validating for the first time the SHI for English-speaking head-neck cancer
patients.
Materials and methods:
Patients
Following local research ethics committee approval, sixty-three consecutive Englishspeaking
patients in follow-up for oral or oropharyngeal cancers at The Royal Marsden
Hospital, London, UK were recruited for this study. All patients had received curative
treatment in the form of surgery (with or without chemo-radiotherapy). Patients with
end-stage disease, other associated malignancies or any diagnosed neuromuscular disease
known to affect speech function were excluded from the study. Tracheostomised patients,
4

patients within the first six months of initial treatment and those over 80 years of age
were also excluded from the study.
Questionnaires
The development of the Dutch version of the Speech Handicap Index (SHI) was largely
based on the widely used and popular voice-specific scale the ‘Voice Handicap Index’
(VHI) 32 by Rinkel et al. 2 Consequently, our English version of SHI (Appendix) is on the
same lines. 32 It has 30 well-constructed questions to evaluate the patient’s speech and
psycho-social functions. These questions were adapted from the original manuscript of
the development and validation of the Dutch version of the SHI. Here the questions were
translated and then back-translated by expert professional translators to ensure that words
and nuances are correctly matched as was confirmed by the Dutch group. Our English
version of the SHI is based on a Likert five- point scale with response categories as never
(0); almost never (1); sometimes (2); almost always (3) and always (4). Total SHI score is
calculated by adding all the response numbers and can range from 0-120; higher scores
indicate more severe speech-related problems. In addition to these 30 questions, there is a
global question which rates the patient’s overall speech quality. Here there are four
response categories: excellent; good; average and bad which are scored as 0, 30, 70 and
100. Higher scores again indicate a greater speech problem.
For the purpose of validity, we have utilized the UWQOL V.04 as a comparative QOL
scale. This is a validated, widely-used, self-administered head and neck cancer-specific
questionnaire with 12 domains for evaluation, speech being one of them. Other domains
included are pain, appearance, activity, recreation, swallowing, chewing, shoulder
5

function, taste, saliva, mood and anxiety. 33,34 Here speech is evaluated by a single
question based on a Guttman four- point scale and scored as 0, 30, 70 and 100. Higher
scores indicate better speech function. UWQOL social function score is computed as the
simple average of 6 domains (anxiety, mood, pain, activity, recreation and shoulder
function).
Administration of questionnaire
Patients were given the SHI and UWQOL questionnaires in the outpatient clinic with a
personalized covering letter explaining briefly the purpose of the study. In addition, the
questionnaires and the purpose of study were also explained (face-to-face) to each
patient. The patients were requested to complete both scales within 24 hours of each
other and return the questionnaires via post. A randomly selected subset of thirty-two
patients was asked to complete both the questionnaires (SHI & UWQOL) again after four
weeks in order to assess test-retest reliability.
Statistical analysis
Demographic and treatment details of all patients were extracted from the medical
records and the data were entered in to a worksheet (Excel 05; Microsoft Corp., WA,
USA). Questionnaire data were also entered in the worksheet for the purpose of analysis.
Analysis was performed using the commercially available Statistical Package for Social
Sciences-15 statistical software (SPSS Inc., Chicago, IL, USA). Questionnaire data were
then subjected to reliability and validity assessment.
6

Reliability
Both the internal consistency and test-retest reliability were measured in this study.
Internal consistency and test-retest reliability were determined using Cronbach’s alpha
coefficient and Spearman’s rank correlation coefficient, respectively. A high Cronbach’s
alpha (>0.70) and Spearman’s correlation (rho > 0.60) value indicates adequate internal
consistency and test-retest reliability. 35
Validity
Construct and group validity were assessed by correlating speech item score with related
constructs from the UWQOL questionnaire. ‘Bench marks’ for evaluating correlation
values are >0.60: strong correlation; 0.40 to 0.60: moderate to substantial correlation;

of 87%. The median age of the group was 59.4 years (range: 35.9-80.0) with 36 males
and 19 females. Detailed patient characteristics are provided in Table 1. Briefly, 17
(30.9%) patients had cancer of the oral cavity while 38 (69.1) patients had oropharyngeal
cancer.
Reliability
Internal consistency
The internal consistency reliability for Total SHI (mean of all 30 questions) and SHI
speech domain (mean of 14 questions specific for evaluation of speech functions) as
calculated by Cronbach’s alpha coefficient was 0.98 and 0.95, respectively. For SHI
psycho-social domain (mean of 14 questions specific for evaluation of psycho-social
function) Cronbach’s alpha coefficient was 0.98. (Table 2)
Test-retest reliability
Test-retest reliability of Total SHI and SHI speech domain as calculated by Spearman’s
rank correlation coefficient were 0.92 and 0.88, respectively. For SHI psycho-social
domain the coefficient was 0.89. (Table 3). Test-retest reliability of additional SHI
question assessing overall speech quality was 0.78.
Validity
Construct validity
To assess convergent construct validity and to determine the extent to which hypothetical
relationships are confirmed 35 , we compared Total SHI values and values of speech and
8

psychosocial domains of SHI with speech and social assessment domains of the UWQOL
questionnaire using Spearman’s rank correlation coefficients. The correlation between
Total SHI score, the SHI speech domain, the SHI psycho-social domain and overall SHI
speech assessment question, and speech domain of UWQOL were 0.72, 0.72, 0.71 and
0.68, respectively (Table 4).
The correlations between Total SHI score, the SHI speech domain, the SHI psycho-social
domain and overall SHI speech assessment question, and social domain of the UWQOL
were 0.44, 0.44, 0.43 and 0.35, respectively (Table 4).
Group validity
To determine the ability of the SHI to detect differences in groups of patients who were
expected to be functioning at different levels, we performed a group validity test using
Mann-Whitney U-test. Significant differences (P

imparted by the articulators in the vocal tract. 1 Therefore use of voice evaluation tools for
evaluating speech outcome is not scientifically justified as the results will not represent or
reflect what is intended to be measured. 1 Also the use of general or disease-specific QOL
questionnaires for evaluating speech outcomes in head-neck cancer patients is not
advisable as they are not sensitive enough utilizing only one or two questions to assess
speech. 1
Reliability refers to the extent to which a test score is free from errors of measurement. 35-
37 The importance of rigorously establishing reliability translates into accurate detection
of change as a result of change in clinical status. The two most commonly used measures
of reliability are internal consistency and test-retest reliability. 37,38 Internal consistency is
useful in the construction of new scales or questionnaires and measures the inconsistency
or non-equivalence of different questions intended to measure the same concept. 35 We
have used alpha reliability which is similar to the split-half approach to measure
consistency except that all possible ways of splitting and comparing sets of questions
used to tap a particular concept are performed. 37-40 Cronbach’s alpha is the measure of the
alpha coefficient. 36,41,42 The value, which can vary from 0.0 to 1.0, represents how well a
set of items measures the same underlying dimension. 35 Cronbach’s alpha values that are
between 0.70 and 0.90 suggest that the scale has adequate internal consistency. 36 We
found SHI to have a high Cronbach’s alpha coefficients for Total SHI, SHI speech
domain and SHI psycho-social domains which is indicative that the questionnaire was
consistent and addressed the same concept reliably. It is assumed that a measure with
limited reliability will not provide a stable score across time. Test-retest reliability is a
10

measure to estimate that the construct or dimension being assessed is stable over time.
The values of Total SHI scores, SHI speech domain, SHI psycho-social domain and
overall speech quality were found to be highly significant by using Spearman’s rank
correlation coefficient.
Validity is often seen as the most important consideration in evaluation of a measure. 37,38
However, it must be remembered here that validity does not refer to any inherent
characteristic of the measure; measures themselves are never valid or invalid. 37 Although
several types of validity have been described in the literature, the most common and
important types are construct validity, group validity, content validity and criterion
validity. 35 Construct validity refers to the extent to which a measure assesses the specific
domain or construct of interest. 35 A widely used method of assessing construct validity is
to examine how hypothetical relationships are confirmed. Therefore, the more often the
hypothetical relationships are confirmed, the greater the construct validity of the survey
variables is assumed to be. 41,42 Different domains of SHI were compared with similar
domains of the existing standard, validated UWQOL questionnaire with the help of
Spearman’s rank correlation coefficient. Total SHI score, the SHI speech domain, the
SHI psycho-social domain and overall SHI speech assessment question and speech
domain of UWQOL were found to be highly significant. The correlations between Total
SHI score, the SHI speech domain, the SHI psycho-social domain and overall SHI speech
assessment question and social domain of UWQOL showed moderate correlation. The
relatively low values of SHI psycho-social domain when compared with social domain of
UWQOL may be because of incorporation of two grossly different sub-domains (pain
11

and shoulder functions) to calculate social domain scores of UWQOL. Group validity
refers to the ability of the questionnaire or tool to be able to detect differences in groups
of patients who were expected to be functioning at different levels. 36 The SHI was able to
differentiate between groups of patients assumed to have different magnitudes of speech
impairment. Some values in group analysis were found to be insignificant, probably
because of smaller sample size or differences in patient characteristics, detailed analysis
of which is currently ongoing in the department. Content validity or face validity
precisely refers to how well the questions represent what is trying to be asked from the
theoretical framework. 37-39 It is most often determined by the use of expert judgments and
is an integral part of developing any psychometric tool. 35
Though we did not develop the
questionnaire, but still as a part of consensus process, every single question was
discussed and debated in multidisciplinary team setting comprising experienced head and
neck cancer specialists, speech and language therapists with over 10 years of experience
in managing head and neck cancer patients and most importantly patients as well. No
items of the questionnaire were flagged by the subjects and experts as inappropriate or
unclear. Criterion or concurrent validity serves to establish whether the new survey
instrument accurately reflects the attitudes of a previously used gold-standard measure of
the same concept. Since there is no other speech-specific questionnaire in the literature
with which SHI can be compared, criterion validity was not assessable.
The English language version of SHI has shown high values of reliability and validity
scores which are parallel to the Dutch version, 2 indicating it to be a good tool for
evaluating the impact of speech impairment in head-neck cancer patients. Patients can
12

easily complete it while waiting for their turn to come in the outpatient department. The
results can be quickly calculated and documented in the patient records and if any speech
impairment is found, it can be addressed - possibly at the same visit. Patients can also be
given feedback on their speech rehabilitative efforts in a temporal manner which will
help them to intensify, continue or decrease their efforts in order to get better speech. We
think this tool will be an effective adjunct in the rehabilitation of head-neck cancer
patients.
Conclusion:
In this study the SHI proved to be a valid and reliable tool for outcome assessment of
speech problems in oral and oropharyngeal cancer patients. It is a precise, reliable and
validated speech questionnaire which can be used in outpatient clinics to assess the nature
and severity of a patient’s complaints. Since it is a new tool, further studies are required
to establish its usefulness in assessing speech impairment in head-neck cancer patients.
Conflict of interest
None to declare.
Appendix:
Speech Handicap Index (SHI) English version (for clinical research and patient use).
13

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Table 1. Patient characteristics (N=55)
Characteristic Number (%)
Age
Mean (range) 59 (35.9-80); SD: 10.0
Median (interquartile range) 59.4 (51.2, 66.3)
Sex
Male 36 (65.5)
Female 19 (34.5)
Tumour location
Oral cancer 17 (30.9)
Oropharyngeal cancer 38 (69.1)
19

Tumour location (sub-site)
Tongue 15 (27.3)
Base of tongue 15 (27.3)
Floor of mouth 2 (3.6)
Tonsil 22 (40)
Soft palate 1 (1.8)
Clinical stage
I 7 (12.7)
II 5 (9.1)
III 9 (16.4)
IV 34 (61.8)
T-stage
T1 15 (27.3)
T2 30 (54.5)
T3 5 (9.1)
T4 5 (9.1)
N-stage
N0 16 (29.1)
N1 7 (12.7)
N2 31 (56.4)
N3 1 (1.8)
Treatment
Surgery 6 (10.9)
Post-operative radiotherapy 27 (49.1)
Post-operative chemoradiotherapy 22 (40.0)
Glossectomy
Yes 31 (56.4)
No 24 (43.6)
Comorbidity
Yes 24 (43.6)
No 31 (56.4)
Follow-up (months)
Mean (range) 78.1 (6-297.6); SD: 59.3
20

Table 2 Reliability: Internal consistency
Index/Domain Cronbach’s alpha coefficient P-value
Total SHI (N=30) 0.98

Table 4 Construct validity (Based on Spearman’s rank correlation coefficient and
associated P-values) (N=55)
SHI
UWQOL
Speech domain
Psycho-social domain
Total SHI 0.72 (P

Speech Handicap Index (SHI) English version
Reg no: Name: Date:
These are some statements that many people may have used to describe their speech and the
effects of their speech on their lives. Please tick the response that indicates how frequently
you have the same experience.
SN Item Never Almost
never
1 My speech makes it difficult for people to
understand me
Some
times
Almost
always
Always
2 I run out of air when I speak
3 The intelligibility of my speech varies
throughout the day
4 My speech makes me feel incompetent
5 People ask me why I’m hard to understand
6 I feel annoyed when people ask me to repeat
7 I avoid using the phone
8 I’m tense when talking to others because of my
speech
9 My articulation is unclear
10 People have difficulty understanding me in a
noisy room
11 I tend to avoid groups of people because of my
speech
12 People seem irritated with my speech
13 People ask me to repeat myself when speaking
face-to face
14 I speak with friends and neighbors or relatives
less often because of my speech
23

15 I feel as though I have to strain to speak
16 I find other people don’t understand my
speaking problem
17 My speaking difficulties restrict my personal
and social life
18 The intelligibility is unpredictable
19 I feel left out of conversations because of my
speech
20 I use a great deal of effort to speak
21 My speech is worse in the evening
22 My speech problem causes me to lose income
23 I try to change my speech to sound different
24 My speech problem upsets me
25 I am less outgoing because of my speech
problem
26 My family has difficulty understanding me
when I call them throughout the house
27 My speech makes me feel handicapped
28 I have difficulties to continue a conversation
because of my speech
29 I feel embarrassed when people ask me to
repeat
30 I’m ashamed of my speech problem
How do you rate your own speech at this moment (please circle the right answer)
Excellent Good Average Bad
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Scoring of SHI
Values for response categories;
Never =0
Almost never=1
Some times=2
Almost always=3
Always=4
For calculation of total SHI score;
Please add scores of all 30 questions. Total score range; 0-120.
For calculation of Speech domain;
Please add scores of questions 1,2,3,5,6,9,10,13,15,18,20,21,26, and 28.
For calculation of Speech domain;
Please add scores of questions 4,7,8,11,12,14,16,17,19,24,25,27,29 and 30.
Values for response categories for overall speech assessment question;
Excellent=0
Good=30
Average=70
Bad=100
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