The impact of speech disorders quality of life : a questionnaire proposal

Purpose: To develop a questionnaire to analyze the impact of speech disorders on quality of life and verify its reliability. Methods: A literature review on instruments that assess the quality-of-life was performed, particularly those concerning communication disorders. The questionnaire was designed with 18 closed questions: one related to speech impairments, another about quality-of-life, and 16 questions covering the physical, emotional, and social domains. The questionnaire was applied to a population of 24 individuals of both sexes, aged between 12 and 50 years; 12 patients (case group) had phonetic speech disorders, and 12 (control group) had no impairment in oral communication. They were paired according to age and sex. To analyze the reliability of the instrument, the internal consistency of the items was assessed through Cronbach’s Alpha coefficient. Results: The internal consistency of the 16 questions concerning the domains was α=0.93; for the physical domain, α=0.71; for the emotional domain, α=0.77; and for the social domain, α=0.85. Conclusion: The questionnaire showed good reliability in identifying the impact of speech disorders on the individuals’ quality of life. 611 Qualidade de vida e distúrbios de fala CoDAS 2013;25(6):610-13 INTRODUÇÃO Os distúrbios de fala podem acarretar dificuldades no processo comunicativo, levar ao isolamento social e afetar a qualidade de vida dos sujeitos. A Organização Mundial da Saúde (OMS) define qualidade de vida (QV) como “percepção do indivíduo sobre sua posição na vida,... e em relação aos seus objetivos, expectativas, padrões e preocupações”, sendo considerado um indicador importante de Saúde Pública. Questionários de QV relacionados à voz, gagueira e deglutição têm sido utilizados na prática clínica fonoaudiológica. Atualmente, não há instrumento que mensure o impacto dos distúrbios da fala na QV e esta perspectiva poderá auxiliar o fonoaudiólogo a direcionar a intervenção, ajustando as estratégias terapêuticas às necessidades do paciente. Assim, os objetivos do estudo foram elaborar um questionário para investigar o impacto dos distúrbios da fala na QV e verificar a sua confiabilidade.


INTRODUCTION
Speech disorders can result in difficulties in the communication process, lead to social isolation, and affect quality of life (1)(2)(3) .The World Health Organization defines quality of life (QOL) as "an individual's perception about his/her position in life [...] and in relation to his/her objectives, expectations, standards, and preoccupations" (4) .This concept is considered an important indicator in Public Health.QOL questionnaires concerning voice (5) , stuttering (6,7) , and swallowing (8) have been used in the clinical practice of speech-language pathology and audiology.Currently, however, there is no instrument to measure the impact of speech disorders on QOL.Such initiative could help speech-language pathologists and audiologists to shape interventions and adjust therapeutic strategies to the patients' needs.Thus, the aim of this study was to elaborate a questionnaire to investigate the impact of speech disorders on QOL and to verify its reliability.

METHODS
This is a transversal study conducted at the Speech-Language Pathology and Audiology Ambulatory of Universidade Federal de Minas Gerais (UFMG).It was approved by UFMG's Ethics Committee under report number 404/09, and carried out in two stages: elaboration of the questionnaire to assess the impact of speech disorders on QOL, and analysis of the reliability of this instrument.
The elaboration of the questionnaire was based on scientific papers that describe protocols used to assess QOL in different situations, published from 1999 to 2009 (4,5,(7)(8)(9) .
In order to analyze the instrument's reliability, the questionnaire was applied in a pilot format to 24 individuals, 12 in the case group and 12 in the control group, aged from 12 to 50 years, paired according to sex and age.The case group was composed of individuals with phonetic speech alterations, and the control group was formed by individuals without any compromise in oral communication, attested by means of a simplified speech assessment.We excluded individuals with cognitive, neurological, and vocal deviation, as well as those with alterations in oral language and fluency, auditory impairment, and/or with speech disorders on the last stages of treatment.The control group was composed of individuals who accompanied patients assisted in the same ambulatory.This latter group was instructed to answer the questions according to their perception of their own speech.
The etiologic factors and speech disorders presented by the participants of the case group were (1) Cleft lip and palate (all had undergone surgery) and compensatory articulatory disorders (such as glottal stop); (2) Musculoskeletal alterations and frontal or lateral lisp; and (3) Partial glossectomy and articulatory distortions.We opted for including different etiologic speech disorder factors in the sample in order to verify the adequacy of the questionnaire in relation to a wide gamma of causes.All participants signed the Informed Consent.
The answers to questions 2-17 in the questionnaire were graded on a Likert scale: 3 points for the option "Always", 2 points for "Sometimes", 1 point for "Rarely", and 0 point for "Never".The option "I do not know" was not considered in the analysis, and, therefore, it did not influence the score.For the comparison between both groups, the analysis was performed considering the percentage of points in relation to the maximum possible score for each individual per domain, and the total score.The analysis of internal consistency was conducted considering each domain and the total score using Cronbach's coefficient.We considered the reliability as poor when α≤0.5, acceptable between 0.6 and 0.7, and good when α≥0.8 (10) .In the analysis, we excluded the questions whose removal from a specific domain increased Cronbach's Alpha value and, consequently, the internal consistency of the questionnaire.
Questions 1 and 18 were analyzed based on the frequency of the answers, with the purpose of identifying an individual's self-perception of his/her speech impairment and QOL.

RESULTS
The questionnaire devised was composed of 18 closed questions, two about self-perception of speech impairment and general QOL, and 16 about self-perception of the physical (questions 2-5), emotional (6-11), and social (12-17) domains (Appendix 1).
The analysis of the internal consistence of the questionnaire is presented in Table 1.

DISCUSSION
In similarity to other studies in the literature (9,11,12) , the instrument was first applied to a pilot population and presented good reliability in each domain and in the questionnaire as a whole.
In regard to the domains, the internal consistency varied from acceptable (α=0.71-physical domain in the case group) to good (α=0.96-social domain in the control group).The exclusion of question 11 from the physical domain and question 16 from the social domain increased their internal consistency, and, therefore, should be investigated further with a larger sample.Concerning the total score of the questionnaire, the internal consistency was good both in relation to the case group (α=0.91) and the control group (α=0.95).Self-perception of speech impairments occurred predominantly in the case group, but apparently without an impact on QOL in both groups.Future studies on this topic are necessary, given that, to our knowledge, this is the first (Brazilian) study of this type.Studies conducted with larger case groups and satisfactory statistical power will enable the assessment of QOL in relation to speech disorders in a more precise manner.Some limitations must be considered in future research, such as the size of the sample, which needs to be amplified, and the selection of case groups, so as to encompass other speech disorders and age ranges.Thus, new analyses must be employed on the validation of this questionnaire in future studies.
Nevertheless, the high Cronbach's Alpha values found for the total score of the questionnaire in both groups indicate that the instrument in question seems to be reliable in assessing the QOL of individuals with speech disorders.

CONCLUSION
We devised a protocol to assess the QOL of individuals with speech disorders, composed of 18 questions concerning the physical, emotional, and social domains.The questionnaire proved to be an instrument of good reliability both in relation to the domains and to the questionnaire as a whole.

Table 1 .
Analysis of the internal consistency of the Questionnaire Impact of Speech Disorders on Quality of Life *Item 11 was deleted with the purpose of increasing internal consistency -regarding that question: α=0.78 (case group), α=0.67 (control group) and α=0.74 (both groups); **Item 16 was deleted with the purpose of increasing internal consistency -regarding that question: α=0.70 (case group), α=0.95 (control group), and α=0.78 (both groups).