Evaluating the Hindi Translation of the Dizziness Handicap Inventory and Its Concurrent Validity With the ABC Scale

INTRODUCTION

Dizziness can be described as a misperception or false sensation of movement, either rotational or non-rotational, often stemming from insults to the ear and nervous system.^[1] In 2008, approximately 15%, i.e., 33 million, of American adults reported experiencing issues with imbalance or dizziness.^[2] In India, an estimated 180 million individuals are affected by balance and dizziness disorders.^[3,4]

Dizziness significantly impacts quality of life and independence, doubling the risk of falls. Symptoms of vestibular disorders may include dizziness or vertigo, feeling unsteady or likely to fall, difficulty walking in a straight line, lightheadedness, faintness, or a sensation of floating. Other symptoms may include blurred vision, confusion, nausea, vomiting, diarrhoea, changes in heart rate, and blood pressure.^[5] These symptoms can fluctuate in intensity and duration, potentially leading to fatigue and depression.

Some of the most common disorders are benign paroxysmal positional vertigo (BPPV), Meniere’s disease, vestibular neuritis, etc.^[2] Dizziness can stem from various causes such as peripheral vestibulopathy (44%), central vestibulopathy (11%), psychiatric conditions (16%), and other or unknown factors (39%) including cerebrovascular disease (6%), cardiac arrhythmia (1.5%), and brain tumour (<1%).In 1990, Jacobson and Newman introduced the Dizziness Handicap Inventory (DHI) to assess the impact of dizziness on physical, emotional, and functional aspects of life. The inventory consists of 25 questions across three subscales—physical (7 items), emotional (9 items), and functional (9 items)—with scores ranging from zero (no handicap) to 100 (severe impairment). Three groups are based on the scores, indicating mild (16-34 points), moderate (36-52 points), and severe impairment (54-100 points). The DHI is indeed a highly reliable and consistent tool, with impressive test-retest reliability (r=0.97) and internal consistency (α=0.89).^[6] Its effectiveness in evaluating how dizziness impacts various aspects of life has led to its translation and validation in multiple languages and cultures. Notably, it has been adapted into Chinese, Brazilian Portuguese, French, German, Italian, Greek, Arabic, and Norwegian.^[7-14] The DHI-E is available in various Indian languages such as Marathi, Kannada, Malayalam, and Gujarati^[15-17] to ensure a comprehensive understanding and effective rehabilitation in diverse linguistic and cultural settings within India. Many people rely on regional languages for everyday communication, making it difficult to use standardised tools like the DHI-E if they are not available in those languages. This language gap can impede effective assessment and treatment for individuals with dizziness who could benefit from the inventory. Given the rising prevalence of dizziness in the general population, a comprehensive understanding of the condition is crucial for effective rehabilitation. Therefore, translating the DHI-E into various native Indian languages is essential to ensure it can be widely understood and used for accurate assessment and treatment across diverse linguistic groups. Since Hindi is commonly spoken in most parts of India, there is a need to develop DHI in Hindi for effective vestibular rehabilitation and accurate interpretation of the impact on their quality of life.

To validate DHI in different regional languages, many scales have been used in the past. One of the scales is the Activities-specific Balance Confidence Scale (ABC), which is a commonly used tool to assess an individual’s confidence in performing various activities without losing balance or becoming unsteady. The scale consists of 16 items that ask individuals to rate their confidence from 0% to 100% in performing certain activities without feeling unsteady. Establishing concurrent validity between the ABC scale and the DHI is essential to confirm that both tools assess related aspects of vestibular disorders. A strong correlation between these scales would validate that they both reflect key components of balance and dizziness, supporting their use in clinical and research settings for evaluating vestibular dysfunction.

According to the researcher’s knowledge, there is no published literature evaluating the self-perceived effects of dizziness in the Hindi language. Therefore, the present study aimed to translate and adapt DHI-E into DHI-H for native Hindi speakers, making it suitable for clinical use in assessment and management, and to investigate its reliability and validity in the Hindi-speaking population of India. The specific objectives of the study were to develop a set of questionnaires that are suitable and easily comprehensible for Hindi speakers and to analyse the internal consistency of the translated questionnaires.

MATERIAL AND METHODS

To meet the aim of the study, a cross-sectional study was conducted. Sample size was calculated, considering the prevalence of 15% individuals having dizziness,^[3] the data sample of 100 was acquired (n=zα²pq/d², wherein α=5%, i.e., confidence interval of 95%). However, data analysis was done on 104 samples, i.e., 50 males and 54 females aged between 16 to 75 years with a mean age of 45.625 (Sd= 13.50) who complaint of dizziness due to vestibular pathology were recruited for the study. The study was conducted in two phases. Phase I consists of the development and validation of the inventory, while Phase II includes the administration of the inventory developed.

RESULTS

Statistical analysis was carried out using SPSS software version 23 (IBM corporation, New York, US) to test the normality, internal consistency, and Mean ± SD for age for all the subjects. Descriptive statistics were applied to analyse the demographic details of the participants. The Kolmogorov-Smirnov test was conducted to check for normal distribution of the data and showed that the data were not normally distributed(p<0.05), and hence, a non-parametric test was applied for further analysis. Cronbach’s alpha value for each question [Supplementary Table S1], domain-wise and for overall scores [Table 1], was determined to check the internal consistency of the questionnaire. The DHI-H demonstrated an overall alpha score of 0.92, reflecting good internal consistency. The subscales’ scores were 0.94, 0.93, and 0.99 for physical, emotional, and functional domains, respectively.

Based on the DHI (Hindi version) results, the degree of handicap was analysed, and it was found that each participant’s self-perceived handicap ranged from mild to severe. The standard deviation (SD) was 24.46, while the mean overall score was 39.79. Individuals were further categorised into mild, moderate, or severe categories of self-perceived impairment based on the classification provided by Jacobson and Newman.^[6] Result illustrates that 27% of the participants had a severe handicap, 40% had a mild handicap, and 33% had a moderate handicap as evaluated by themselves.

Table 2 displays the self-perceived handicap across the various DHI subscales and categories. It is evident that the functional domain indicated the highest level of handicap severity, followed by the emotional and physical domains.

Kendall’s tau correlation coefficient was also used to evaluate the relationship between the two questionnaires used in the present study. The test results indicated that among the 25 questions of the DHI-H, one question (F6) exhibited a strong correlation with the ABC-H, while five questions (F3, E9, F14, F16, E20) demonstrated a moderate correlation. However, 12 questions (E2, P4, F5, P8, P11, F12, P17, F19, E21, E23, F24, P25) from the DHI-H displayed a weak correlation, and 7 questions (P1, F7, E10, P13, E15, E18, E22) showed a negligible correlation. Overall, the DHI-H score had a moderate correlation with the ABC-H. Figure 1 illustrates the scatter plot of these relationships.

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Figure 1:

Scatter plot between DHI score and ABC-H score. DHI: Dizziness handicap inventory, ABC-H: Activities-specific balance confidence scale (hindi version).

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DISCUSSION

Dizziness is a common symptom in neurological conditions, significantly affecting social, emotional, and professional well-being. To accurately gauge its severity and impact on quality of life, it is essential to use a specific questionnaire. The DHI is widely recognised for its reliability and validity in assessing the self-perceived handicap associated with acute dizziness. In addition to its robust psychometric properties, the DHI stands out for its straightforwardness, relevance of questions, and its ability to encompass the health aspects outlined in the WHO’s International Classification of Functioning, Disability and Health.^[22] Clinically, the DHI serves as a practical tool for measuring the impact of dizziness symptoms triggered by various causes, enabling clinicians to assess and monitor patients’ conditions effectively. Therefore, the objective of this study was to create and establish norms for the DHI-H, which was administered to individuals reporting symptoms of dizziness or vertigo. Based on the current investigation into the measurement properties of an adapted Hindi version of the DHI, administered to individuals experiencing acute dizziness, the findings indicate that the 25-item DHI-H demonstrates strong internal consistency for the overall scale (Cronbach’s α = 0.92). Specifically, the Cronbach’s α values for the three DHI-H subscales—functional (0.99), emotional (0.93), and physical (0.94), indicate robust internal consistency comparable to the different versions of DHI, such as Arabic, Italian, Greek and Malay versions,^[23] as shown in Table 2. Similarly, studies conducted in other Indian regional languages such as Kannada, Malayalam, and Gujarati reported overall Cronbach’s alpha scores of 0.74, 0.94, and 0.92, respectively, which align with the current findings. This study also aimed to assess the impact of dizziness across three subscales: physical, emotional, and functional, yielding scores of 0.94, 0.93, and 0.99, respectively, on each subscale. These results are comparable to those of the DHI in other languages, such as the English version (with alpha scores for functional, physical, and emotional domains reported as 0.78, 0.72, and 0.85, respectively), the Arabic version (with alpha scores of 0.81, 0.79, and 0.87), and the Italian version (with alpha scores of 0.75, 0.84, and 0.82 respectively), as summarised in Table 2. Therefore, this study demonstrates good internal consistency, with alpha values similar to those of the original English version of the DHI and its counterparts in other languages. The DHI findings revealed that individuals experiencing dizziness primarily perceive significant impacts in the functional domain, followed by the emotional domain, and then the physical domain. These results partially align with findings from other studies, which consistently report that the self-perceived handicap associated with dizziness is most influenced by limitations in functioning, followed closely by challenges in daily activities, and to a lesser extent, by emotional well-being. The functional aspects assessed by the DHI-H measure how dizziness affects specific movements involving the eyes, head, and body. It also evaluates the individual’s ability to carry out professional, domestic, social, and recreational activities independently. Additionally, it considers tasks such as walking without assistance and navigating through dimly lit areas within the home. The emotional aspects assessed by the DHI-H revealed significant abnormalities among the patients studied. These aspects explored the potential negative impacts of dizziness on quality of life, including feelings of frustration, fear of being alone outside or at home, embarrassment about clinical symptoms, concerns about concentration difficulties, a sense of incapacity, changes in family or social relationships, and experiences of depression. These findings align with previous research by Paiva and Kuhn,^[24] who found that patients with vertigo frequently experience concurrent psychological symptoms, with anguish being the most prevalent (47.38%), followed by anxiety, fear, depression, and memory issues. This underscores the link between vestibular disorders and emotional disturbances. Furthermore, correlation analysis between the self-perceived handicap and activities-specific balance confidence studied using the Hindi version of DHI and ABC revealed that some of the questions of DHI had strong to moderate correlation, whereas some had weak or negligible correlation with ABC-H. Therefore, it can be concluded that not all questions concerning the physical, functional, or emotional aspects directly pertain to the challenges encountered in daily activities. The overall DHI score in our study demonstrates a moderate correlation with the ABC-H scale, which is consistent with previous research findings reported by Whitney et al.^[25] and Herssens et al.^[26] This alignment suggests a robust relationship between dizziness-related handicap, as measured by the DHI, and balance confidence, as assessed by the ABC-H scale, across different studies. These findings underscore the reliability and validity of using both measures to assess the impact of dizziness on individuals’ daily lives and their confidence in maintaining balance.

CONCLUSION

The current study aimed to develop and standardize the Dizziness Handicap Inventory (DHI) in Hindi, a language spoken widely in India. This adaptation was undertaken to effectively assess how dizziness impacts an individual’s daily life. According to the study’s findings, the Hindi version of the DHI has demonstrated good internal reliability. Therefore, this inventory can further be utilized among Hindi-speaking individuals to measure the impact of dizziness, providing valuable insights into the condition both before and after intervention. Moreover, the study identifies a need for further research to explore the complex relationships between the DHI and other related assessments across different populations and contexts. Understanding these interactions more deeply could lead to improvements in how dizziness and its impacts are evaluated and managed in clinical practice. Ultimately, this could enhance the development of more effective strategies for supporting individuals affected by vestibular-related symptoms. In summary, the development and standardization of the Hindi DHI represent a significant step toward better understanding and managing dizziness in Hindi-speaking populations, with implications for improving clinical interventions and support strategies.