Cross‐Cultural Adaptation, Validity, and Reliability of the Dysphonia Risk Screening Protocol‐General for Turkish‐Speaking Individuals

ABSTRACT

Background

Screening is a critical first step in the early identification and prevention of voice disorders, particularly among at‐risk populations. The Dysphonia Risk Screening Protocol‐General (DRSP‐G) is a comprehensive screening tool that also functions as a standardized patient history; however, no equivalent instrument has previously been available for Turkish‐speaking individuals. This study aimed to translate and culturally adapt the DRSP‐G into Turkish (DRTP‐TR) and to examine its validity and reliability.

Methods and Procedures

The DRSP‐G was translated following the Scientific Advisory Committee of the Medical Outcomes Trust (SAC) guidelines, which comprise forward and backward translation, expert review, and a pilot study. A total of 140 participants (70 dysphonic, 70 healthy) across three groups: women, men, and children completed the DRSP‐G. Validity was assessed using known‐groups comparisons and correlations with the Voice Handicap Index, Pediatric Voice Handicap Index, auditory‐perceptual (GRBAS) ratings, and acoustic measures. Receiver operating characteristic (ROC) analysis was used to determine cutoff scores. Reliability was evaluated via test–retest and inter‐rater analyses.

Outcomes and Results

DRTP‐TR scores significantly differentiated dysphonic from healthy participants across all groups (p < 0.001). The DRTP‐TR demonstrated excellent discriminatory power in women (AUC = 0.96) and children (AUC = 1.00), and very good discriminatory power in men (AUC = 0.85). Cutoff scores were 39, 32.5, and 19.5 for women, men, and children, respectively. Test–retest reliability was strong (r = 0.95).

Conclusion and Implication

The DRTP‐TR is a valid and reliable screening instrument for dysphonia risk among Turkish‐speaking individuals across age and gender groups.

1. Introduction

Voice disorder, or dysphonia, is characterized by alterations in normal voice quality due to structural or functional causes [1]. Dysphonia significantly impacts an individual's personal, social, and professional life, often leading to reduced overall quality of life [2, 3].

Regular screening of at‐risk populations, including professional voice users, the elderly, and women, is critical for preventing dysphonia and its effects [4]. Early diagnosis through screening enables more effective treatment and lowers the risk of further complications. Therefore, screening these groups is the initial step in prevention strategies [5]. Current clinical voice assessments are often time‐intensive, require specialized personnel and technological resources, and may not be feasible or accessible in all settings [2]. In contrast, screening tests can be administered rapidly and at low cost on a large scale. Consequently, screening tests are valuable for identifying high‐risk individuals and for determining the need for advanced evaluation procedures [6, 7].

Several tools have been developed to screen for voice disorders [2, 4, 6, 7, 8, 9, 10]. Among these, Nemr et al. [11] developed the Dysphonia Risk Screening Protocol‐General (DRSP‐G). The DRSP‐G includes 18 questions distributed across domains such as occupation and gender, self‐assessment of voice, signs and symptoms, voice use, dietary habits, hydration, sleep patterns, physical and leisure activities, family history and dynamics, and medical history. The DRSP‐G essentially serves as a standardized patient history, the first phase of clinical voice assessment. Thus, beyond screening, it can also help clinicians obtain comprehensive patient histories.

Many scales are used in clinical voice assessment for Turkish‐speaking individuals; however, none of these has been specifically developed for screening [12, 13]. A literature review indicates that the Screening Index for Voice Disorder‐Turkish version (SIVD‐TR) is currently the only screening tool available in Türkiye. The SIVD‐TR, a 12‐item instrument, is designed to screen for voice disorders among teachers [7]. Although the SIVD‐TR represents a significant advancement as the first screening tool for Turkish‐speaking individuals, its use is confined to teachers, thereby limiting its scope. The DRSP‐G, by contrast, offers a more comprehensive screening framework that is not restricted to a single occupational group and, given its dual function as both a screening tool and a standardized patient history, no equivalent instrument has previously been available for Turkish‐speaking individuals. To address this gap, this study aimed to adapt the DRSP‐G for use in Turkish‐speaking individuals, ensuring both cultural and linguistic appropriateness.

2. Materials and Methods

A comparative descriptive research design was employed in this study. Ethical approval was granted by the Anadolu University Health Sciences Scientific Research and Publication Ethics Committee. Written informed consent was obtained directly from adult participants and from the parents of pediatric participants.

2.1. Participants

The sample size was determined using widely accepted psychometric standards, which recommend enrolling at least three times the number of scale items to ensure stability in validation research [14]. Accordingly, a minimum of 54 participants per group was required for the 18‐item Turkish version of DRSP‐G. This target was exceeded, with a total of 140 participants recruited, comprising 70 dysphonic and 70 healthy individuals. Dysphonic participants were enrolled from individuals presenting to the Otolaryngology Department at Konya City Hospital with voice complaints. The inclusion criteria for the dysphonic group required a diagnosis of a voice disorder, confirmed by an otolaryngologist using laryngeal videostroboscopy. Individuals with any concomitant speech or language disorders that could affect communication were excluded. The specific diagnostic categories are summarized in Table 1.

TABLE 1.

Voice disorder diagnoses of participants with dysphonia.

Diagnosis	Women		Men		Children
	n	%	n	%	n	%
Vocal fold nodules	18	52.9	0	0	8	100
Vocal fold polyp	5	14.7	11	39.3	0	0
Unilateral vocal fold paralysis	1	2.9	1	3.6	0	0
Presbyphonia	0	0	2	7.1	0	0
Functional dysphonia	2	5.9	0	0	0	0
Vocal fold cyst	2	5.9	3	10.7	0	0
Vocal fold mass	0	0	2	7.1	0	0
Reinke's edema	4	11.8	4	14.3	0	0
Papilloma	0	0	1	3.6	0	0
Puberphonia	0	0	1	3.6	0	0
Vocal fold leukoplakia	0	0	1	3.6	0	0
Nodules + laryngopharyngeal reflux (LPR)	1	2.9	0	0	0	0
Polyp + Reinke's edema	1	2.9	0	0	0	0
Vocal fold mass + LPR	0	0	2	7.1	0	0
Total	34	100	28	100	8	100

Note: Percentages may not total 100% due to rounding.

Healthy participants were recruited using the snowball sampling method, in which data collection from an initial eligible individual leads to referrals to subsequent participants, thereby forming a chain‐like sample [15]. A total of 70 individuals of varying ages and genders were included in this group. The inclusion criteria for healthy participants were as follows: (1) no known diagnosis of a voice disorder, (2) no concomitant speech or language disorders that could affect communication, and (3) a Grade (G) score of 0 on the GRBAS Scale.

Participants were divided into three groups: adult women, adult men, and children. The adult women group consisted of 34 women with dysphonia (M_age = 37.41, SD = 10.02) and 41 healthy women (M_age = 30.88, SD = 9.58). The adult men group comprised 28 men with dysphonia (M_age = 45.89, SD = 16.10) and 24 healthy men (M_age = 28.96, SD = 6.36). The children group included 8 children with dysphonia (6 girls, 2 boys; M_age = 9.38, SD = 1.84) and 5 healthy children (4 boys, 1 girl; M_age = 7.00, SD = 1.00).

2.2. Translation and Cross‐Cultural Adaptation of the DRSP‐G

The adaptation process followed the guidelines recommended by the Scientific Advisory Committee of the Medical Outcomes Trust (SAC), which outlines a two‐phase framework: establishing linguistic/conceptual equivalence and evaluating measurement properties. In the first phase, which aimed to ensure the linguistic and conceptual equivalence of the scale in Turkish, a structured plan comprising forward translation, backward translation, expert review, and a pilot study was implemented [16]:

1. Forward translation: Two speech‐language therapists (SLTs) fluent in English independently translated the DRSP‐G items into Turkish. Throughout this process, linguistic and cultural differences were carefully considered. Subsequently, the two translations were reviewed and synthesized by a panel consisting of a Turkish‐English language expert and two SLTs specializing in voice disorders to reach a consensus version.

2. Backward translation: The consensus version was back‐translated into English by an independent SLT fluent in English who had not participated in the forward translation phase. This backward translation was then compared with the original protocol for conceptual alignment.

3. Expert review: After the translation process, the preliminary Turkish version was evaluated by two PhD‐level SLTs, one specializing in voice disorders and the other in clinical linguistics. Based on their expert feedback, necessary revisions were made.

4. Pilot study: Within the scope of the pilot study, 15 participants completed the form. They were instructed to identify any items they found difficult to comprehend and to provide feedback. Following the pilot application, the final version of the Dysphonia Risk Screening Protocol‐Turkish version (Disfoni Risk Tarama Protokolü / DRTP‐TR) was established.

2.3. Data Collection

With the development of the DRTP‐TR, data collection began to evaluate its measurement properties [16]. All participants initially completed the DRTP‐TR. Additionally, the Voice Handicap Index (VHI) was administered to adult participants, while the Pediatric Voice Handicap Index (pVHI) was administered to child participants [12, 17]. To examine test–retest reliability, 28 randomly selected participants were re‐administered the DRTP‐TR after an interval of 7–14 days.

Audio recordings, including a sustained/a/phonation and a connected speech sample, were obtained from participants who completed the forms. Recordings were made with a Samson Go Mic Portable USB Condenser Microphone with a frequency range of 20 Hz to 18 kHz and a laptop. They were recorded in a soundproof room using Audacity at 16‐bit resolution and a 44.1 kHz sampling rate. Before data collection, a systematic pilot study was conducted, evaluating different microphone distances and angles to identify the setup that produced the clearest, most consistent recordings with the least background noise. The evaluations led to selecting a 90° angle to the mouth at 15 cm, which aligns with the manufacturer's recommended range (4–18 in.) and with distances commonly cited in the voice acoustic literature [18].

Acoustic and auditory‐perceptual analyses were performed on the voice recordings. For acoustic analysis, a 3‐s segment from the middle portion of each sustained /a/ phonation was chosen to eliminate instabilities present at the onset and offset of phonation. Recordings were imported into Praat, and fundamental frequency (F0), jitter, shimmer, and noise‐to‐harmonic ratio (NHR) were measured.

For the auditory‐perceptual analysis, the first author assigned G scores of the GRBAS to all participants based on the audio recordings. To assess inter‐rater reliability, a randomly selected 20% of the recordings (n = 28) were independently rated by a second SLT specializing in voice disorders. Inter‐rater reliability was assessed using Spearman's rho, revealing a high level of consistency between the two raters (r _s = 0.875, p < 0.05).

2.4. Data Analysis

Data analysis was performed using IBM SPSS Statistics, version 21.0 (IBM Corp., Armonk, NY, USA). The Shapiro–Wilk normality test was initially conducted to assess whether the data followed a normal distribution. Based on the distribution results, parametric tests were applied to normally distributed data, while nonparametric tests were used for data that did not meet the normality assumption.

Receiver Operating Characteristic (ROC) analysis was performed to evaluate the classification accuracy and determine cutoff scores for the DRTP‐TR as a screening tool. This analysis provided specificity and sensitivity values. Sensitivity is defined as the ability of the test to correctly identify positive cases, while specificity is the ability to correctly identify negative cases [19]. ROC curves depicting the relationship between sensitivity and specificity were generated for each group. Cutoff scores were established using the Youden index, which identifies the point that maximizes the combined sensitivity and specificity [20].

The area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the test's discriminatory power. AUC values range from 0.5 (indicating no discriminatory ability) to 1 (indicating perfect discriminatory power), with values closer to 1 reflecting greater discriminatory ability [21].

The validity of the DRTP‐TR was assessed using known‐groups and concurrent validity analyses. Known‐groups validity determines whether the test yields different results across two groups known to differ. Concurrent validity assesses whether the test correlates with another instrument measuring similar domains [22, 23]. In this study, DRTP‐TR and VHI/pVHI scores were correlated using Spearman's rho to evaluate concurrent validity, and DRTP‐TR scores between healthy and dysphonic participants were compared using an independent‐samples t‐test to examine known‐groups validity.

The reliability of the DRTP‐TR was evaluated using test–retest and inter‐rater reliability analyses. Pearson's correlation, applied to normally distributed data, measured consistency between two administrations for test–retest reliability, while Spearman's rho, applied due to the ordinal nature of GRBAS ratings, assessed agreement between two raters for inter‐rater reliability.

Finally, the association between participants' DRTP‐TR scores and other assessment findings (G scores and acoustic values) was examined using Spearman's rho. In all statistical analyses, p < 0.05 was considered statistically significant.

3. Results

Participants' scores ranged from 0 to 102. Table 2 provides descriptive statistics for these scores. An independent‐samples t‐test was performed to assess differences in DRTP‐TR scores between healthy and dysphonic participants. The analysis revealed a statistically significant difference in scores between dysphonic and healthy participants overall (t(106.64) = 10.905, p < 0.001, d = 1.84). To further explore this difference, DRTP‐TR scores of dysphonic and healthy participants were also compared within each subgroup. Similarly, statistically significant differences were found between dysphonic and healthy participants among women (t(54.09) = 10.892, p < 0.001, d = 2.53), men (t(42.72) = 5.712, p < 0.001, d = 1.59), and children (t(11) = 5.47, p < 0.001, d = 3.12). All these differences reflected a large effect size [24].

TABLE 2.

Analyses of DRTP‐TR scores for dysphonic and healthy participants.

Group				Dysphonic					Healthy		t	p
	n	Min	Max	X̄	SD	N	Min	Max	X̄	SD
Total	70	5	102	54.92	21.40	70	0	57	23.15	11.66	10.905	< 0.001
Women	34	21	102	66.08	18.61	41	0	57	25.82	11.92	10.892	< 0.001
Men	28	5	86	45.82	20.15	24	3	51	20.62	10.89	5.712	< 0.001
Children	8	21	54	39.37	10.11	5	10	18	13.40	3.43	5.47	< 0.001

Note: Bold values indicate statistical significance.

Sensitivity, specificity, and cutoff scores for each group were determined using ROC analysis. In the female participants, the DRTP‐TR demonstrated a sensitivity of 94.1%, specificity of 95.1%, and classification accuracy of 94.7%. For male participants, sensitivity was 75%, specificity was 91.7%, and accuracy was 82.6%. In the children's group, sensitivity, specificity, and accuracy were all 100%.

Figure 1 presents the ROC curves for each group. Accordingly, the AUC values at a 95% confidence level were 0.96 (p < 0.001) for women, 0.85 (p < 0.001) for men, and 1.00 (p < 0.001) for children. The cutoff scores for the DRTP‐TR were calculated as 39 for women, 32.5 for men, and 19.5 for children. Accordingly, individuals scoring at or above these cutoff points were classified as dysphonic, while those scoring below were classified as healthy.

FIGURE 1.

ROC curves illustrating the discriminatory power of the DRTP‐TR in classifying dysphonic versus healthy participants among women, men, and children. The blue line represents the ROC curve for each group, plotting sensitivity against 1‐specificity across all possible cutoff scores; the red diagonal line represents the reference line of no discrimination (area under the curve = 0.5). The area under the curve (AUC) was 0.96 for women, 0.85 for men, and 1.00 for children, indicating excellent, very good, and excellent discriminatory power, respectively.

Scale validity was assessed by examining the relationship between DRTP‐TR scores and VHI/pVHI scores. Table 3 presents the descriptive statistics for VHI scores among adults and pVHI scores among children.

TABLE 3.

Descriptive statistics for participants' VHI and pVHI scores.

	Groups	N	Min.	Max.	Mean	SD
VHI	Dysphonic women	34	1	40	20.88	12.230
	Healthy women	41	0	7	0.74	1.531
	Dysphonic men	28	0	36	15.82	12.341
	Healthy men	24	0	4	0.74	1.176
pVHI	Dysphonic children	8	7	56	35.13	16.040
	Healthy children	5	0	11	3.80	4.550

Analysis of VHI and pVHI scores in relation to DRTP‐TR scores revealed a statistically significant, strong positive correlation for adults (r _s = 0.779, p < 0.001) and for children (r _s = 0.835, p < 0.001), as shown in Table 4.

TABLE 4.

The examination of the relationship between DRTP‐TR and VHI/pVHI scores among adult and child participants.

	Variable	N	1	2
Adults	1. DRTP‐TR score	127	—
	2. VHI score	127	0.779 **	—
Children	1. DRTP‐TR score	13	—
	2. pVHI score	13	0.835 **	—

^** p < 0.01.

Analysis of the auditory‐perceptual data indicated that all healthy participants received a G score of 0. The G scores for dysphonic participants are summarized in Table 5. The relationship between participants' DRTP‐TR scores and auditory‐perceptual (G score) findings was examined, revealing a statistically significant, strong positive correlation (r _s = 0.726, p < 0.001).

TABLE 5.

Descriptive statistics for dysphonic participants' G scores.

Groups	N	Min.	Max.	Mean	SD
Dysphonic women	34	0	3	1.91	0.793
Dysphonic men	28	0	3	1.43	0.959
Dysphonic children	8	1	3	1.88	0.641

Descriptive statistics for participants' acoustic analysis findings are presented in Table 6. The association between DRTP‐TR scores and acoustic values was also examined.

TABLE 6.

Descriptive statistics for participants' acoustic values.

Acoustic value	Groups		n	Min.	Max.	Mean	SD
F0	Dysphonic	Women	34	91.170	283.999	186.283	43.606
		Men	28	84.768	226.094	133.864	32.436
		Children	8	211.666	291.597	254.255	29.788
	Healthy	Women	41	151.902	260.012	217.522	24.697
		Men	24	92.690	149.726	120.130	14.886
		Children	5	212.876	279.956	246.206	25.361
Jitter	Dysphonic	Women	34	0.236	1.200	0.629	0.312
		Men	28	0.282	4.806	0.970	1.139
		Children	8	0.283	1.862	0.906	0.567
	Healthy	Women	41	0.142	1.350	0.379	0.221
		Men	24	0.142	0.657	0.390	0.133
		Children	5	0.163	0.693	0.361	0.207
Shimmer	Dysphonic	Women	34	0.016	17.086	6.493	3.152
		Men	28	1.932	21.797	6.850	3.758
		Children	8	3.484	10.947	6.881	2.580
	Healthy	Women	41	1.911	8.643	3.798	1.259
		Men	24	1.385	7.629	3.740	1.740
		Children	5	2.299	7.796	4.367	2.268
NHR	Dysphonic	Women	34	0.005	0.278	0.063	0.067
		Men	28	0.007	0.886	0.127	0.201
		Children	8	0.013	0.266	0.097	0.082
	Healthy	Women	41	0.003	0.074	0.018	0.015
		Men	24	0.003	0.097	0.024	0.020
		Children	5	0.006	0.035	0.015	0.011

No significant correlation was found between DRTP‐TR scores and F0 in either the female or male groups (p > 0.05). However, positive correlations were identified between DRTP‐TR scores and jitter, shimmer, and NHR values among female participants (r _s = 0.433, p < 0.001; r _s = 0.533, p < 0.001; r _s = 0.491, p < 0.001, respectively). Similarly, significant positive correlations were found between DRTP‐TR scores and jitter, shimmer, and NHR values in the male group (r _s = 0.445, p < 0.001; r _s = 0.435, p < 0.001; r _s = 0.417, p = 0.002, respectively). In contrast, no significant correlations were found between acoustic measures and DRTP‐TR scores in the child participants (p > 0.05).

Finally, the test–retest reliability analysis indicated a very strong and statistically significant Pearson correlation between the two administrations of the DRTP‐TR (r = 0.95, p < 0.001).

4. Discussion

Assessment of voice disorders is a comprehensive process that involves multiple steps [25]. Screening serves as the first step, aiming to identify individuals at high risk for voice disorders, refer them for further evaluation, and enable early diagnosis [6, 26]. In this study, the DRSP‐G was adapted into Turkish, and its validity and reliability were examined.

In the current study, a statistically significant difference in DRTP‐TR scores was observed between healthy and dysphonic participants across all groups (p < 0.001). Dysphonic participants consistently obtained higher DRTP‐TR scores than healthy participants, indicating that the DRTP‐TR differentiates between these groups. This finding aligns with the original study, which also reported significant differences between healthy and dysphonic participants' scores [11]. Similarly, a study assessing the DRSP‐G in an English‐speaking population in India found significant differences in scores between dysphonic and healthy groups [27].

The DRTP‐TR demonstrated a sensitivity of 94.1% in identifying women at high risk for dysphonia and a specificity of 95.1% in correctly classifying healthy women. The classification accuracy for the female group was 94.7%. In comparison, the original study reported sensitivity and specificity values of 95% and 97%, respectively [11]. Although the original study yielded slightly higher sensitivity and specificity, the results from both studies are comparable. Analysis of the ROC curve for the female group in the current study revealed a curve approaching the top‐left corner, indicating near‐perfect test performance, with an AUC of 0.96. This AUC value further supports the excellent discriminatory performance of the test in women [21].

In the male group, DRTP‐TR correctly identified 75% of individuals at high risk for dysphonia and 91.7% of healthy individuals, indicating that the test was more successful at identifying healthy individuals than dysphonic individuals among men. Although its sensitivity was lower than that for women, DRTP‐TR's classification accuracy for men was 82.6%, reflecting good discrimination. Additionally, the AUC for men was 0.85, indicating very good discriminatory power [21]. In the original study, sensitivity and specificity were both 90% in the male group [11]. When the two studies were compared, the current study had lower sensitivity but higher specificity. However, Nemr et al. [11] also found that specificity and sensitivity were lower in men than in women, similar to the current study. This lower sensitivity in men may be attributed to several factors. First, in the present sample, nodules, commonly associated with vocal abuse/misuse, were the predominant diagnosis among dysphonic women, whereas Reinke's edema and polyps predominated among men; as items assessing vocal misuse and related risk factors (e.g., hydration, diet) are more extensively queried in the DRTP‐TR, the protocol may more readily capture nodule‐related symptomatology, resulting in more accurate discrimination in women. Second, prior research has shown that women report significantly higher rates of hoarseness, vocal tract discomfort, neck pain, and foreign body sensation than men [28], and that female professors report more voice‐related complaints overall [29]. This pattern of greater symptom awareness and reporting among women may similarly enhance the discriminatory accuracy of a self‐report‐based protocol such as the DRTP‐TR, particularly within its “signs and symptoms” section.

The sensitivity and specificity values for the pediatric group were both 100%, and the AUC was 1.00, indicating excellent discriminatory power [21]. Nevertheless, these seemingly perfect results should be interpreted cautiously as they were derived from a small pediatric sample (n = 13) and have not yet been evaluated in a larger cohort of children. Performance estimates based on small samples may be unstable and could overstate the true discriminatory power of DRTP‐TR. Notably, in the original study, Nemr et al. [11] reported lower sensitivity and specificity for children from a larger sample (94% and 95%, respectively). These findings should be replicated in a larger Turkish pediatric cohort before firm conclusions can be drawn.

Analysis of DRTP‐TR cutoff scores by group revealed values of 39 for women, 32.5 for men, and 19.5 for children. Individuals scoring at or above these thresholds are considered at high risk for dysphonia. In contrast, Nemr et al. [11] reported cutoff scores of 29.25 for women, 22.75 for men, and 22.5 for children. Compared with the original study, the cutoff scores are higher for Turkish‐speaking women and men, whereas the cutoff score for children is lower. This discrepancy may reflect cultural or linguistic differences in self‐perception of voice symptoms between the two populations and warrants further investigation. In addition, this difference might be partially explained by the substantial age gap observed between dysphonic and healthy male participants in this study, as well as by variations in the distribution of underlying pathologies, for example, a greater prevalence of nodules among women and polyps among men. Both factors could have affected item responses and, in turn, influenced the derived cutoff scores. It is also important to note that the diagnostic composition of the current sample, primarily nodules among children and women, and Reinke's edema or polyps among men, may restrict the generalizability of the reported sensitivity, specificity, and cutoff scores to populations with different distributions of voice disorders (such as those with a higher prevalence of neurological voice conditions, vocal fold paralysis, or functional dysphonia).

When the correlation between the DRTP‐TR and self‐assessment scales was examined, the results showed that as the DRTP‐TR score increased, the VHI score in adults and the pVHI score in children increased significantly (p < 0.001). This implies that as an individual's risk of dysphonia increases, their voice‐related symptoms and complaints also increase. Furthermore, examination of the relationship between the DRTP‐TR and auditory perceptual assessment findings revealed that higher DRTP‐TR scores were significantly correlated with higher G scores (p < 0.001). Thus, as dysphonia risk increased, perceived voice quality declined, demonstrating the predictive capacity of the DRTP‐TR.

Similar correlations have been identified in additional screening tools reported in the literature. Nemr et al. [26] investigated the relationships among the DRSP‐G, the VHI, and the Voice‐Related Quality of Life (VRQOL) tools. Their findings indicated a statistically significant positive correlation between the DRSP‐G and both the VHI and VRQOL. Additionally, the study found a positive but weak association between the overall severity score on the Consensus Auditory‐Perceptual Evaluation of Voice (CAPE‐V) and the DRSP‐G score.

Ghirardi et al. [8] identified a significant correlation between VHI and G scores using the Screening Index for Voice Disorder (SIVD), a tool designed to screen teachers for voice disorders. Additionally, a study evaluating the validity and reliability of the Turkish version of the SIVD (SIVD‐TR) demonstrated a significant relationship between SIVD‐TR and VHI [7]. Unlike the SIVD‐TR, which is limited to teachers, the DRTP‐TR was validated across three distinct populations (women, men, and children), thereby addressing a broader range of at‐risk groups in the Turkish‐speaking population.

More recently, a strong correlation was observed between VHI and the Screen11 screening tool, which was developed for use in Nordic populations [4]. Pernambuco et al. [2] compared the Rastreamento de Alterações Vocais em Idosos (RAVI; Screening for Voice Alterations in the Elderly) scores, developed to screen for voice disorders in older adults, with a composite reference comprising the individual's self‐assessment and an auditory‐perceptual evaluation of the voice. The study found that RAVI produced results consistent with both self‐assessment and auditory‐perceptual analysis. Taken together, these findings across different screening tools and populations support the pattern observed in the present study, wherein DRTP‐TR scores correlated significantly with both self‐assessment (VHI/pVHI) and auditory‐perceptual (G score) measures.

A study evaluated the validity of the Cepstral Spectral Index of Dysphonia (CSID) screening tool by comparing it with two reference measures: self‐assessment and auditory‐perceptual assessment. The VHI was employed for self‐assessment, while the overall severity score from the CAPE‐V was utilized for auditory‐perceptual assessment. Results indicated that the CSID demonstrated the highest agreement with the auditory‐perceptual assessment and also showed a substantial degree of agreement with self‐assessment [6]. Similarly, in the present study, a positive, highly significant correlation was identified between DRTP‐TR scores and jitter, shimmer, and NHR in both women (p < 0.001) and men (p < 0.01). Thus, higher DRTP‐TR scores are associated with higher jitter, shimmer, and NHR values. Previous studies have reported elevated jitter, shimmer, and NHR values in individuals with voice disorders [30, 31, 32]. These findings suggest that as the risk of dysphonia increases, the degree of voice distortion also increases.

Among child participants, a moderate positive correlation similar to that observed in adults was identified; however, this relationship did not reach statistical significance (p > 0.05). Although jitter, shimmer, and NHR values increased with higher DRTP‐TR scores, these associations were not statistically significant. This outcome may be attributed to the small sample size of child participants (n = 13), which limited statistical power to detect significant relationships.

Finally, test–retest reliability analysis indicated a very strong correlation between the two administrations (r = 0.95, p < 0.001). This finding demonstrates that the DRTP‐TR exhibits consistent measurement capability across different time points.

5. Conclusions

An effective dysphonia screening tool should accurately identify individuals at risk for voice disorders. The present study demonstrated that the DRTP‐TR has excellent discriminatory power for women, very good discriminatory power for men, and preliminary evidence of excellent discriminatory power for children that requires replication in a larger pediatric sample. Turkish‐speaking women with scores of 39 or higher, men with scores of 32.5 or higher, and children with scores of 19.5 or higher were classified as being at high risk for voice disorders. It is recommended that these individuals undergo monitoring for voice disorders or receive preventive interventions, such as participation in a voice hygiene program.

In conclusion, the DRTP‐TR is a valid and reliable instrument for screening dysphonia risk among Turkish‐speaking individuals. Unlike existing Turkish screening tools such as the SIVD‐TR, which is limited to teachers, the DRTP‐TR was validated across three distinct populations: women, men, and children, thereby addressing a significant gap in the Turkish‐language literature and offering a screening protocol applicable across a broader range of age, gender, and occupational groups. A key strength of this study is the comprehensive validation of the DRTP‐TR using multiple reference measures, including self‐assessment, auditory‐perceptual evaluation, and acoustic analysis, across these three populations. Beyond its utility as a screening protocol, the DRTP‐TR offers clinical value: it enables therapists to obtain comprehensive case histories by capturing information on patients' risk factors, voice complaints, and voice‐use habits, thereby informing decisions about whether to monitor or initiate therapy. Additionally, the DRTP‐TR may be an effective tool for epidemiological research on voice disorders.

5.1. Limitations and Recommendations

This study also aimed to evaluate the discriminatory power of the DRTP‐TR for the elderly population, in addition to women, men, and children. However, due to insufficient recruitment of participants aged 65 and older, cutoff scores for this group could not be established. Future studies should investigate the discriminatory power and cutoff scores of the DRTP‐TR for individuals aged 65 and older.

The DRTP‐TR demonstrated excellent discriminatory power in the pediatric group, and cutoff scores were established for this population. However, the small pediatric sample may have influenced outcomes, including cutoff scores and classification accuracy. Future research should include a larger pediatric sample to enhance the reliability of these findings.

Additionally, a notable age difference was observed between dysphonic and healthy male participants, which may have acted as a confounding factor in the comparison of DRTP‐TR scores between these groups. Future studies should aim to recruit age‐matched dysphonic and healthy samples to control for this potential confound.

The diagnostic makeup of the present sample, which consisted mainly of nodules in children and women and Reinke's edema or polyps in men, may restrict the applicability of the reported performance metrics to populations with different diagnostic profiles. Future studies should investigate the discriminatory validity of the DRTP‐TR in more diagnostically diverse samples.

Funding

This study has been supported by Anadolu University Scientific Research Project Coordination Unit under grant number THD‐2026‐3670.

Ethics Statement

Ethical approval was obtained from the Anadolu University Health Sciences Ethics Committee (approval no. 667292), and the study was conducted in accordance with the Declaration of Helsinki. All adult participants and parents provided written informed consent for themselves and their children to participate in this study.

Conflicts of Interest

Regarding this study, the authors and/or their family members do not have any scientific or medical committee memberships or relationships with their members, consultancy, expertise, employment in any company, shareholding, or similar situations that may pose a potential conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.