1. Introduction Vertigo is an erroneous perception of self or object motion or an unpleasant distortion of static gravitational positioning that is a result of a mismatch between the three sensory systems i.e. vestibular, visual, and somatosensory [ 1 ]. Vertigo disorders are a group of conditions that cause a sensation of spinning or movement, even when a person is stationary. These disorders can significantly disrupt daily life, leading to difficulties in balance, coordination, and overall functioning. Common causes include benign paroxysmal positional vertigo (BPPV)-which is triggered by specific head movements, and Meniere’s disease (MD)-a chronic condition affecting the inner ear [ 2 ]. Other causes include vestibular neuritis, labyrinthitis, head injuries, and migraines. Vertigo can be accompanied by symptoms such as sensation of spinning or movement, nausea, vomiting, abnormal eye movements, and hearing loss [ 3 ].

Although vertigo affects both sexes, women experience it around two to three times more frequently than men. It has been linked to several comorbid medical conditions, such as depression and heart disease. The prevalence fluctuates based on the underlying diagnosis and rises with age. Vertigo has a yearly incidence of 1.4% and a 1-year frequency of around 5%, according to a general population survey. Every year, 15% to 20% of individuals experience dizziness, including vertigo [ 4 ].

Universally, about 1 in 10 people will comprehend vertigo at some point in their lives, with an estimated 0.71% prevalence in India, impacting over 9 million individuals. Effective diagnosis and treatment are crucial, involving physical examinations, hearing tests, and sometimes imaging studies, along with medications, physical therapy, or specific maneuvers to alleviate symptoms. Understanding and addressing vertigo is essential for improving patient care and enhancing the quality of life for those affected by this debilitating condition [ 4-6 ]. Vertigo and balance disorders are common clinical issues that can severely impact an individual’s ability to perform daily activities.

~ 4 ~ These conditions often lead to significant social, physical, emotional, and functional activity impairments, affecting the overall quality of life. The Dizziness Handicap Inventory (DHI-E) scale is a specialized tool designed to assess the extent to which vertigo affects a person’s daily functioning.

It includes 25 questionnaires that evaluate three primary domains: Physical, Functional, and Emotional activities [ 7 ].

Originally developed in English, the DHI-E scale has been translated and validated in several languages to ensure its applicability across different cultural and linguistic contexts.

Some of the languages into which the DHI has been translated include Argentina [ 8 ], French [ 9 ], Chinese [ 10 ], Italian [ 11 ], Brazilian [ 12 ], Sweden [ 13 ], Arabic [ 14 ], Japanese [ 15 ], Dutch [ 16 ], Persian [ 17 ], Greek [ 18 ], Hebrew [ 19 ], Thai [ 20 ] German [ 21 ] and Bulgarian [ 22 ]. It is now only accessible for Hindi [ 23 ], Kannada [ 24 ], Malayalam [ 25 ], and Gujarati [ 26 ], leaving out a large number of other regional Indian languages. This presents a challenge to regular clinical practice as India is a multilingual country with diverse cultures, and a significant portion of the population relies on regional languages for communication.

Although the DHI Questionnaires are not yet available in the Telugu version, which is spoken by 83 million people in the Indian states of Telangana and Andhra Pradesh [ 27 ]. This study aims to fill this gap by translating and validating the DHI into Telugu, providing a reliable and culturally relevant tool for assessing the impact of vertigo on daily living among Telugu-speaking individuals.

The Trans-Adaptation and validation process will follow established guidelines for cross-cultural adaptation [ 28 ]. The psychometric properties of the Telugu version of the DHI, including its reliability and validity, will be thoroughly evaluated to ensure that it meet the standards required for clinical and research use [ 7, 11, 16, 18, 21, 26, 30 ].

By making the DHI-Telugu accessible to Telugu-speaking populations, this study seeks to enhance the questionnaire assessment and management of vertigo and balance disorders. The availability of a validated Telugu version of the DHI will facilitate accurate diagnosis, treatment planning, and evaluation of therapeutic outcomes, ultimately improving patient care and quality of life for individuals affected by vertigo in Telangana and Andhra Pradesh (Telugu Speaking Population).

This research is to translate, validate and verify the reliability of the questionnaire. The translation and transcultural adaptation of the Telugu was carried out with the authorization of Manipal Hospital. The questionnaire was then translated to Telugu with the help of qualified Telugu-speaking professors of linguistics and audiologists and speech-language therapist department using the standard translation-back-translation method.

The translated questionnaire was distributed to 8 native Telugu speakers who were thorough in reading and writing the Telugu language for content validity. These speakers were asked to rate individual questions using a three-point rating scale from very familiar to non-familiar. The standard translation-back-translation method was utilized where two professors in the Telugu language performed a forward translation of the questionnaire. For content validation, the translated version of the Dizziness Handicap InventoryTelugu (DHI-T) language was then administered to 8 native literate Telugu speakers (1 teacher, 5 audiologists, and 2 linguists).

The Dizziness Handicap Inventory (DHI) will be translated into Telugu and validated using a cross-sectional approach in this study. The study will follow established guidelines for cross-cultural adaptation of self-report measures, ensuring both linguistic and cultural relevance.

A total sample of 136 subjects participated i.e. 62 (45.58%) were male and 74 (54.42%) were female as shown in Table 1, who are native Telugu speakers. The study took place between June to October 2024 in the healthcare settings in Andhra Pradesh (Manipal Hospital Tadepall, Guntur-, A.P.). Participants will include individuals diagnosed with vertigo or balance disorders, which include Normal Hearing, Tinnitus, Post-lingual hearing loss, Conductive Hearing Loss (Chronic), sensorineural hearing loss (SNHL), benign paroxysmal positional vertigo, meniere’s disease and participants with any psychological, traumatic injury, and neurological problems excluded from the study.

The recommendations made by Beaton et al. (2000) for cross-cultural adaptation and translation were followed by us.28 We divided this process of translation and cultural adjustment into 6 phases, which included the following as shown procedure of translation of DHI-T Table 2.

The scale was first translated from English, the target language Telugu, the source language. At least two separate translators worked on this project. The questionnaire was ideally translated into the native tongue of these multilingual translators.

Two native Telugu-speaking experts in audiology and linguistics independently translated the Dizziness Handicap Inventory (DHI) questionnaires. Their translations were then compared and synthesized into a unified version of DHI-T. Any discrepancies or confusion regarding the translated items were thoroughly discussed and resolved among the raters, ensuring clarity and accuracy in the final version.

To ensure the accuracy of the translation, the translated text was independently back-translated by two bilingual translators. This process involved translating the text back from the target (Telugu) language into the original (English) language. To avoid any potential bias, the back-translators were kept completely unaware of the original version. This method confirmed the fidelity and accuracy of the translation, ensuring that the final version accurately reflected the original content.

To create the final draft of the translation, a group of experts were formed. This group included people who understand the topic well, 5 Audiologists, 2 linguistics and one teacher who worked on the initial and back translations, and if possible, the original creators of the questionnaire. The main job of this expert group was to review all the different versions of the translation and make sure they matched the original in terms of meaning, expressions, experiences, and concepts. Their work resulted in a final draft of the questionnaire, which was then ready for testing in the field.

The pre-final version of the DHI-T questionnaire and the prefinal version of the translated questionnaire were filled by the patients, preferably 11 from a targeted setting. After completing the questionnaire, patients were asked to explain their understanding of each question and their responses. This approach ensured that the translated questions retained the same meaning as the original, with no confusion. This process may be repeated, and patients were selected based on inclusion criteria to confirm the final translated version.

Based on the feedback from the pre-test, necessary modifications were made to the DHI-Telugu. The final version was then approved by the expert committee of five experts in the field of audiology (experience 5-10 years), one teacher, and two linguists, who use Telugu as their first language.

The final translated questionnaire (DHI-T) was given to 8 validators for content validation. These validators are fluent in both English and Telugu. The translated DHI (Telugu version) content was verified in different aspects, such as grammar of the sentences, sentence structures, socio-cultural aspects, and reader friendliness. The validated DHI (Telugu version) was then administered to participants, who were instructed to read each question thoroughly and respond based on their perception of their condition. The first part of the questionnaire consisted of demographic details about the participants’ names, ages, gender, and general complaint. They were questioned about their drug history, blood pressure, diabetes, tinnitus, and other conditions. Most participants, having basic educational qualifications, completed the questionnaire independently and some with the help of the clinician. ~ 6 ~ ివవరనలత

C/O: రనిద ేశ్నలత

After the DHI-Telugu Version questionnaire was validated, the results were documented and included in Table 3. This validated translation was then implemented across various clinical settings and private hospitals. The use of the DHITelugu in these diverse environments allowed for a comprehensive assessment of its effectiveness and reliability in real-world conditions.

Data collected from these different settings provided valuable insights about the questionnaire’s performance, helping to ensure its robustness and applicability for Teluguspeaking patients experiencing dizziness or vertigo.

The Dizziness Handicap Inventory (DHI) questionnaire comprises 25 items designed to evaluate the impact of vertigo on a patient’s daily life. These items are divided into three subscales: Functional: This assesses the impact of dizziness on everyday physical activities and the ability to perform tasks. These tasks include walking, bending, quick head movements, and daily routines. Emotional: This evaluates the emotional impact of dizziness, including feelings of frustration, fear of falling, anxiety, and depression. Physical: This subscale focuses on the physical symptoms of dizziness and vertigo, including how certain movements or positions exacerbate these symptoms7. , భావోదదా,గ మరియు

కరయిాతమక. ఈ రశాప్లత అంనశ్లప దైాని యొకక రభప్ావననిా మ ైకము / అంచనా వేయడాకనిర ఉదే శదంచడబ్విన్ . రతీప్ "అవపన్ర ," "కొనిాసనుర ు ," లేదా "కనదర " అని సమాధాన్ం ఇవనాల. మీ సమసూ

కనరణంగన రుమీ రశాప్కత S.N. 1.

(F): (F): (F): (F): (F): (F): (F): (F): సబ్ కస్ేల్ భౌతిక

(P): భావోద్వేగ (E):

భౌతిక (P): ిక్రయాత్మక ిక్రయాత్మక ిక్రయాత్మక ిక్రయాత్మక

భౌతిక (P): భావోద్వేగ (E): మీ భావోద్వేగ (E):

భౌతిక (P): ిక్రయాత్మక ిక్రయాత్మక ిక్రయాత్మక ిక్రయాత్మక

భౌతిక (P): భావోద్వేగ (E):

భౌతిక (P): భావోద్వేగ (E): భావోద్వేగ (E): భావోద్వేగ (E): భావోద్వేగ (E): భావోద్వేగ (E): ిక్రయాత్మక

(F): భౌతిక (P): రప్శాలత సమసూన్ర ప చైకరూడటం ీమ ప ంచతర ం?దా ీమ సమసూ కనణరంగనుమీర ుతనిరాసహానికర గవరుపతారన ? ీమ సమసూ కనణరంగనుమీర వనూపనరననికర లేదా శ్విన ి ంతి కోసం రప్యాణాాని మితప్రం సూప్ర మారకకట్ లో అనివనూరంగన న్డవటం ీమ సమసూరన్ ప ంచరత ీమ సమసూ కనణరంగనప్డక న్రండి లేచదందరకతలేదా డప్కలోకర వెళ్ళందరకత ఇబ్బంద చదు సనరాానర ? ం?దా గనఉందా? ీమ సమసూ కనణరంగనభోజనానికర వెళ్ళటం , ్సథనిమా చూడటం , ్నృతూం చదయటం లేదా పనటర ీలకతవెళ్ళటం వంటి సనమాజక కనూరకలాపనలు ో మీ

పనలాన్డగం గణనీయంగన తగాంిదా? ీమ సమసూ కనణరంగనచదవటానికర ఇబ్బంద ప్డుత నాానర ? కరిడలత, న్ృతూం , గృహ ప్నరలత (డ్పమోం లేదా పన తరలన్ర సర ేటం ) వంటి ముఖ్ూమ నై్ ్పనరలన్ర చదయటం మీ సమసూన్ర ప ంచతర ం?దా సమసూ కనణరంగనుమీర ఎవిర సహాయం లేకతండాఇంటి న్రండి ్బయటకత వెళ్ ు ందకరత భయప్డుత నాానర ? ీమ ీమ ీమ ీమ ీమ ీమ ీమ సమసూ కనణరంగనుమీర ఇతులర ముందర ంిచతిసర ు నాాుర ? తదలకగతనల టంతిప్ు సమసూన్ర ప ంచరత సమసూ కనణరంగనుమీర ఎతు న్ రదప్తదశ్నలన్ర విననిసరర ు నాానర ? మంచంలో ుగతిరటం సమసూన్ర ప ంచరత ం?దా ం?దా ీమ సమసూ కనణరంగనకష్ ీ మ ైన్ గృహ ప్నరలత లేదా తోట ప్నరలత చదయటం మీకత కష్ ీ ంగనఉందా? ీమ ీమ సమసూ కనణరంగనమిమమలా ఇతులరత మదూం స్ంేవిన్చిటల ు అకన్రతంటానర ? సమసూ కనణరంగనుమీర

ఒంటరిగన పనదచాులర మార ాం మీద డ్నవటం ీమ ్నడవటం సమసూన్ర కష్ ీ ంగనఉందా? ప ంచతర ం?దా ీమ సమసూ కనణరంగనమీకత

ఏకన గిత తగాుత న్ాదా ? ీమ సమసూ కనణరంగనుమీర ఇంటిలో కచీలట ు న్డవటం కష్ ీ ంగనఉందా? సమసూ కనణరంగనుమీర ఒంటరిగన ఇంలటు ఉండటానికర భయప్డుత నాానర ? సమసూ కనణరంగనుమీర ివకలాంగగునిన భాసవిర ు నాానర ? ీమ సమసూ మీ కతటలంబ్ సభుూలత లేదా మిత ర లతో ఉాన్ సంబ్ంధాలన్ర రభప్ావితం చదస్థందా? సమసూ కనణరంగనుమీర డిప నరష్ కతగవరుపత నాారన ? ీమ సమసూ మీ ఉదో ూగం లేదా గృహప్నరలన్ర

చదయటంలో అంతనరయంగనఉందా? వంగటం మీ సమసూన్ర ప ంచరత ం?దా అవపన్ర కొానిసనుర ు కనదర అంశ్నకనిర కరంద విధ్ంగన

సో కుర ు ఇవనాల: తొమ DHI సో కరింగ్

సూచన్లత ు ం సో కర్ 0 ్నరండి

100 వరకత ఉంటలంద . సో కర్ ఎకతకవగనఉంటే , assessment. Scores of 0-16 reflect no dizziness impairment, 16-34 indicate mild impairment, 36-52 moderate impairment, and 54 or higher indicate severe impairment [ 7 ].

The total scores and mean scores of each subscale (Physical, Functional, and Emotional) were acquired using SPSS version 30.0 software following the administration of the translated Questionnaire (DHI-T) to patients complaining of vertigo or dizziness. Results were presented as percentages for categorical variables and as means and standard deviations (SD) for continuous variables. Overall Cronbach alpha value, and individually for functional, physical, and emotional Cronbach alpha value, mean, Standard Deviation, Test-retest reliability for the DHI-Telugu scores, and its subscales (functional, physical, and functional) were analyzed using the intraclass correlation coefficient (ICC).

A total sample of 136 participants in the study, 62 (45.58%) were male (mean 12.40, SD 3.78) and 74 (54.42%) were female (mean 14.80, SD 3.83) Table 4, The participants in this study were categorized based on their age. The classification of the number of individuals in each age group is provided below in Table 4. 3.1 Reliability of overall score of DHI-T (1-25 Questioners): To assess the internal consistency of the Dizziness Handicap Inventory (DHI)-Telugu Version, Cronbach’s alpha test and item-total correlation were conducted. The DHI-Telugu demonstrated excellent reliability, achieving an overall Cronbach’s alpha score of 0.918 (0.92) and a Cronbach alpha score of 0.917 based on standardized items. These scores indicate a high level of internal consistency, as shown in Table 5. 3.2 Analysis of the mean scores, Std. Deviation and Cronbach's Alpha for three subscales of the DHI-Telugu questionnaire The Dizziness Handicap Inventory (DHI)-Telugu questionnaire was administered to patients experiencing dizziness or vertigo symptoms. For the physical subscale, the mean score was 16.79, SD of 6.54 and Cronbach Alpha (0.772). The emotional subscale had a mean score (14.87), SD (7.61) and Cronbach Alpha (0.775). The functional subscale showed a mean score (20.72), SD (8.26) and Cronbach Alpha (0.835). These scores indicate the varying impact of dizziness on different aspects of the patients’ lives. 3.3 Analysis of the mean if item deleted, scale variance if item deleted, the corrected item-total correlation, and Cronbach’s alpha if Item Deleted for each set of 25 questions in the DHI-T (Telugu Version) Questionnaire ~ 8 ~

50% of Data (68 Patient Data) Over All ICC (Cronbach Alph Value-0.923)

Post (136 Patient Data)

Over All ICC (Cronbach Alph Value-0.918) Note:-SEM-Standard error of Mean, Std. Deviation-Standard Deviation, ICC Interclass Coefficient correlation.

The Dizziness Handicap Inventory-Telugu (DHI-T) questionnaire's three subscales are examined more thoroughly in Table 4.4, which also includes the mean, standard deviation, standard error of the mean (SEM), minimum, maximum, and intraclass correlation coefficient (ICC). Two groups are created from the data: one has 68 patients, or 50% of the total, and the other contains 136 patients or the whole dataset. Regarding the 50% dataset, the Physical shows a mean score of 17.65, an SD of 6.32, an SEM of 0.76, with scores ranging from 6 to 28, and an ICC of 0.772, indicating good reliability. The Emotional has a mean score of 15.44, an SD of 7.78, an SEM of 0.95, with scores ranging from 2 to 30, and an ICC of 0.797, also indicating good reliability. The Functional reports a mean score of 21.22, an SD of 7.98, an SEM of 0.97, with scores ranging from 4 to 36, and an ICC of 0.836, indicating excellent reliability. Regarding the full database, the Physical subscale has a mean score of 16.79, an SD of 6.54, an SEM of 0.56, with scores ranging from 6 to 28, and an ICC of 0.772, showing good reliability. The Emotional shows a mean score of 14.87, an SD of 7.604, an SEM of 0.65, with scores ranging from 2 to 30, and an ICC of 0.775, indicating good reliability. The Functional has a mean score of 20.72, an SD of 8.259, an SEM of 0.71, with scores ranging from 4 to 36, and an ICC of 0.835, indicating excellent reliability. A DHI-Telugu questionnaire with an ICC (Cronbach's Alpha) value between 0.918 (0.92) and 0.923(0.93) demonstrates high internal consistency and reliability. This shows that the questionnaire is a valid and trustworthy method for determining the handicap caused by dizziness on various subscales. 3.5 Cronbach’s alpha coefficient of DHI-Telugu version being compared with another country's different versions of DHI Arabic Chinese German

Italian Norwegian

Persian

Polish Bulgarian

Japanese Version

Telugu Malayalam Kannada Gujarati Hindi

A common symptom of Oto-neurological problems is dizziness, which can have an undesirable impact on one's social, emotional, and professional well-being. Thus, an evaluation of a symptom-specific questionnaire is necessary to determine the severity of the ailment and its effect on quality of life. Additionally, the symptom-specific selfadministering inventory helps with assessment and possible rehabilitation by offering insight into the patient's perception of the issue.

Therefore, the present study aimed at developing and standardizing the DHI-Telugu, which is the native language of Andhra Pradesh and Telangana which is situated in the southern part of India. The authors observed in the study center that, which was administered to individuals with the complaint of dizziness/vertigo. Due to their dizziness, several of the patients reported having a lower quality of life and finding it difficult to concentrate on their daily lives, both personal and professional.

At this point, it was essential to administer some inventories to understand how severely the dizziness is affecting an individual and what aspects of an individual are getting affected because of dizziness. This was the primary motive behind translating DHI into Telugu language. The original DHI quantifies the handicap due to dizziness on the physical, emotional, and functional aspects of an individual. Questions in the physical part assess various physical activities that induce dizziness such as looking up, walking down the aisle, quick movements of the head, etc. Questions in the emotional part assess various emotional problems the patients suffer because of dizziness such as frustrations, isolation from family members, difficulty concentrating on work, etc. The questions in the functional section evaluate the functional elements that are impacted by dizziness, including travel limitations, trouble falling asleep, social interaction, etc.

This can be understood from the results of Cronbach’s alpha results and the Item-Total Correlation results. The Telugu version of DHI has a global Cronbach’s alpha score of 0.917 based on standardized items and a Cronbach’s alpha score of 0.918 (0.92). These scores indicate a high level of reliability according to the statistics. Any scale with an alpha score of greater than 0.9 has an excellent internal consistency, an alpha score between 0.8-0.9 has a good internal consistency, 0.7-0.8 has an acceptable internal consistency, 0.6-0.7 has a questionable internal consistency, 0.5-0.6 has a poor internal consistency and any score less than 0.5 is unacceptable [ 29 ].

Other Indian regional languages such as Hindi, Gujarati, Kannada, and Malayalam revealed overall Cronbach’s alpha scores of 0.78, 0.92, 0.73, and 0.93 respectively, which were accepted with the present findings [ 23-26 ]. Moreover, the current study made an effort to comprehend the impact of dizziness on the physical, emotional, and functional subscales.

The DHI-Telugu scores of 0.77, 0.77, and 0.84 were achieved on each subscale of physical, functional, and emotional correspondingly. The DHI-English and other DHI versions created in different languages showed comparable results to ours (alpha scores for functional, physical, and emotional domains were 0.85, 0.78, and 0.72, respectively) [ 7 ]. DHI-Arabic version (alpha scores for functional, physical, and emotional as 0.87, 0.81 and 0.79 respectively), [ 14 ] and DHI-Italian version (alpha scores for functional, physical and emotional as 0.82, 0.75, and 0.84 respectively), [ 11 ] DHI-Chinese version (alpha scores for functional, physical and emotional as 0.87, 0.79 and 0.84 respectively), [ 10 ] DHI-German version (alpha scores for functional, physical and emotional as 0.80, 0.71 and 0.82 respectively), [ 21 ] DHI-Persian version (alpha scores for functional, physical and emotional as 0.90, 0.83 and 0.82 respectively), [ 17 ] DHI-Polish version (alpha scores for functional, physical and emotional as 0.84, 0.81 and 0.85 respectively), [ 30 ] DHIBulgarian version (alpha scores for functional, physical and emotional as 0.75, 0.72 and 0.81 respectively) [ 22 ], DHIJapanese version (alpha scores for functional, physical and emotional as 0.87, 0.82 and 0.83 respectively) [ 15 ], as given in Table 10. As a result, it was discovered that the current research had strong internal consistency and reliability, with alpha values that were comparable to those of the original DHI in both English and other languages.

Since many people in India, a multicultural and multilingual nation, communicate primarily in their native tongue, it is not feasible to use the DHI-E to measure the degree of dizziness. Therefore, to evaluate the impact of the condition on day-to-day functioning, native Telugu speakers experiencing dizziness can self-administer the created and standardized DHI-Telugu. The present study verified that, in comparison to the original English version and other recognized variants, the DHI-Telugu exhibits exceptional internal consistency and reliable to administer to the Teluguspeaking community. Following the publication of this study, the DHI-Telugu may be used to better understand dizziness patients throughout the states of Andhra Pradesh and Telangana. 6. Ethics approval and consent to participate This study received ethical approval from the relevant institutional review board. Data collection permission was granted by Manipal Hospital Tadepall, Guntur-522501 (A.P.). Informed consent was obtained from all participants before their involvement in the study.

The datasets and materials used in this study are available upon request.

Authors’ contributions All the authors have important contributions and participation in this research.

I want to thank my older brother from the bottom of my heart for all of his help and encouragement during this research. His support and faith in me have been priceless. My senior and I are also incredibly appreciative of their guidance and wise counsel, which have been crucial to the achievement of our project. Their wisdom and expertise have served as a continual source of motivation.

BPPV-Benign Paroxysmal Positional Meniere’s disease, SD-Standard deviation. Vertigo,

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