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AUT19110.1177/1362361313508025AutismAl-Sharbati et al.
Original Article
Awareness about autism among school teachers in Oman: A cross-sectional study
Autism 2015, Vol. 19(1) 6–13 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361313508025 aut.sagepub.com
Marwan M Al-Sharbati, Yahya M Al-Farsi, Allal Ouhtit, Mostafa I Waly, Mohamed Al-Shafaee, Omar Al-Farsi, Maha Al-Khaduri, Mona F Al-Said and Samir Al-Adawi
Abstract Children with special needs such as those with autism spectrum disorder have been recorded as ostracized and stigmatized in many parts of the world. Little is known about whether such negative views are present among mainstream teachers in Oman. A cross-sectional study was conducted to evaluate school teachers’ awareness about autism spectrum disorder in an urban region in Oman. A total of 164 teachers were randomly enrolled from five schools. Misconceptions about autism spectrum disorder were found to be common among mainstream teachers in the country. We posit that such lack of awareness was likely to be rooted with sociocultural patterning as well as conflicting views often “spun” by the scientific community and mass media. Enlightened views toward children with autism spectrum disorder should be presented to Omani teachers to overcome misconceptions and negative attitudes toward children with autism spectrum disorder. Keywords autism, autism spectrum disorder, awareness, misconceptions, Oman, teachers
Sultanate of Oman is a Middle Eastern country that stretches across approximately 309,500 km2. According to the 2010 census (National Center for Statistics and Information, 2013), its population is estimated to be 3.3 million. The country is classified by the World Bank as a “middleincome economy” among the emerging economies (Central Intelligence Agency, 2011). Prior to the turn of the century, Oman spent the bulk of its Gross National Product (GNP) annually to furnish universal free education for both sexes, which was heralded by the motto “Education for All by the year 2000.” As a result, literacy has now reached all strata of the Omani society with abundant public schools in all corners of the country, experiencing a negligible gender-gap (Al-Adawi, 2006). As a result of this initiative, the enrollment in tertiary education has increased (Al-barwani et al., 2009). Considering this background, the question remains whether “Education for All” has reached children with special abilities and needs. One rough estimate indicated that approximately 23% of children in Oman are likely to have special needs (Profanter, 2009). Education in Oman is provided for free but attendance is optional. Expenditure on education was reported to be 4.3% of the Sultanate’s Gross Domestic Product (GDP) and 26.1% of total government spending (World Bank, 2012).
According to Human Development Index, Oman is ranked 84 out of 186 countries in its public expenditure on education (World Bank, 2012). The public education system in Oman consists of two phases: Basic and post-Basic Education. The Basic Education is organized into two cycles: the first cycle covers Grades 1–4, and the second cycle covers Grades 5–10. These two cycles are followed by 2 years of post-Basic Education system known as “Secondary Education” (Ministry of Education, 2007). The Department of Special Education was established within the Ministry of Education to oversee special education (Profanter, 2009). The Ministry of Education coordinates special education programs for those with communication disorders, physical disabilities, mental retardation, and the resultant varied spectrum of handicapping conditions stemming from such disorders (Ministry of Education, 2002). However, enrollment in Special Education Sultan Qaboos University, Sultanate of Oman Corresponding author: Yahya M Al-Farsi, Department of Family Medicine and Public Health, College of Medicine & Health Sciences, Sultan Qaboos University, P.O. Box 35, 123 Al-Khoudh, Sultanate of Oman. Email: [email protected]
Downloaded from aut.sagepub.com at UNIV OF NORTH DAKOTA on May 17, 2015
7
Al-Sharbati et al. program is non-compulsory and is often limited to “higher functioning” children with special needs and talents. There is a tendency for this special education program to “lump” all types of children with special needs education under one “roof” (Al-Adawi, 2006). The country lacks a specific educational initiative which is tailor-made for children with autism spectrum disorders (ASDs) (Al-Farsi et al., 2011). However, special education programs have recently increased in number and size and are reaching different parts of the country from their earlier concentration in the urban areas. In addition to public institutions for Special Education, Early Childhood Intervention programs for preschool children have come to the forefront in order to provide aid to children who are physically or developmentally challenged, so that they will be able to join the mainstream school education (Al-Belushi et al., 1999). With an increasing population and resultant “baby boom,” discussions on the mainstream education system and attitudes currently available for children with special needs therein have come to the forefront. An increase in the general population brings with it an anticipated increased number of children with special needs, seeking mainstream education. It is therefore imperative to explore the awareness and attitude of mainstream teachers in Oman toward children with special needs, such as those with ASD (American Psychiatric Association, 2000). It has been estimated that 0.14 per 1000 Omani children (aged 0–14 years) have been identified as having ASD (Al-Farsi et al., 2011). This low prevalence rate is most likely the result of under-diagnosis and under-reporting of ASD in the country, so such magnitude is likely to be merely the “tip of the iceberg.” While the correct magnitude has yet to be determined, the situation on the ground points to a need to address increased number of children with ASD (Al-Farsi et al., 2011). Unfortunately, due to the stigma of having a child with special needs, there is a tendency in Oman to “hide” challenged children within the familial household, limiting their access to educational or remedial services (Profanter, 2009). Al-Farsi et al. (2013a) surveyed the perceived socioeconomic burden for caring for children with ASD in an urban setting in Oman. This study indicated the presence of perceived social and financial burden among parents of children with ASD. It also suggested that regardless of their socioeconomic status, most parents’ complaint was that they themselves were left to care for their offspring with ASD. Studies examining awareness and attitudes among teachers toward children with ASD have been carried out in different parts of the world. Some studies have indicated that teacher’s knowledge toward autism is not equivalent to that of mental health professionals’ (Helps et al., 1999). Lee Mendoza indicated that while children with autism in the developed world are generally enrolled in regular or special education institutes, such privilege has yet to be available in the developing world (Mendoza, 2010). In the Arab part
of the world including Oman, there are few studies that examine psychosocial variables relevant for children with ASD (Alghazo et al., 2003; Al-Shammari, 2006). Alghazo et al. (2003) examined the attitudes of teachers and preservice teachers in the United Arab Emirates toward the integration of children with special needs into regular schools. The majority of teachers expressed reservation toward having children with special needs and disabilities in mainstream education. The psychosocial issue relevant for the higher functioning children with ASD seeking mainstream education has not been explored in Oman, although there are some data from other Arab countries, which indicate that the focus has been geared toward the spectrum of challenged children rather than children with ASD. Therefore, with the background that some children with ASD are likely to seek mainstream education, there is a need to quantify teachers’ awareness and attitudes toward these children. This study aims to solicit (a) teachers’ awareness about the etiology of autism, (b) its signs and symptoms, and (c) social–demographic factors and educational needs of children with ASD.
Methods This is a cross-sectional study conducted among school teachers teaching in Basic Education which covers Grades 1–5 in selected public and private schools in Muscat, the capital of Oman. The study was conducted during January to June 2012. Allowing an error rate of 2.5%, the level of significance (type 1 error) of 1%, and 99% confidence interval, and with a priori estimate that 20% of teachers would have high awareness about ASD, the computer program indicated that a sample size of 150 participants was required to achieve the objectives of our study. Using the administrative structure of Basic Education schools in the Muscat Governorate, a multistage stratified sampling design was developed over three levels: school, wilayat (district), and teachers. A total of 51 Basic Education schools (Grades 1–5) were identified in the Governorate. They comprised a total of 1832 teachers, wherein 1087 were females and 745 were males. The lists of schools and teachers were assigned digits randomly. Using the Statistical Package for Social Sciences (SPSS) software (Version 19.0, IBM, Chicago, IL, USA), the participants were selected in two stages. First, a sample of 5 schools was randomly selected from the list of schools; then, among the teachers working in those randomly selected schools, a random sample of 200 teachers was selected. Those 200 teachers were approached, and 187 (94%) expressed their consent to participate in this study. The questionnaires were distributed by trained research assistants who utilized the time to explain the importance of the study, and motivated the participants, which resulted in obtaining a high response rate. A total of 23 eligible participants were excluded from the study due to incompletely filled questionnaires, or no
Downloaded from aut.sagepub.com at UNIV OF NORTH DAKOTA on May 17, 2015
8
Autism 19(1)
Table 1. Sociodemographic characteristics of participants by gender, Oman, 2012. Characteristics
Total (N = 164)
Men (N = 46)
Women (N = 118)
p-value
n (%)
n (%)
n (%)
138 (84.1) 23 (14.0)
35 (76.1) 5 (10.9)
103 (87.3) 18 (15.3)
35 (21.3) 129 (78.7)
17 (37.0) 29 (63.0)
18 (15.3) 100 (84.7)
93 (56.7) 47 (28.7) 24 (14.6)
33 (71.7) 8 (17.4) 5 (10.9)
60 (50.8) 39 (33.1) 19 (16.1)
101 (61.6) 26 (15.9) 37 (22.6) 146 (89.0) 18 (11.0) 10 (6.1) 85 (51.8)
33 (71.7) 3 (6.5) 10 (21.7) 41 (89.1) 9 (19.6) 5 (10.9) 30 (65.2)
68 (57.6) 23 (19.5) 27 (22.9) 105 (89.0) 9 (7.6) 5 (4.2) 55 (46.6)
Nationality Omani Non-Omani School Private Public Age 20–29 30–39 40–49 Number of years in teaching 0–4 5–9 10 or more Heard about autism Ever contacted a child with autism If yes, was the contact through your educational profession Can easily identify a child with autism
response, probably due to lack of time. Responses were therefore obtained from 82% of the original sample. A questionnaire was designed for this purpose and then administered to the enrolled teachers. The tool and criteria for knowledge and attitude toward autism were defined and developed as reported elsewhere (Al-Sharbati et al., 2012; Rahbar et al., 2011). The questionnaire covered teacher’s awareness about the etiology, signs, and symptoms of autism, as well as items on sociodemographic factors and educational needs of children with ASD. For the purpose of validation, the instrument was targeted toward bilingual teachers because they were able to give feedbacks about both the English and Arabic content of the instrument. The English and Arabic versions of the questionnaire were formatted. To improve its conceptual content similarly, a standard forward–backward procedure was applied to translate the English version into Arabic and vice versa. The translated Arabic version of the questionnaire was checked by a bilingual professional who was independent from the team of investigators. The questionnaire was tested on 20 randomly selected teachers caring for children with ASD, and validated internally after. The validity of our questionnaire was assessed by comparing the information obtained through self-filled questionnaire versus questionnaire filled during the interview. The information gathered during the interview was considered the standard for comparison. Construct validity was assessed using Spearman correlations over an overall number of correct answers related to concept of awareness (r = 0.80, p < 0.01) which showed highly significant correlation, supporting the very good construct validity. Interrater reliability was established among interviewers to
0.43 0.002 0.05 0.1 0.98 0.04 0.14 0.17
standards of 90% agreement on questions related to etiology, signs and symptoms, and social–demographic correlates of autism. The overall percentage agreement between the raters on the selected parameters (test–retest reliability) was found to be 87% (kappa = 0.82). Therefore, the global psychometric assessment of the questionnaire indicated that the overall reliability and validity were both high. Chi-square analyses were used to evaluate the statistical significance of differences among proportions of categorical data. The nonparametric Fisher’s exact test (two-tailed) was used instead of the chi-square test for small sample sizes, where the expected frequency was less than 5 in any of the 2 × 2 table cells. All statistical analyses were performed using the SPSS software; a cutoff p-value of
AUT19110.1177/1362361313508025AutismAl-Sharbati et al.
Original Article
Awareness about autism among school teachers in Oman: A cross-sectional study
Autism 2015, Vol. 19(1) 6–13 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361313508025 aut.sagepub.com
Marwan M Al-Sharbati, Yahya M Al-Farsi, Allal Ouhtit, Mostafa I Waly, Mohamed Al-Shafaee, Omar Al-Farsi, Maha Al-Khaduri, Mona F Al-Said and Samir Al-Adawi
Abstract Children with special needs such as those with autism spectrum disorder have been recorded as ostracized and stigmatized in many parts of the world. Little is known about whether such negative views are present among mainstream teachers in Oman. A cross-sectional study was conducted to evaluate school teachers’ awareness about autism spectrum disorder in an urban region in Oman. A total of 164 teachers were randomly enrolled from five schools. Misconceptions about autism spectrum disorder were found to be common among mainstream teachers in the country. We posit that such lack of awareness was likely to be rooted with sociocultural patterning as well as conflicting views often “spun” by the scientific community and mass media. Enlightened views toward children with autism spectrum disorder should be presented to Omani teachers to overcome misconceptions and negative attitudes toward children with autism spectrum disorder. Keywords autism, autism spectrum disorder, awareness, misconceptions, Oman, teachers
Sultanate of Oman is a Middle Eastern country that stretches across approximately 309,500 km2. According to the 2010 census (National Center for Statistics and Information, 2013), its population is estimated to be 3.3 million. The country is classified by the World Bank as a “middleincome economy” among the emerging economies (Central Intelligence Agency, 2011). Prior to the turn of the century, Oman spent the bulk of its Gross National Product (GNP) annually to furnish universal free education for both sexes, which was heralded by the motto “Education for All by the year 2000.” As a result, literacy has now reached all strata of the Omani society with abundant public schools in all corners of the country, experiencing a negligible gender-gap (Al-Adawi, 2006). As a result of this initiative, the enrollment in tertiary education has increased (Al-barwani et al., 2009). Considering this background, the question remains whether “Education for All” has reached children with special abilities and needs. One rough estimate indicated that approximately 23% of children in Oman are likely to have special needs (Profanter, 2009). Education in Oman is provided for free but attendance is optional. Expenditure on education was reported to be 4.3% of the Sultanate’s Gross Domestic Product (GDP) and 26.1% of total government spending (World Bank, 2012).
According to Human Development Index, Oman is ranked 84 out of 186 countries in its public expenditure on education (World Bank, 2012). The public education system in Oman consists of two phases: Basic and post-Basic Education. The Basic Education is organized into two cycles: the first cycle covers Grades 1–4, and the second cycle covers Grades 5–10. These two cycles are followed by 2 years of post-Basic Education system known as “Secondary Education” (Ministry of Education, 2007). The Department of Special Education was established within the Ministry of Education to oversee special education (Profanter, 2009). The Ministry of Education coordinates special education programs for those with communication disorders, physical disabilities, mental retardation, and the resultant varied spectrum of handicapping conditions stemming from such disorders (Ministry of Education, 2002). However, enrollment in Special Education Sultan Qaboos University, Sultanate of Oman Corresponding author: Yahya M Al-Farsi, Department of Family Medicine and Public Health, College of Medicine & Health Sciences, Sultan Qaboos University, P.O. Box 35, 123 Al-Khoudh, Sultanate of Oman. Email: [email protected]
Downloaded from aut.sagepub.com at UNIV OF NORTH DAKOTA on May 17, 2015
7
Al-Sharbati et al. program is non-compulsory and is often limited to “higher functioning” children with special needs and talents. There is a tendency for this special education program to “lump” all types of children with special needs education under one “roof” (Al-Adawi, 2006). The country lacks a specific educational initiative which is tailor-made for children with autism spectrum disorders (ASDs) (Al-Farsi et al., 2011). However, special education programs have recently increased in number and size and are reaching different parts of the country from their earlier concentration in the urban areas. In addition to public institutions for Special Education, Early Childhood Intervention programs for preschool children have come to the forefront in order to provide aid to children who are physically or developmentally challenged, so that they will be able to join the mainstream school education (Al-Belushi et al., 1999). With an increasing population and resultant “baby boom,” discussions on the mainstream education system and attitudes currently available for children with special needs therein have come to the forefront. An increase in the general population brings with it an anticipated increased number of children with special needs, seeking mainstream education. It is therefore imperative to explore the awareness and attitude of mainstream teachers in Oman toward children with special needs, such as those with ASD (American Psychiatric Association, 2000). It has been estimated that 0.14 per 1000 Omani children (aged 0–14 years) have been identified as having ASD (Al-Farsi et al., 2011). This low prevalence rate is most likely the result of under-diagnosis and under-reporting of ASD in the country, so such magnitude is likely to be merely the “tip of the iceberg.” While the correct magnitude has yet to be determined, the situation on the ground points to a need to address increased number of children with ASD (Al-Farsi et al., 2011). Unfortunately, due to the stigma of having a child with special needs, there is a tendency in Oman to “hide” challenged children within the familial household, limiting their access to educational or remedial services (Profanter, 2009). Al-Farsi et al. (2013a) surveyed the perceived socioeconomic burden for caring for children with ASD in an urban setting in Oman. This study indicated the presence of perceived social and financial burden among parents of children with ASD. It also suggested that regardless of their socioeconomic status, most parents’ complaint was that they themselves were left to care for their offspring with ASD. Studies examining awareness and attitudes among teachers toward children with ASD have been carried out in different parts of the world. Some studies have indicated that teacher’s knowledge toward autism is not equivalent to that of mental health professionals’ (Helps et al., 1999). Lee Mendoza indicated that while children with autism in the developed world are generally enrolled in regular or special education institutes, such privilege has yet to be available in the developing world (Mendoza, 2010). In the Arab part
of the world including Oman, there are few studies that examine psychosocial variables relevant for children with ASD (Alghazo et al., 2003; Al-Shammari, 2006). Alghazo et al. (2003) examined the attitudes of teachers and preservice teachers in the United Arab Emirates toward the integration of children with special needs into regular schools. The majority of teachers expressed reservation toward having children with special needs and disabilities in mainstream education. The psychosocial issue relevant for the higher functioning children with ASD seeking mainstream education has not been explored in Oman, although there are some data from other Arab countries, which indicate that the focus has been geared toward the spectrum of challenged children rather than children with ASD. Therefore, with the background that some children with ASD are likely to seek mainstream education, there is a need to quantify teachers’ awareness and attitudes toward these children. This study aims to solicit (a) teachers’ awareness about the etiology of autism, (b) its signs and symptoms, and (c) social–demographic factors and educational needs of children with ASD.
Methods This is a cross-sectional study conducted among school teachers teaching in Basic Education which covers Grades 1–5 in selected public and private schools in Muscat, the capital of Oman. The study was conducted during January to June 2012. Allowing an error rate of 2.5%, the level of significance (type 1 error) of 1%, and 99% confidence interval, and with a priori estimate that 20% of teachers would have high awareness about ASD, the computer program indicated that a sample size of 150 participants was required to achieve the objectives of our study. Using the administrative structure of Basic Education schools in the Muscat Governorate, a multistage stratified sampling design was developed over three levels: school, wilayat (district), and teachers. A total of 51 Basic Education schools (Grades 1–5) were identified in the Governorate. They comprised a total of 1832 teachers, wherein 1087 were females and 745 were males. The lists of schools and teachers were assigned digits randomly. Using the Statistical Package for Social Sciences (SPSS) software (Version 19.0, IBM, Chicago, IL, USA), the participants were selected in two stages. First, a sample of 5 schools was randomly selected from the list of schools; then, among the teachers working in those randomly selected schools, a random sample of 200 teachers was selected. Those 200 teachers were approached, and 187 (94%) expressed their consent to participate in this study. The questionnaires were distributed by trained research assistants who utilized the time to explain the importance of the study, and motivated the participants, which resulted in obtaining a high response rate. A total of 23 eligible participants were excluded from the study due to incompletely filled questionnaires, or no
Downloaded from aut.sagepub.com at UNIV OF NORTH DAKOTA on May 17, 2015
8
Autism 19(1)
Table 1. Sociodemographic characteristics of participants by gender, Oman, 2012. Characteristics
Total (N = 164)
Men (N = 46)
Women (N = 118)
p-value
n (%)
n (%)
n (%)
138 (84.1) 23 (14.0)
35 (76.1) 5 (10.9)
103 (87.3) 18 (15.3)
35 (21.3) 129 (78.7)
17 (37.0) 29 (63.0)
18 (15.3) 100 (84.7)
93 (56.7) 47 (28.7) 24 (14.6)
33 (71.7) 8 (17.4) 5 (10.9)
60 (50.8) 39 (33.1) 19 (16.1)
101 (61.6) 26 (15.9) 37 (22.6) 146 (89.0) 18 (11.0) 10 (6.1) 85 (51.8)
33 (71.7) 3 (6.5) 10 (21.7) 41 (89.1) 9 (19.6) 5 (10.9) 30 (65.2)
68 (57.6) 23 (19.5) 27 (22.9) 105 (89.0) 9 (7.6) 5 (4.2) 55 (46.6)
Nationality Omani Non-Omani School Private Public Age 20–29 30–39 40–49 Number of years in teaching 0–4 5–9 10 or more Heard about autism Ever contacted a child with autism If yes, was the contact through your educational profession Can easily identify a child with autism
response, probably due to lack of time. Responses were therefore obtained from 82% of the original sample. A questionnaire was designed for this purpose and then administered to the enrolled teachers. The tool and criteria for knowledge and attitude toward autism were defined and developed as reported elsewhere (Al-Sharbati et al., 2012; Rahbar et al., 2011). The questionnaire covered teacher’s awareness about the etiology, signs, and symptoms of autism, as well as items on sociodemographic factors and educational needs of children with ASD. For the purpose of validation, the instrument was targeted toward bilingual teachers because they were able to give feedbacks about both the English and Arabic content of the instrument. The English and Arabic versions of the questionnaire were formatted. To improve its conceptual content similarly, a standard forward–backward procedure was applied to translate the English version into Arabic and vice versa. The translated Arabic version of the questionnaire was checked by a bilingual professional who was independent from the team of investigators. The questionnaire was tested on 20 randomly selected teachers caring for children with ASD, and validated internally after. The validity of our questionnaire was assessed by comparing the information obtained through self-filled questionnaire versus questionnaire filled during the interview. The information gathered during the interview was considered the standard for comparison. Construct validity was assessed using Spearman correlations over an overall number of correct answers related to concept of awareness (r = 0.80, p < 0.01) which showed highly significant correlation, supporting the very good construct validity. Interrater reliability was established among interviewers to
0.43 0.002 0.05 0.1 0.98 0.04 0.14 0.17
standards of 90% agreement on questions related to etiology, signs and symptoms, and social–demographic correlates of autism. The overall percentage agreement between the raters on the selected parameters (test–retest reliability) was found to be 87% (kappa = 0.82). Therefore, the global psychometric assessment of the questionnaire indicated that the overall reliability and validity were both high. Chi-square analyses were used to evaluate the statistical significance of differences among proportions of categorical data. The nonparametric Fisher’s exact test (two-tailed) was used instead of the chi-square test for small sample sizes, where the expected frequency was less than 5 in any of the 2 × 2 table cells. All statistical analyses were performed using the SPSS software; a cutoff p-value of
