LSHSS

Research Article

Modifying Attitudes of Arab School Teachers Toward Stuttering Fauzia Abdallaa and Kenneth O. St. Louisb

Purpose: The authors of this quasi-experimental design study explored the effect of an educational documentary video that presented factual and emotional aspects of stuttering on changing attitudes toward stuttering of preservice trainees and in-service public school teachers in Kuwait. Method: Participants were 99 preservice trainees (48 control, 51 experimental) and 103 in-service teachers (49 control, 54 experimental). All participants completed 22 items from the Public Opinion Survey of Human Attributes—Stuttering (POSHA–S; St. Louis, 2005; translated into Arabic) and 17 additional items pre and post treatment. Participants in the experimental group viewed the awareness video. Results: Pretreatment comparisons confirmed that the control and experimental groups did not differ on their attitudes toward stuttering. As predicted, the posttreatment

ratings for the control group were not different from the pretreatment ratings. A significant shift in attitudes (mostly in a positive direction) from pre to post treatment was observed for the experimental group of preservice trainees but not for the experimental group of in-service teachers. Interpretation of the difference in outcomes for the experimental preservice group as compared to the experimental in-service group is confounded by gender differences across groups. Conclusion: The authors of this study demonstrated that it is possible to positively modify preservice trainees’ attitudes of people who stutter by using an educational documentary video.

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stereotyping can lead to discriminatory actions and can create social and occupational obstacles for people who stutter (Daniels, Gabel, & Hughes, 2012; Gabel, Blood, Tellis, & Althouse, 2004; Klompas & Ross, 2004). Stuttering affects the psychological and social well-being of preschool and school-age children. Investigations have documented that children who stutter are teased and bullied (Blood & Blood, 2007), are perceived unfavorably by peers (Langevin, Packman, & Onslow, 2009), are rejected (Davis, Howell, & Cooke, 2002), and are recipients of social penalty (Langevin et al., 2009; Langevin, Packman, & Onslow, 2010). Because children spend much of their waking hours in schools, malleability of teacher attitudes toward stuttering is particularly important to understand.

growing body of research has established the ubiquity of negative attitudes toward stuttering held by people of various ages (Dorsey & Guenther, 2000; Ezrati-Vinacour, Platzky, & Yairi, 2001; Flynn & St. Louis, 2011) and across multiple professions (Cooper & Cooper, 1996; Crowe & Walton 1981; Hurst & Cooper, 1983; Ruscello, Lass, Schmitt, & Pannbacker, 1994; Yeakle & Cooper 1986). People who stutter are perceived as anxious, nervous, shy, fearful, and introverted individuals whose speech deficits arise as a result of psychological or emotional causes (e.g., Blood, Blood, Tellis, & Gabel, 2003; Craig, Tran, & Craig, 2003; Doody, Kalinowski, Armson, & Stuart, 1993; Klassen, 2001; St. Louis, 2005; Van Borsel, Verniers, & Bouvry, 1999). Despite the lack of empirical data supporting these perceptions, negative attitudes have continued to persist regardless of an individual’s exposure or family relationship to people who stutter (Doody et al., 1993; Leahy, 1994; McGee, Kalinowski, & Stuart, 1996). Negative

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Kuwait University, Kuwait West Virginia University, Morgantown

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Correspondence to Fauzia Abdalla: [email protected] Editor: C. Melanie Schuele Associate Editor: Ellen Kelly Received January 31, 2013 Revision received June 9, 2013 Accepted December 4, 2013 DOI: 10.1044/2013_LSHSS-13-0012

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Key Words: stuttering, attitudes, cross-cultural, Arab teachers, stereotyping, modifications

Measuring Changed Attitudes Toward Stuttering There is a need for more public education and awareness campaigns targeting teachers (Abdalla & St. Louis, 2012; Crowe & Walton, 1981; Irani & Gabel, 2008), speechlanguage pathologists (SLPs; St. Louis & Lass, 1981), the general public, and parents of school children (Al-Khaledi, Lincoln, McCabe, Packman, & Alshatti, 2009; Gabel et al., 2004) in order to increase their knowledge of stuttering and minimize the social stigma associated with stuttering. Investigations of changing attitudes toward stuttering have Disclosure: The authors have declared that no competing interests existed at the time of publication.

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included university students (Leahy, 1994; Mayo, Mayo, Gentry, & Hildebrandt, 2008; Reichel & St. Louis, 2004, 2006; Snyder, 2001), adolescents (Flynn & St. Louis, 2011; McGee et al., 1996), and teachers (Gottwald, Fraas, Hawver, Hartley, & St. Louis, 2011). Studies in the 1990s found that public attitudes toward stuttering had remained negative and immutable (e.g., Leahy, 1994; McGee et al., 1996), whereas studies conducted in the last few years have reported positive changes (e.g., Flynn & St. Louis, 2011; Gottwald et al., 2011). Snyder (2001) suggested that the failure to reduce negative attitudes toward people who stutter can be attributed to the lack of effectiveness of the educational material as well as the inadequacy of instruments to detect change. Three instruments that have been used to detect change in attitudes toward people who stutter are the Semantic Differential Scale (Woods & Williams, 1976), the Clinician Attitudes Toward Stuttering inventory (Cooper, 1975), and the Public Opinion Survey of Human Attributes—Stuttering (POSHA–S; St. Louis, 2005, 2011a, 2011b, 2011c, 2012b). It appears that the POSHA–S shows the most promise for capturing change in public attitudes toward stuttering. Thus far, the POSHA–S has been translated into 11 languages. The POSHA–S has undergone extensive testing to demonstrate its utility as a measure of public attitudes toward stuttering. Empirical studies have demonstrated test–retest reliability (St. Louis, 2012b; St. Louis, Lubker, Yaruss, & Aliveto, 2009), construct and concurrent validity (St. Louis, Reichel, Yaruss, & Lubker, 2009), internal consistency (Al-Khaledi et al., 2009; St. Louis, 2012b), readability and resistance to order effects or respondent errors (St. Louis, Lubker, Yaruss, Adkins, & Pill, 2008), translatability (St. Louis, Andrade, Georgieva, & Troudt, 2005; St. Louis & Roberts, 2010), robustness in paper-and-pencil versus online administration (St. Louis, 2012b), sensitivity to probability versus convenience sampling (Özdemir, St. Louis, & Topbaş, 2011a), and equivalence with or without a printed definition of stuttering (St. Louis, 2012b; St. Louis et al., 2011). In terms of measured attitudes, the POSHA–S has been shown to be sensitive to attempts to modify attitudes (Flynn & St. Louis, 2011; St. Louis, Reichel, et al., 2009), changes between and among cultures (e.g., St. Louis, 2012b; St. Louis & Roberts, 2010; St. Louis et al., 2005, 2011), and demographic differences that should predict positive attitudes (St. Louis & George, 2008).

Teachers’ Attitudes Toward Stuttering Early studies of teachers’ attitudes toward people who stutter (e.g., Crowe & Walton, 1981; Lass et al., 1992, 1994; Yeakle & Cooper, 1986) reported largely negative attitudes among American teachers and school administrators. But more recently, Irani and Gabel (2008) noted a positive change in American school teachers’ attitudes toward people who stutter. Variations in social attitudes and cultural values can influence the public’s reactions to people who stutter. For example, people in Nepal, Brazil, Turkey, Bulgaria, Cameroon, and China have been observed to hold more negative

attitudes toward people who stutter than persons in North America, Western Europe, and Australia (e.g., Ip, St. Louis, Myers, & An Xue, 2012; Özdemir, St. Louis, & Topbaş, 2011a, 2011b; St. Louis et al., 2005; St. Louis & Roberts, 2010; Xingming, Jing, Yi-wen, & Van Borsel, 2001). Thus, it is important to explore teachers’ attitudes toward stuttering within different regions and subcultures around the world. Heite (2000) found that most Icelandic teachers have limited knowledge about stuttering, and that their cultural myths and stress reactions seem to influence their judgments as listeners. In contrast, Pachigar, Stansfield, and Goldbart (2011) reported that in India, teachers expressed relatively favorable attitudes toward stuttering. As the current review portrays, attitudes toward and beliefs about people who stutter continue to be mixed. Several studies have demonstrated special challenges that students who stutter confront during the school years, such as negative experiences, teasing, and bullying (Hayhow, Cray, & Enderby, 2002; Hugh-Jones & Smith, 1999; Klompas & Ross, 2004; Langevin et al., 2009, 2010). It is rather worrisome when influential figures such as teachers hold negative attitudes toward people who stutter. Not only can these beliefs and attitudes affect the educational development of students who stutter (Lass et al., 1992; Stewart & Turnbull, 2007), but they can also impact the actions of typically fluent students and their relationships with people who stutter (Jenkins, 2010; Turner & Helms, 1995). Thus, it seems essential to enhance teachers’ knowledge and skills to support children who stutter at school (Gottwald & Hall, 2003; Jenkins, 2010; Klompas & Ross, 2004; Lass et al., 1992). The purpose of the current investigation was to explore the malleability of teachers’ attitudes toward people who stutter, specifically, teachers in Kuwait. Only a few studies, predominantly from the State of Kuwait, have probed the attitudes of Arab teachers toward people who stutter (Abdalla & Al-Saddah, 2009; Abdalla & St. Louis, 2012; Irani, Abdalla, & Gabel, 2012). Kuwaiti individuals who stutter have recounted negative school experiences. Qualitative interviews conducted with two adults who stutter and an adolescent who stutters revealed a lack of understanding of stuttering among teachers, with some teachers expressing pity, impatience, and discrimination toward students who stutter (Abdalla & Al-Saddah, 2009). Abdalla and St. Louis (2012) used an Arabic version of the POSHA–S to explore the knowledge, beliefs, and reactions related to stuttering of 471 Arab preservice trainees in a university training program and in-service public school teachers living in Kuwait. The respondents held unfavorable opinions of people who stutter and often were misinformed about the etiology of stuttering. Some believed that stuttering was caused by psychological factors or, often, by ghosts, demons, or spirits. Although the participants viewed people who stutter as intelligent and capable of making friends and leading normal lives, they also attributed negative traits like fearfulness and shyness to them. Irani et al. (2012) also found that, on semantic differential scale items related to social skills and employability, teachers in Kuwait held less favorable attitudes toward those who stutter in comparison

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with teachers from the United States. Abdalla and St. Louis emphasized the need for awareness campaigns to dispel misconceptions about stuttering not only for in-service teachers, but also for teachers in training (i.e., preservice trainees).

Rationale and Purpose of the Study Speech-language pathology is a budding field in Kuwait and other Arab countries. Kuwait did not have a formal training program for SLPs until very recently when Kuwait University initiated a Bachelor of Science degree in Communication Disorders in 2004. A majority of the country’s SLPs serve individuals with communication disorders in special education schools or medical settings. As there are no SLPs in regular public schools, students who stutter often are referred to the school’s psychologist or social worker. There are limited resources for teachers (such as leaflets or websites) on stuttering in Arabic, which is the language primarily spoken by the teachers. Therefore, there is a dire need in the region to find an effective means for spreading awareness about stuttering among Arab teachers. We attempted to fill this void by exploring the effect of an educational awareness video on the knowledge and attitudes of teachers in Kuwait toward stuttering as measured by an Arabic adaptation of the POSHA–S. We hypothesized that after viewing the video, the experimental group would display a positive shift in their ratings, whereas the control group would not show a change. If this short 17-min documentary was found to be effective, then it could serve as an awareness campaign to increase knowledge about stuttering among Arab teachers in Kuwait and the Middle East. With greater knowledge about both stuttering and ways to interact with students who stutter, teachers can make the school environment healthier.

Method In contrast to other studies in which public attitudes toward people who stutter have been explored, the current study was designed to include a control group. A nonequivalent (pretest and posttest) control group design (Creswell, 2003) was adopted. The investigation was reviewed and approved by the Kuwait Ministry of Education, and all participants signed an informed consent form. Although the instrument used to measure change was the same as that used by Abdalla and St. Louis (2012), the participants of this study were a distinct group of preservice trainees and in-service teachers.

Participants The participants of this study were preservice trainees who were enrolled at the College of Basic Education in Kuwait and in-service teachers who were working at Kuwait local public schools. With respect to the preservice trainees, six randomly selected classes of approximately 108 second-year students at the College of Basic Education participated as the

control group, and six other classes of roughly equal number served as the experimental group. Completed pretest questionnaires were returned by 163 preservice trainees (75%); 99 (48 control and 51 experimental) preservice trainees (61%) completed the posttest questionnaire. Communication between control and experimental participants was precluded given their different locations (schools and classes). To recruit the in-service teacher sample, we selected 12 schools randomly from two governorates. The teachers in the two governorates were similar, as the Ministry of Education assigns teachers randomly to governorates depending on the need. Two hundred teachers (100 from each governorate) were randomly selected from a list of potential participants that was provided by the school principals and then were randomly assigned to the control (n = 100) or experimental group (n = 100). The final sample of in-service teachers (n = 103; 54 experimental and 49 control) were those who completed the pretest and posttest questionnaires. The return rate on the pretest questionnaire was 79% (158 of 200); the return rate on the posttest questionnaire was 65% (103 of 158). The control and experimental preservice trainee groups individually averaged 20.3 years of age (SD = 2.1 and 2.9, respectively), with 12.0 years of education (SD = .00 for both groups). The mean age of the control in-service teachers was 34.6 years (SD = 6.5), with 15.9 years of education (SD = .63), or just slightly lower than that for the experimental in-service teachers (38.6 years [SD = 8.5], and 16.0 years [SD = .00], respectively). A significant age difference emerged between the control and experimental in-service teachers, t(100) = –2.64, p < .01, two-tailed. All preservice trainees were female; virtually none reported being employed. All control in-service teachers were female, whereas all experimental in-service teachers were male. (This imbalance resulted from those participants who chose to complete the pre- and posttest). Almost all of the in-service teachers identified themselves as nonstudents. Sixty-six percent of the preservice trainees indicated knowing more than one language, compared to 50% of the in-service teachers.

Survey Questionnaire Following Abdalla and St. Louis (2012), the questionnaire in this study comprised a subset of 22 items from the POSHA–S (translated into Arabic) and 17 additional items adapted from various sources (e.g., Crowe & Walton, 1981; Guitar, 2006; Heite, 2000; Yeakle & Cooper, 1986). The questionnaire used a paper-and-pencil format, and participants were required to respond to each statement by circling yes, no, or not sure. The items from the POSHA–S were selected for their relevancy to the current study. These items pertained to the etiology of stuttering, the question of who should help people who stutter, the participants’ reactions to stuttering (e.g., feel impatient), and the participants’ thoughts on the effect of the disorder on people who stutter (such as the ability to lead a normal life) and on the personality traits of people who stutter (e.g., shy or fearful), as well as what the participants would do when speaking with an individual who

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stutters (e.g., fill in the person’s words). Seventeen items were added to provide insights about other aspects of the disorder, such as characteristics of stuttering and what action a teacher could take to help a student who stutters (e.g., excuse people who stutter from class discussions and oral tasks).

Documentary Video A professionally generated, specially designed, 17-min documentary video served as the stimulus material in this study. The content of the video was drawn from two main sources. The first source, the Stuttering Foundation of America (2007), was used to provide general information about stuttering that was displayed on Microsoft PowerPoint slides and explained by a 25-year-old Arabic-speaking female SLP narrator with training in public speaking. The narrator used standard Arabic and did not make persuasive or inferential comments. The second source consisted of video segments from interviews with three Kuwaiti individuals— two adolescent students (male 17 years, female 14 years) with moderate stuttering and a fluent male public middle school teacher. The documentary video provided factual content, such as core and secondary characteristics of stuttering (using pertinent examples from the speech sample of the interviewees), etiology, basic information about treatment, and tips on how a teacher can interact with a student who stutters. The video segments of the students who stutter also conveyed emotional aspects of stuttering that the students experienced socially and educationally. For example, the female student related an incident in school: I raised my hand in class one time and the teacher interrupted me while I was speaking and told me I couldn’t answer the question because I am so disfluent. She [the teacher] embarrassed me further in front of the class by asking students to correct my speech. I wish my teacher would be patient and give me a chance to express my thoughts and feelings. I just want to be treated like other students in my class who do not stutter. Both adolescent students described aspects of their teachers’ reactions and strategies that they found to be productive (e.g., listening without interruption or filling in his/her words) and those they found to be counterproductive (e.g., asking the student to take a deep breath or relax while speaking). The teacher related a positive experience he had teaching a student who stuttered. He indicated that the student was not different from any of his peers academically, emotionally, or socially. The teacher discussed teasing experienced by the student who stuttered and described strategies the student used to handle negative comments in and out of class.

Procedure Each participant received a survey package at pretest consisting of a cover page with information about the study, a consent form, reassurance of anonymity, and survey instructions. The survey included a demographic section on the

age, gender, and citizenship of the respondent, followed by questions to check if the respondent stuttered, had a friend or relative who stuttered, had taught students who stutter, had previous knowledge about stuttering, or knew how to obtain information about stuttering. Participants who identified themselves as an individual who stutters were not included in the study. The video was played on a Toshiba Satellite laptop with external speakers, projected on a screen, and viewed by 10 to 15 participants in a classroom. All of the participants indicated that they could hear and view the video comfortably. The experimental participants completed the pretest survey and then watched the video presentation on the same day. The experimental participants completed the posttest survey 1 week later in order to allow time for them to reflect on the video content. The control participants completed the survey on the same schedule, but they did not view the video between pretest and posttest. However, the control participants viewed the video after the posttest in order to give them the benefit of the educational awareness campaign.

Data Analysis Tests of between-group differences on the categorical measures were conducted using the chi-square test of independence. For analyses involving matched or repeated categorical measures design (i.e., pre- and posttest) in which participants served as their own controls, we used the McNemar test (family-wise Bonferroni correction = .001; Pett, 1997). To provide a more meaningful interpretation of the differences in the participants’ pre- and posttreatment responses, we reduced the three original response options ( yes, no and not sure) to two categories: target response (1) versus nontarget response (0). Responses that were recoded as “target” represented accurate, desirable, and more positive ratings according to current consensus regarding stuttering (St. Louis, 2011a). Nontarget responses recoded as 0 consisted of not sure ratings and responses that were more negative, inaccurate, or less desirable. For example, participants who circled no for the item “People who stutter should try to hide their stuttering” were considered to have more desirable attitudes than those who circled yes or not sure. In the coding scheme adopted in this study, a rating of no for this item was recoded as the target response (1), and the remaining responses received a 0 (i.e., nontarget). The Appendix provides scoring for each item of the adapted POSHA–S.

Results Group Comparison of Pre- and Posttest Ratings To establish that there were no significant pretest differences between the control and experimental groups (preservice, in-service), we compared the pretest ratings using the chi-square test of independence. For preservice trainees, there were no between-group differences on the 39 items ( p > .001). For the in-service teachers, one of the 39 items yielded a between-group statistical difference. The control

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in-service teachers were less likely to feel comfortable (30.8%) while speaking with a person who stutters than the experimental in-service teachers (69.2%), c2(1, n = 103) = 11.89, p < .001, Cramer’s V = .340. Given the lack of difference, we compared the pre–post ratings within each participant group in order to evaluate the impact of the video training. The Appendix displays proportions of target preand posttest questionnaire responses (i.e., more desirable, accurate, and positive responses) for each individual item for the control and experimental preservice and in-service teachers. The McNemar test was conducted to assess significant within-group pre- to posttest differences with regard to the proportion of participants displaying target responses for questionnaire items that measured their beliefs, attitudes, and knowledge about stuttering. Significant pre–post differences were found only within the experimental preservice trainee group; 10 POSHA–S and eight added items displayed a statistically significant improvement as compared to pretest (see Appendix).

Preservice Trainees’ Changes in Attitudes and Beliefs The pretest to posttest changes in the attitudes and beliefs of the experimental preservice trainees after watching the video are described in the following paragraphs. Beliefs about people who stutter. After viewing the video, the preservice trainees were less likely to believe that people who stutter were to blame for their stuttering ( p < .001) or were shy or fearful ( p < .0001), and they more often believed that a person who stutters can lead a normal life ( p < .0001) and do any job he or she wants ( p < .001). In terms of knowing accurately the causes of stuttering, the preservice trainees were more correct in rejecting frightening events as a cause of stuttering ( p < .0001) and rejecting virus

or disease etiology ( p < .0001) after viewing the video. Despite these improvements, more than 50% of the experimental preservice trainees continued to hold the belief after viewing the video that stuttering can be caused by a frightening event (Figure 1). There was no opportunity to assess change with regard to who can help people who stutter with their speech because ratings for identifying an SLP as a source for assistance were already at ceiling, as evident in Figure 1. Self-reactions to people who stutter. With regard to social distance, watching the video was associated with a significant change in the experimental preservice trainees feeling comfortable around people who stutter ( p < .001). In the realm of help and advice they would provide to a person who stutters, the experimental preservice trainees were significantly less likely to fill in words on which the person was stuttering ( p < .0001) and to advise the person “to slow down/relax” ( p < .0001) after viewing the video. Additional items. As noted above, there was a shift in the experimental preservice trainees’ ability to accurately identify causes of stuttering after viewing the video. A statistically significant change from 2% to 45% was witnessed for another etiology item, that is, psychological problems ( p < .0001). Despite this change, more than half of the experimental preservice trainees at posttest appeared to still regard stuttering as stemming from psychological causes. In terms of traits, the posttreatment ratings showed that the experimental preservice trainees were less prone to believe that people who stutter have lower than average academic performance ( p < .0001). At the pretest, a high proportion of experimental preservice trainees accurately recognized that people who stutter can vary in the severity of their stuttering and that repetitions are a symptom of stuttering (see Figure 2). After

Figure 1. Proportion of the experimental preservice trainees’ target responses (i.e., more desirable, accurate, and positive) on the Public Opinion Survey of Human Attributes—Stuttering (POSHA–S) pre and post treatment for 14 beliefs about stuttering.

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Figure 2. Proportion of the experimental preservice trainees’ target responses (i.e., more desirable, accurate, and positive) on the POSHA–S pre and post treatment for six stuttering symptoms.

watching the video, this group of participants was significantly more likely to regard prolongations ( p < .0001) and facial muscle tension ( p < .0001) as stuttering symptoms (Figure 2). As for help and advice for individuals who stutter, the participants in the experimental preservice group were significantly less likely to believe that it would help a person who stutters to keep repeating until the word was uttered ( p < .0001; see Figure 3). Moreover, the participants in the experimental preservice group were less likely to advise a person who stutters to “take a deep breath,” ( p < .001) or “think before you speak” ( p < .001; Figure 3). Additionally, a significantly positive change was found in the experimental preservice participants’ views that it would help the student

who stutters if he/she “discusses his/her feelings about stuttering openly with classmates” ( p < .0001). As shown in Figure 3, the experimental preservice group was in favor of “warning students who tease or make fun of the speech of a student who stutters” and against “punishing a student who stutters in class.”

Discussion Researchers have emphasized the importance of disseminating accurate information about stuttering in order to reduce the persistent negative attitudes held by various sectors of society toward people who stutter (e.g., Abdalla & St. Louis, 2012; Al-Khaledi et al., 2009; Crowe & Walton,

Figure 3. Proportion of the experimental preservice trainees’ target responses (i.e., more desirable, accurate, and positive) on the POSHA–S pre- and posttreatment added items for eight ways of accommodating/ helping a student who stutters.

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1981; McGee et al., 1996). We endeavored to contribute to this aim by exploring the effect of a specially created educational awareness video on the attitudes of preservice trainees and in-service teachers toward people who stutter. The pretreatment comparisons corroborated findings of Abdalla and St. Louis (2012) that preservice trainees and public school teachers in Kuwait are misinformed about stuttering and ways of effectively interacting with students who stutter in the classroom. As predicted, the pre- and posttreatment scores for the control groups (preservice trainees and in-service teachers) were unchanged. A shift in attitudes (mostly in a positive direction) was observed in the experimental preservice trainees; however, no such change was witnessed for the experimental in-service teachers. Some aspects of these findings as discussed in the following paragraphs are consistent with those of previous studies, but others are incompatible.

Stimuli to Measure Attitudinal Change Researchers have adopted various creative approaches to effect changes in respondents’ attitudes toward people who stutter. Some have opted for coursework and exposure to people who stutter; others have resorted to video or live presentations by people who stutter. Well-planned and carefully edited videos are appealing because they can provide factual and emotional information while maintaining the same treatment across varying groups of viewers (Flynn & St. Louis, 2011). The nature of videos, no doubt, is one reason that researchers frequently have employed videos to effect change. However, video presentations also have given rise to inconsistent results. Flynn and St. Louis (2011), Gottwald et al. (2011), and Mayo et al. (2008) found noticeable improvement in people’s attitudes toward people who stutter using video presentations. By contrast, McGee et al. (1996) and Snyder (2001) found video documentaries to have little to no effect in sensitizing their participants to people who stutter. Perhaps videos that show more negative content and/or emotional hardships as a result of living with stuttering may sensitize viewers to how difficult life may be for people who stutter. McGee et al. indicated that vignettes from Voices to Remember (Bondarenko, 1992) that they used in their study could have reinforced preexisting negative stereotypes of people who stutter in their participants. McGee et al. (p. 245) cited an example from Voices to Remember whereby the clinician says “when a child can’t communicate fluently, they tend to withdraw and sometimes they just can’t get anything out and when they can’t communicate, they can’t show people their personality.” This may have been why these researchers found no positive changes in participants’ attitudes toward people who stutter. In the present study, we used a video stimulus that was effective with the preservice trainees but not with experienced (in-service) teachers. It is not at all clear why this dramatic difference occurred between the two experimental groups. Nevertheless, we submit that the stimuli alone cannot fully explain why one group (preservice trainees) would improve but not the other (in-service teachers) given that videos were found

to be effective with other groups of participants (e.g., Flynn & St. Louis, 2011; Gottwald et al., 2011; Mayo et al., 2008). One could propose that a gender difference could account for the variation in performance. The experimental preservice trainees in the present study were all female, whereas the experimental in-service teachers were all male. Alghazo and Gaad (2004) found that Arab male teachers were less accepting than Arab female teachers of including students with disability in regular classrooms. Additionally, Kuwaiti male adults were more likely to report unfavorable social inclusion and acceptance attitudes toward people with voice disorders than their female counterparts (Irani, Abdalla, & Hughes, 2013). Gender distinctions also have been reported generally in teachers’ beliefs and teaching practices (Organization for Economic Cooperation and Development, 2009). The results of a questionnaire, Teaching and Learning International Survey, administered by the Organization for Economic Cooperation and Development around the globe revealed that female teachers were more likely to use professional teaching practices (structuring and studentoriented) and to be involved in cooperative activities than their male counterparts. The authors interpreted this difference as evidence of greater motivation and professionalism on the part of the female teachers. The lack of shift in attitudes among the in-service teachers in the present investigation may be related to motivation and attitude toward change that male teachers are said to hold. Although it is likely that these factors could have played a role in the difference between the two experimental groups, pretest ratings demonstrated that even though the experimental in-service teachers were all male, their attitudes were essentially no different from the attitudes of the control in-service teachers, who were all female. This finding corroborates St. Louis’ (2012a) that the gender of the respondent did not make a difference on their ratings on the POSHA–S. Contact with a person who stutters may be an additional variable that could explain the difference in findings between the preservice trainees and in-service teachers. However, a chi-square test of independence revealed no significant differences between the preservice trainees who knew a friend/ relative who stutters (47.6%) and the in-service teachers who knew a friend/relative who stutters (52.4%), p > .05. Moreover, the two groups were also not statistically different in their previous reported knowledge of stuttering: preservice trainees (61%) and in-service teachers (39%), p > .05. In fact, a high proportion of teachers (87%) reported having taught a student who stutters. Therefore, neither previous knowledge of stuttering nor direct contact with people who stutter seems to account for why the in-service teachers failed to display an attitudinal change after the educational awareness video campaign. One would expect that having taught a student who stutters, as reported by 47 out of 54 teachers, the in-service teachers would be more open to change than the inexperienced (i.e., preservice) participants. We can only speculate, but we believe that some participants may require more than one means to effect attitude change. For example, combining the video presentation used in the current study with a humorous live presentation

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by an individual who stutters, as indicated in Flynn and St. Louis (2011), may have had a stronger impact on the teachers than just viewing a video. Moreover, providing the participants in the present study (especially the in-service teachers) with an opportunity to interact with an SLP may have proved to be more fruitful than just a video presentation with no contact with an SLP. Jenkins (2010) noted that teachers in the United Kingdom preferred in-service training with direct contact with an SLP for expanding their knowledge about stuttering over websites or leaflets.

Instruments to Measure Attitudinal Change A variety of measures have been used to study a shift in people’s attitudes toward people who stutter. The Semantic Differential Scale (Woods & Williams, 1976) has been used widely with conflicting outcomes. McGee et al. (1996) and Leahy (1994) reported no significant differences in the semantic differential ratings of their participants, whereas Mayo et al. (2008) found a positive change. Snyder (2001), on the other hand, used the Clinician Attitudes Toward Stuttering inventory (Cooper, 1975) and found no substantive modification in the attitudes of speechlanguage pathology students. Some researchers, like us, opted for the POSHA–S, which is a more standardized instrument that has been designed specifically to measure public opinion. Indeed, several studies have shown the POSHA–S to be sensitive in capturing changes in posttreatment attitudes toward stuttering. Flynn and St. Louis (2011) found that POSHA–S scores improved in adolescents, and Gottwald et al. (2011) found that they improved in teachers and students. In a recent study, St. Louis, Reichel, Williams, Guendouzi, and Hall (2012) reported that some items or combinations of items in the POSHA–S correlate significantly with the Woods and Williams (1976) scale, but many do not. The discrepancy in findings of the preservice trainees and in-service teachers in this study cannot be attributed solely to the type of measure used, given that the preservice trainees did show the expected change on the POSHA–S.

Attitudinal Shift in the Preservice Trainees The extant literature indicates that negative attitudes and stereotyping toward people who stutter is pervasive. The anchoring-adjustment theory explains that stereotypes about stuttering may be based on a fluent speaker’s personal experience with typical disfluencies (MacKinnon, Hall, & Macintyre, 2007). In other words, as postulated by White and Collins (1984), negative feelings (e.g., nervous or shy) may be associated with the stuttering of people who stutter because, superficially, stuttering simulates the typical disfluencies that fluent speakers experience when they are confronted with anxiety-provoking situations like public speaking. Individuals who do not stutter might assume that these difficulties are magnified for an individual who stutters, thereby leading these persons to perceive stuttering negatively. Goffman’s (1963) explanation of stigma and Wright’s (1983) idea of “spread phenomenon” would predict negative

perceptions of a specific disability (in this case, stuttering) to generalize or spread to views about the whole person, thereby leading to negative views of other characteristics of the person who stutters, such as the individual’s capability, personality, or intelligence. Such beliefs may contribute to stigmatizing the person who stutters and in turn to creating educational, social, and occupational barriers for this person (Gabel et al., 2004). Therefore, it was rather encouraging to see that a brief video presentation was an effective means of improving the preservice trainees’ knowledge about stuttering and their attitudes toward people who stutter. After exposure to the video, these participants were less likely to believe that people who stutter were to blame for their stuttering, were shy or fearful, or have lower than average academic performance. In our study, positive changes in people’s perceptions of various aspects of stuttering (i.e., traits, etiology, symptoms, social distance), as well as strategies for dealing with students who stutter in the classroom, were also demonstrated. After viewing the video, the preservice trainees were significantly more likely to regard prolongations and facial tensions as symptoms of stuttering. With regard to causes, the preservice trainees were significantly more accurate in refuting virus/disease, psychological problems, or a frightening event as the etiology of stuttering. The findings are further confirmed in that the control group of preservice trainees failed to show such a change. Half of the experimental preservice trainees continued to believe that stuttering is caused by psychological problems or a frightening event. The belief that stuttering has a psychological etiology is a common finding among individuals from various countries (St. Louis, 2005), even though a considerable body of research has provided evidence that does not support this assumption (Bloodstein & Ratner, 2008). Often, families attempt to relate the onset and cause of stuttering to a particular occasion or time (e.g., birth of a new sibling, relocation, etc.). In line with this, the participants of this study may have regarded “a frightening event” as a trigger for stuttering. The fact that students who stutter are referred to psychologists in Kuwaiti public schools perhaps made it more difficult for the participants of the present study to readily accept that psychological problems or frightening events do not cause stuttering. Psychologists and social workers may help students who stutter to cope with emotions and attitudes that result from living with stuttering. However, the roles of each professional should be clarified for teachers in order to ensure that students who stutter are receiving optimal services.

Conclusion As researchers have established that negative attitudes toward people who stutter are prevalent in many diverse populations, we agree with McGee et al. (1996) that “it appears warranted to shift our focus from attempting to determine which individual or groups of individuals hold the negative stereotype to concentrating on possible means of altering or even preventing the negative stereotype

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from developing” (p. 245). In the present investigation, we demonstrated that it is possible to positively modify certain listeners’ attitudes toward people who stutter by using an educational documentary video that presented factual and emotional aspects of stuttering. Such brief educational materials and presentations could be directed toward various sections of society that have been shown to harbor unfavorable attitudes toward people who stutter. The observation that preservice trainees’ attitudes may be more malleable than those of in-service teachers supports the need to include information about stuttering as part of preservice training for teachers. It is essential to further explore teacher malleability and whether it varies depending on whether teachers are preservice or in-service and whether they are male or female. Both male and female preservice trainees and in-service teachers should be included in future studies so that the role of gender can be considered more carefully. A clearer picture regarding type of treatment will also emerge, for example, whether in-service teachers require more treatment and/or a different treatment in order to change attitudes.

Acknowledgments A special gratitude goes to the College of Basic Education, Kuwait Ministry of Education, principals of government schools, and teachers for their contributions. We express our appreciation to the Kuwaiti middle school teacher and two youths who stutter who were featured in the video. We wish to acknowledge the assistance of students from the Kuwait University’s Department of Communication Disorders, especially Latifa Al-Salmi, for distributing and gathering the questionnaires. We thank Latifa Al-Salmi, Marwa Al-Rahmani, and Fatima Dikrallah for help in producing the video documentary; Fatima Hassan for data rendering; and Bharathi Prabhu for proofreading the article.

References Abdalla, F., & Al-Saddah, A. (2009, October). Stuttering and teachers in Kuwait: The story so far. Paper presented at the 12th International Stuttering Awareness Day (ISAD) online conference. Retrieved from www.mnsu.edu/comdis/isad12/papers/ abdalla12.html Abdalla, F., & St. Louis, K. O. (2012). Arab school teachers’ knowledge, beliefs and reactions regarding stuttering. Journal of Fluency Disorders, 34, 54–69. Alghazo, E., & Gaad, E. (2004). General education teachers in the United Arab Emirates and their acceptance of students with disabilities. British Journal of Special Education, 31, 94–99. Al-Khaledi, M., Lincoln, M., McCabe, P., Packman, A., & Alshatti, T. (2009). The attitudes, knowledge and beliefs of Arab parents in Kuwait about stuttering. Journal of Fluency Disorders, 34, 44–59. Blood, G., & Blood, I. (2007). Preliminary study of self-reported experience of physical aggression and bullying of boys who stutter: Relation to increased anxiety. Perceptual and Motor Skills, 104, 1060–1066. Blood, G., Blood, I., Tellis, G., & Gabel, R. (2003). A preliminary study of self-esteem, stigma, and disclosure in adolescents who stutter. Journal of Fluency Disorders, 28, 143–159. Bloodstein, O., & Ratner, N. B. (2008). A handbook on stuttering (6th ed.). New York, NY: Thomson-Delmar. Bondarenko, V. (1992). Voices to remember. Oakville, ON: Magic Lantern Communication.

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Irani, F., Abdalla, F., & Gabel, R. (2012). Arab and American teachers’ attitudes toward people who stutter: A comparative study. Contemporary Issues in Communication Science and Disorders, 39, 12–20. Irani, F., Abdalla, F., & Hughes, S. (2013). Perceptions of voice disorders: A survey of Arab adults. Logopedics Phoniatrics Vocology. Advance online publication. Irani, F., & Gabel, R. (2008). Schoolteachers’ attitudes towards people who stutter: Results of a mail survey. Canadian Journal of Speech-Language Pathology and Audiology, 32, 129–134. Jenkins, H. (2010). Attitudes of teachers towards dysfluency training and resources. International Journal of SpeechLanguage Pathology, 12, 253–258. Klassen, T. R. (2001). Perceptions of people who stutter: Re-assessing the negative stereotype. Perceptual and Motor Skills, 92, 551–559. Klompas, M., & Ross, E. (2004). Life experiences of people who stutter, and the perceived impact of stuttering on quality of life: Personal accounts of South African individuals. Journal of Fluency Disorders, 29, 275–305. Langevin, M., Packman, A., & Onslow, M. (2009). Peer responses to stuttering in a preschool setting. American Journal of SpeechLanguage Pathology, 18, 264–278. Langevin, M., Packman, A., & Onslow, M. (2010). Parent perceptions of the impact of stuttering on their preschoolers and themselves. Journal of Communication Disorders, 43, 407–423. Lass, N., Ruscello, D., Pannbacker, M., Schmitt, J., Kiser, A., Mussa, A., & Lockhart, P. (1994). School administrators’ perceptions of people who stutter. Language, Speech, and Hearing Services in Schools, 25, 90–93. Lass, N., Ruscello, D., Schmitt, J., Pannbacker, M., Orlando, M., Dean, K., . . . Bradshaw, K. (1992). Teachers’ perceptions of stutterers. Language, Speech, and Hearing Services in Schools, 23, 78–81. Leahy, M. M. (1994). Attempting to ameliorate student therapists’ negative stereotype of the stutterer. International Journal of Language & Communication Disorders, 29, 39–49. MacKinnon, S., Hall, S., & Macintyre, P. (2007). Origins of the stuttering stereotype: Stereotype formation through anchoringadjustment. Journal of Fluency Disorders, 32, 297–309. Mayo, R., Mayo, C., Gentry, A., & Hildebrandt, M. (2008, November). Can listeners’ attitudes towards person who stutter be modified? Paper presented at the annual convention of the American Speech-Language-Hearing Association, Chicago, IL. McGee, L., Kalinowski, J., & Stuart, A. (1996). Effect of a videotape documentary on high school students’ perceptions of a high school male who stutters. Canadian Journal of Speech-Language Pathology and Audiology, 20, 240–246. Organization for Economic Cooperation and Development. (2009). Creating effective teaching and learning environments: First results from TALIS. Retrieved from www.oecd.org/berlin/ 43541655.pdf Özdemir, R. S., St. Louis, K. O., & Topbaş, S. (2011a). Public attitudes toward stuttering in Turkey: Probability versus convenience sampling. Journal of Fluency Disorders, 36, 262–267. Özdemir, R. S., St. Louis, K. O., & Topbaş, S. (2011b). Stuttering attitudes among Turkish family generations and neighbors from representative samples. Journal of Fluency Disorders, 36, 318–333. Pachigar, V., Stansfield, J., & Goldbart, J. (2011). Beliefs and attitudes of primary school teachers in Mumbai, India towards children who stutter. International Journal of Disability, Development and Education, 58, 287–302.

Pett, M. (1997). Nonparametric statistics for health care research: Statistics for small samples and unusual distribution. Thousand Oaks, CA: Sage. Reichel, I., & St. Louis, K. O. (2004). Effects of emotional intelligence training in graduate fluency disorders courses. In A. Packman, A. Meltzer, & H. Peters (Eds.), Proceedings of the 4th World Congress of Fluency Disorders (pp. 474–481). Nijmegen, the Netherlands: Nijmegen University Press. Reichel, I., & St. Louis, K. O. (2006, July). Ameliorating negative stereotyping of stuttering in a graduate fluency disorders class. Seminar presented at the Fifth World Congress on Fluency Disorders, Dublin, Ireland. Ruscello, D., Lass, N., Schmitt, J., & Pannbacker, M. (1994). Special educators’ perceptions of stutterers. Journal of Fluency Disorders, 19, 125–132. Snyder, G. (2001). Exploratory research in the measurement and modification of attitudes toward stuttering. Journal of Fluency Disorders, 26, 149–160. St. Louis, K. O. (2005, October 18). A global project to measure public attitudes of stuttering. The ASHA Leader, 10, pp. 12–13, 22. St. Louis, K. O. (2011a). International project on attitudes toward human attributes (IPATHA). Morgantown, WV: Populore. Retrieved from www.stutteringattitudes.com St. Louis, K. O. (2011b). The Public Opinion Survey of Human Attributes—Stuttering (POSHA–S): Summary framework and empirical comparisons. Journal of Fluency Disorders, 36, 256–261. St. Louis, K. O. (2011c). User’s guide: Public Opinion Survey of Human Attributes—Stuttering (POSHA–S): Measuring public attitudes toward stuttering. Morgantown, WV: Populore. St. Louis, K. O. (2012a). Male versus female attitudes toward stuttering. Journal of Communication Disorders, 45, 246–253. St. Louis, K. O. (2012b). POSHA–S public attitudes toward stuttering: Online versus paper surveys. Canadian Journal of Speech-Language Pathology and Audiology, 36, 116–122. St. Louis, K. O., Andrade, C. R. F., Georgieva, D., & Troudt, F. O. (2005). Experience and personal report about an international cooperation research—Brazil, Bulgaria and Turkey—Attitudes toward stuttering. Pró-Fono Revista de Atualização Cientifica, 17, 413–416. St. Louis, K. O., Filatova, Y., Coşkun, M., Topbaş, S., Özdemir, S., Georgieva, D., . . . George, R. D. (2011). Public attitudes toward cluttering and stuttering in four countries. In E. L. Simon (Ed.), Psychology of stereotypes (pp. 81–114). Hauppauge, NY: Nova Science. St. Louis, K. O., & George, R. D. (2008, November). Attitudes toward stuttering: In search of a gold standard. Poster presented at the annual convention of the American Speech-LanguageHearing Association, Chicago, IL. St. Louis, K. O., & Lass, N. (1981). A survey of communicative disorders students’ attitudes toward stuttering. Journal of Fluency Disorders, 6, 49–79. St. Louis, K. O., Lubker, B. B., Yaruss, J. S., Adkins, T. A., & Pill, J. C. (2008). Development of a prototype questionnaire to survey public attitudes toward stuttering: Principles and methodologies in the first prototype. The Internet Journal of Epidemiology, 5(2). Retrieved from www.ispub.com/IJE/5/2/ 7561 St. Louis, K. O., Lubker, B. B., Yaruss, J. S., & Aliveto, E. F. (2009). Development of a prototype questionnaire to survey public attitudes toward stuttering: Reliability of the second prototype. Contemporary Issues in Communication Science and Disorders, 36, 101–107.

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Appendix Proportion (Percentages) of Desirable Pre and Post POSHA–S Ratings by the Control Versus Experimental Preservice Trainees and In-Service Teachers Preservice trainees Control Variable Cause Genetic (yes) Learning (no) Fright (no) Virus/Disease (no) Ghost/Demon (no) Psychological (no) Symptoms Repetitions (yes) Prolongations (yes) Sudden Stops (yes) Severity varies (yes) Seizures (no) Facial tension (yes) Traits/personality Blame themselves for stuttering (no) Nervous/excitable (no) Shy/fearful (no) Low academic performance (no) Some can recover without help (yes) Distance/sympathy Feel comfortable/relaxed (yes) Feel pity (no) Feel impatient (no) Potential Can make friends (yes) Can lead normal life (yes) Can do any job they want (yes) ReactionsIHelping Act like S is talking normally (yes) Fill in person’s words (no) Make a joke about stuttering (no) Hide their stuttering (no) Tell to “slow down/relax” (no) Tell S to take deep breath (no) Tell S to think then speak (no) Tell S to speak faster (no) Tell S to repeat till word out (no) Discuss feelings about stuttering (yes) Excuse S from oral tasks (no) Punish S for stuttering (no) Warn/Punish teaser/bully (yes) Help source Speech Therapist (yes) Other People who Stutter (yes) Medical doctor (no)

In-service teachers

Experimental

Control

Experimental

Pre

Post

Pre

Post

Pre

Post

Pre

Post

62.5 64.6 6.3 81.3 72.9 8.3

60.4 54.2 6.3 72.9 66.7 8.3

54.9 49.0 7.8 52.9 60.8 2.0

78.4 56.9 43.1* 84.3* 78.4* 45.1*

61.2 55.1 10.2 67.3 77.6 8.2

38.8 38.8 14.3 57.1 63.3 4.1

53.7 57.4 24.1 55.6 63.0 18.5

53.7 70.4 20.4 72.2 74.1 24.1

89.6 68.6 87.5 95.8 66.7 79.2

89.6 75.0 91.7 93.8 54.2 66.7

86.3 52.9 88.2 94.1 62.7 52.9

100 94.1* 98.0 98.0 72.5 84.3*

63.3 32.7 81.6 93.9 53.1 51.0

79.6 36.7 75.5 91.8 65.3 34.7

87.0 48.1 83.3 94.4 57.4 57.4

81.5 70.4 81.5 92.6 66.7 74.1

37.5 22.9 8.3 72.9 41.7

35.4 12.5 12.5 79.2 43.8

21.6 33.3 7.8 51.0 54.9

58.8* 41.2 39.2* 88.2* 45.1

40.8 20.4 10.2 69.4 24.5

34.7 16.3 16.3 67.3 32.7

42.6 25.9 11.1 75.9 24.1

68.5 20.4 14.8 64.8 31.5

56.3 33.3 95.8

62.5 47.9 83.3

51.0 43.1 84.3

82.4* 70.6 90.2

32.7 28.6 91.8

38.8 32.7 87.8

66.7 20.4 88.9

63.0 31.5 85.2

89.6 72.9 35.4

81.3 72.9 33.3

76.5 43.1 33.3

96.1 88.2* 60.8*

83.7 69.4 38.8

73.5 67.3 42.9

90.7 64.8 55.6

85.2 79.6 51.9

97.9 35.4 93.8 60.4 41.7 39.6 43.8 47.9 4.2 52.1 66.7 91.7 83.3

97.9 29.2 89.6 72.9 31.3 31.3 31.3 54.2 6.3 56.3 68.8 91.7 87.5

98.0 27.5 96.1 62.7 43.1 41.2 41.2 52.9 5.9 49.0 56.9 98.0 92.2

98.0 82.4* 90.2 84.3 82.4* 78.4* 72.5* 60.8 37.3* 80.4* 64.7 84.3 84.3

93.9 34.7 93.9 73.5 14.3 22.4 32.7 49.0 8.2 26.5 69.4 95.9 89.8

95.9 46.9 91.8 63.3 14.3 22.4 34.7 55.1 10.2 20.4 67.3 89.8 85.7

98.1 40.7 96.3 64.8 27.8 37.0 33.3 46.3 14.8 31.5 63.0 88.9 81.5

100. 48.1 90.7 79.6 33.3 38.9 33.3 51.9 20.4 44.4 55.6 83.3 79.6

97.9 70.8 39.6

95.8 60.4 37.5

96.1 72.5 37.3

94.1 72.5 52.9

98.0 79.6 36.7

93.9 77.6 34.7

94.4 72.2 37.0

96.3 77.8 42.6

Note. Items added to the POSHA–S are in italics. Responses coded as “target” appear in parentheses next to each statement. Target responses represented accurate, desirable, and more positive ratings according to current consensus regarding stuttering (St. Louis, 2011a). Capital, underlined “S” stands for person/student who stutters. *Items that were statistically significant for the pre- and posttreatment ratings on the McNemar test ( p < .001).

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Modifying attitudes of Arab school teachers toward stuttering.

The authors of this quasi-experimental design study explored the effect of an educational documentary video that presented factual and emotional aspec...
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