10.1007 s10447 011-9143-3


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10.1007 s10447 011-9143-3

  1. 1. Jordanian School Counselors’ Knowledge About and Attitudes Toward Diabetes Mellitus Adel G. Tannous, Jamal M. Khateeb, Hatem A. Khamra, Muna S. Hadidi & Mayada M. Natour International Journal for the Advancement of Counselling ISSN 0165-0653 Int J Adv Counselling DOI 10.1007/s10447-011-9143-3 1 23
  2. 2. Your article is protected by copyright and all rights are held exclusively by Springer Science+Business Media, LLC. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your work, please use the accepted author’s version for posting to your own website or your institution’s repository. You may further deposit the accepted author’s version on a funder’s repository at a funder’s request, provided it is not made publicly available until 12 months after publication. 1 23
  3. 3. Author's personal copy Int J Adv Counselling DOI 10.1007/s10447-011-9143-3 ORIGINAL ARTICLE Jordanian School Counselors’ Knowledge About and Attitudes Toward Diabetes Mellitus Adel G. Tannous & Jamal M. Khateeb & Hatem A. Khamra & Muna S. Hadidi & Mayada M. Natour # Springer Science+Business Media, LLC 2012 Abstract This study investigated the knowledge and attitudes of Jordanian school counselors toward diabetes mellitus. A sample of 295 counselors completed a questionnaire consisting of two parts concerning knowledge and attitudes. The face validity of the questionnaire was assessed using an informed panel of judges, and its reliability was established using the test- re-test method. Results showed that counselors as a whole had a moderate level of knowledge about diabetes. This level of knowledge was related to counselor gender (females were more knowledgeable than males) and to knowing a person with diabetes, but not to counselor age. Results also showed that counselors showed favorable attitudes toward students with diabetes. Knowing a student with diabetes had no influence on attitudes. Keywords Diabetes mellitus . Knowledge . Attitudes . School counselors . Jordan Introduction Diabetes mellitus is one of the most common endocrine diseases in the world, with a prevalence rate for all age-groups worldwide estimated at 2.8% (Wild et al. 2004). It is a serious life-long disease in which the body is unable to use food for energy due to its deficiency in making or properly using insulin. Although there is no cure for diabetes, it can be managed and serious health complications delayed or prevented. Among long-term complications of diabetes are serious problems with eyes, heart and blood vessels, kidneys, nerves, skin and feet, bones and joints, and teeth and gums. Diabetes not only has a negative impact on physical functioning, it may also have negative effects on psychological, social, and educational functioning. In schools, students with diabetes need knowledgeable personnel to assist them in managing their diabetes and allowing them to participate fully and safely in school activities (Tahirovic and Toromanovic 2006). Studies have shown that the majority of school personnel have an inadequate understanding of diabetes A. G. Tannous : J. M. Khateeb (*) : H. A. Khamra : M. S. Hadidi : M. M. Natour University of Jordan, Amman, Jordan e-mail: khateeb53@yahoo.com
  4. 4. Author's personal copy Int J Adv Counselling (American Diabetes Association 2001; Tolbert 2006). Consequently, programs must be developed to educate them about the nature of diabetes, ways to manage it, and the role of each member of staff in meeting the needs of such students. In the Hashemite Kingdom of Jordan, studies conducted by Ajlouni and his colleagues demonstrate that the prevalence of diabetes is high in that country and is increasing. While the overall prevalence of type-2 diabetes, or adult-onset diabetes, in 1998 was 13.4% (Ajlouni et al. 1998), it had become 17.1% ten years later (Ajlouni et al. 2008). There has also been an increase in the prevalence of type-1 diabetes, formerly known as juvenile or insulin-dependent diabetes mellitus (Ajlouni et al. 1999). Considering the high prevalence of diabetes as well as unsatisfactory diabetic control among more than half of persons with diabetes, these researchers recommended formulating and implementing national plans to face this disease and its complications. In schools, students with diabetes need support to manage their diabetes throughout the school day. Since school personnel in Jordan do not include healthcare professionals (i.e., physicians, nurses, dieticians), school counselors and teachers may be expected to initiate programs aimed at counseling students with diabetes on lifestyle changes required for managing this disease. Studies have indicated that the majority of school counselors know students who have diabetes in their schools (Tolbert 2006; Wagner 2006). Studies related to diabetes in Jordan have focused on medical aspects of the disease, such as incidence, risk factors, and treatment. Little, if any, consideration has been given to psychoeducational and social aspects of this disease. With this background information in mind, this study was carried out to investigate attitudes toward and knowledge of diabetes among counselors in Jordanian schools. The study also examined whether counselors’ gender, age, and knowing a student with diabetes had an influence on their knowledge of diabetes and their attitudes toward these students. Method Participants According to the Ministry of Education census, it is estimated that there are around 2,300 counselors working in both the private and public sector in Jordan, most of them working in the capital, Amman. The capital city has the largest population with around half the total of the country residing there. Accordingly, to achieve acceptable representation of this population a convenience sample of 350 counselors (15% of the counselor population) working in both public and private schools was invited to participate in this study. The educational directorates sent out the surveys to the schools with a cover letter explaining the purpose of the research. A list of cooperating schools and contact information was forwarded later to the researchers for follow-up purposes. After 2 weeks from sending out the survey, (241) copies had been returned to the researchers. Follow-up calls were made to the rest of the selected sample to urge them to complete the survey. The total number obtained was 295 surveys out of 350, reflecting a return rate of (84%). Table 1 shows the distribution of counselors according to age and gender. It can be observed that 22% of respondents were males and 78% were females. Forty seven percent of participants were between 20 years and 30 years, 43% between 31 years and 45 years, and 9% were above the age of 45 years. More than one fourth (0.29%) of counselors knew a student or more than one with diabetes. This is a relatively high percentage since Jordanian parents generally do not disclose their child’s diabetes or other illnesses.
  5. 5. Author's personal copy Int J Adv Counselling Table 1 Distribution of counselors according to age and gender Age 20–30 years Males 31–45 years Above 45 years Totals 16 (5%) 39 (13%) 9 (3%) 64 (22%) Females 124 (42%) 89 (30%) 18 (6%) 231 (78%) Totals 140 (48%) 128 (43%) 27 (9%) 295 (100%) Instrument The researchers developed a survey instrument consisting of three parts. The first part involved demographic data on the respondents. The second part consisted of 22 items exploring counselors’ attitudes towards diabetes. Participants were asked to rate each item according to a six-point Likert-type scale (6 0 strongly agree, 1 0 strongly disagree). The third part of the instrument consisted of 40 items assessing knowledge of diabetes. Questions focused on types of diabetes, symptoms, insulin handling, diet, and precautions when dealing with diabetes. Answers to these questions were based largely on multiple-choice questions, in addition to a few ‘yes’ and ‘no’ responses. The items were formulated based on a review of relevant literature (He and Wharrad 2007). Means of the item responses were used as measures of the respondents’ knowledge or global attitude, with higher scores representing more enlightened knowledge and more favorable attitudes. Some of the items related to attitudes were formulated in a negative way, and the scoring direction of these items was reversed because agreement with them reflected negative attitudes toward diabetes. To establish face validity of the instrument, a pilot version was given to seven faculty members from the Faculty of Educational Sciences at the University of Jordan (Counseling and Special Education Department and the Department of Educational Psychology), in addition to three medical physicians. Comments and feedback were provided from the panel involving additions, rephrasing and eliminating some of the items. The panel’s comments were taken into consideration in preparing the final version of the instrument. Furthermore, the instrument was piloted on a convenience sample of pre-service students (n030) from the counseling and special education department at the University of Jordan; a re-test was administered after two weeks on the same group for reliability purposes. Their comments were also incorporated into the final version of the instrument. However, this pilot sample was excluded from the actual sample of the study. Reliability of the instrument was established using the test- re-test method. Correlation coefficients were calculated for the second part (attitudes) and the third part (knowledge) of the survey. The former had a correlation coefficient of .86, and the latter a correlation coefficient of .92. Procedure A letter from the University of Jordan, along with the survey instrument, was sent to the Counseling Department/Ministry of Education. A request was made to send the survey to 350 selected counselors either through the internal mail at the Ministry of Education or via field training students. A letter from the researchers explaining the purpose of the study and requesting counselor participation was sent, accompanied by a copy of the instrument. Counselors were assured that the study was for scientific purposes only and that their responses
  6. 6. Author's personal copy Int J Adv Counselling would be confidential and anonymous. They were urged to respond to all items to the best of their knowledge. Data Analysis A variety of statistical techniques were used to analyze the research data. These techniques included: means, standard deviations, one-way analysis of variance (ANOVA), and independent sample t-test. Results Table 2 shows that school counselors in Jordan demonstrated a moderate level of knowledge of diabetes (M00.66 out of 1.00). The table shows that the items with the highest means were related to food portions consumed (0.95), symptoms of diabetes (0.93), quantity of food intake (0.92), protection and hygiene (0.92), and practicing sports (0.91). On the other hand, items with lowest means were related to the level of saturated fat in nuts and cereals (M00.38), diabetes medications (0.28), activities for diabetics (0.26), and the difference between type-1 and type-2 diabetes (0.25). Results showed apparent differences in counselors’ knowledge of diabetes according to gender, with females showing a higher level of knowledge of diabetes (M00.68, SD0.01) than males (M00.62, SD00.03). These differences were statistically significant [t (293)0−3.03, p0 0.05]. ANOVA revealed no statistically significant differences due to counselors’ age (F00.57, Table 2 Means and standard deviations of counselors’ responses to knowledge items Numbera Item Mean SD 10 People with diabetes should be consuming fewer portions of pastas, rice and other materials made of carbohydrates and sugar. 0.95 0.23 31 Excessive thirst, frequent urination, weight loss and dizziness are all symptoms of diabetes. 0.93 0.25 21 Quantities of food must be organized when dealing with diabetes. 0.92 0.27 32 Foot care (protection and hygiene) can prevent or mitigate injury, inflammation, wounds, sores or any other problems affecting feet in students with diabetes. 0.92 0.28 12 Practicing sports regularly helps to regulate blood sugar and reduce blood pressure and cholesterol level. 0.91 0.29 23 Food, exercise, medication and psychological pressure can affect glucose levels in the blood. 0.90 0.30 11 Diabetes happens when kidneys do not perform their work in controlling the level of glucose in urine. 0.40 0.49 18 Nuts and cereals are bad for the body due to the increased levels of saturated fat incorporated. 0.38 0.49 22 Some diabetes medicines can help reduce weight. 0.28 0.45 7 People with diabetes can participate in activities that require intensive muscular effort. 0.26 0.44 8 a People with type-1 and type-2 diabetes will be insulin dependent all their life. 0.25 0.43 Average of knowledge 0.66 0.15 This number represents the original item in the survey, only the highest and lowest items were included in the table
  7. 7. Author's personal copy Int J Adv Counselling p00.5). To find out whether counselors’ knowledge differed due to knowing a student with diabetes, an independent sample t-test was conducted. Results showed that knowing a student with diabetes did influence the degree of knowledge of counselors [t (293)03.53, p00.000]. Table 3 shows the distribution of counselors’ attitude scores. It can be seen that counselors had a higher than average mean (M04.05 out of 6). The highest mean ratings were associated with statements related to the way people think of diabetes as not a disability (M0 5.12), the right of having a family life and not being scrutinized just for being diabetic (M0 4.94), general rights and duties of people with diabetes in comparison to others without diabetes (M04.86), and the need for further knowledge about diabetes and the way of dealing with it (M04.84). The lowest mean ratings were associated with statements related to the perception that people with diabetes like to be associated with others who are diabetics (M02.43), the need for continuous protection in schools by teachers (M02.60), the effect of medications on the emotional, psychological and academic status of students with diabetes Table 3 Means and standard deviations for counselors’ responses to attitude items Number Items Mean SD 1a People with diabetes are considered as having a disability. 5.12 2a Having diabetes in a family is a viable reason to have a divorce. 4.94 1.69 3 People with diabetes have the same rights and duties granted to people without diabetes. 4.86 1.56 4 I have no problem in having information on how to deal with diabetic episodes when 4.84 they occur. 1.34 5a Health problems related to diabetes are the issue of physicians only and not teachers. 4.83 1.36 6 7 Children with diabetes should be educated in the regular classroom. Equal employment opportunities must be provided to people with diabetes. 1.66 1.51 8 Marriage among people with diabetes should be fully allowed with no restrictions. 4.38 1.38 9 School rules and regulations must take into account the special needs of children with diabetes. 4.33 1.44 10a People with diabetes should not be allowed to bear children. 4.32 1.72 11 12 People with diabetes can maintain a normal quality of life. Teachers should have the same expectations from students with diabetes just like students without diabetes. 4.23 4.12 1.16 1.51 13 People with diabetes can use tools and equipment safely. 4.11 1.55 14a Children with diabetes might have a negative impact on their peers. 4.10 1.69 15 16a People with diabetes should benefit from health insurance. Families of individuals with diabetes do not need any special assistance or support. 3.98 3.77 2.19 1.45 17 People with diabetes can drive cars. 3.69 1.61 18 Diabetes imposes pressures and constraints on the lifestyle of the family. 3.64 1.24 19a People with diabetes have their own psychological characteristics that distinguish them from everybody else. Diabetes and medications affect the emotional, psychological and academic status of students with diabetes. 3.32 1.37 3.09 1.37 21a Children with diabetes should always be protected by their teachers. 2.60 1.36 22a People with diabetes prefer to associate with other diabetic persons. 2.43 1.51 Average of Attitudes 4.08 0.73 20a a Items for which a “disagree” response (scored negatively) indicates a positive attitude 4.82 4.53 1.56
  8. 8. Author's personal copy Int J Adv Counselling (M03.09)—nevertheless, even though those are the lowest items in comparison to other items, they can still be seen as positive responses rather than negative. An independent sample t-test was conducted to find out whether counselors’ attitudes differed due to knowing a student with diabetes. Results showed that knowing a student with diabetes did not have a significant effect on attitudes of counselors [t (288)0.65, p0.100]. Discussion and Conclusions The purpose of this study was to explore Jordanian school counselors’ knowledge of diabetes mellitus and their attitudes toward students having this disease. The results showed that counselors demonstrated a moderate level of knowledge about diabetes. Counselor gender and knowing a person with diabetes had a significant impact on the level of knowledge. Results also showed that counselors showed favorable attitudes toward students with diabetes. Finally, it was found that knowing a student with diabetes influenced the level of counselors’ knowledge but not their attitudes. These findings are interesting in light of the fact that preparation programs for school counselors in Jordan rarely include elements related to diabetes or other chronic illnesses. Almost all counselors reported that they obtained information about diabetes either from the media or from parents. None of them reported participating in pre-service or in-service training on diabetes mellitus. However, with the exception of a few private schools, school staff in Jordan do not include health care providers. In light of this, counselors apparently face the challenge of dealing with most health problems. The findings that counselors had a moderate level of knowledge of diabetes and positive attitudes toward students with diabetes are in agreement with those of several other studies (e.g., Abdel Gawwad 2008; Alnasir and Skerman 2004; Gormanous et al. 2002; Greenhalgh 1997; Warne 1988). These findings may be attributed to several reasons. First, the high incidence of diabetes in Jordan might have played a role in improving counselors’ understanding and attitudes. Second, counselors’ exposure to students with diabetes in schools might have a significant impact on their knowledge and attitudes. Furthermore, intensive public education programs about diabetes over the past decade could have helped to transform diabetes into a much better understood and accepted illness. Nevertheless, there were clear deficits in terms of knowledge of appropriate management of diabetes in the school. This was apparent in counselors’ responses to items like the type of diets used for diabetics, medications useful to control sugar levels, and differences between type-1 and type-2 diabetes. Furthermore, having acceptable levels of knowledge of diabetes or positive attitudes towards it does not necessarily mean that counselors are well prepared or have the time to provide effective support for students with diabetes (Tolbert 2006; Wagner 2006). Similarly, the finding that counselors’ attitudes toward students with diabetes were generally positive may not necessarily reflect counselors’ willingness or preparedness to have a role in supporting these students in school. This was reflected in responses to items such as: children with diabetes might have a negative impact on their peers; health problems related to diabetes is the issue of physicians only and not teachers; and people with diabetes prefer to live with other diabetic persons. This study has methodological limitations. First, the findings of this study cannot be generalized to all of Jordan, as the data were derived from Amman city only. Thus, further similar studies in other parts of the country are needed. Second, because this descriptive study was conducted on a convenience sample of counselors, it does not allow generalizations to all counselors in the country. Third, school personnel likely to have an effect on this issue include
  9. 9. Author's personal copy Int J Adv Counselling administrators, teachers, and people in other roles. Thus, further studies investigating knowledge and attitudes of these practitioners are also needed in Jordan. Another limitation of the present study was the questionnaire used. It was a self-reported questionnaire and the participants’ responses to the attitude part may have suffered from social desirability. This questionnaire was relatively long and focused on theoretical knowledge related to diabetes. Future research utilizing different data collection instruments focusing on other kinds of information that may be important in school settings is needed. Despite these limitations, the results of this study are enlightening. However, more research is needed to understand the complexity of relationships between knowledge and attitudes. Furthermore, the scarcity of research literature in this country hindered comparison of the findings and understanding of the implications of the results obtained. In conclusion, the study showed moderate overall knowledge of diabetes mellitus and generally favorable attitudes toward students with this disease among school counselors in Jordan. Therefore, the study recommends further research to explore the practical aspects of diabetes knowledge needed by counselors to promote improved health outcomes for students. The study also recommends conducting research on practical knowledge and behaviors of other key school personnel, such as teachers and administrators. References Abdel Gawwad, E. (2008). Teacher’s knowledge, attitudes and management practices about diabetes care in Riyadh’s schools. Journal of the Egyptian Public Health Association, 83(3), 205–222. Ajlouni, K., Jaddou, H., & Batieha, A. (1998). Diabetes and impaired glucose tolerance in Jordan: Prevalence and associated risk factors. Journal of Internal Medicine, 244(4), 317–23. Ajlouni, K., et al. (1999). Incidence of insulin-dependent diabetes mellitus in Jordanian children aged 0–14 y during 1992–1996. Acta Paediatrica, 88, 11–13. Ajlouni, K., Khader, Y., Batieha, A., & El-Khateeb, M. (2008). An increase in prevalence of diabetes mellitus in Jordan over 10 years. Journal of Diabetes and its Complications, 22(5), 317–324. Alnasir, F., & Skerman, J. (2004). Schoolteachers’ knowledge of common health problems in Bahrain. Eastern Mediterranean Health Journal, 10(4/5), 537–546. American Diabetes Association. (2001). Diabetes care in the school and day care setting. Diabetes Care, 34 (3), 70–74. Gormanous, M., Hunt, A., Pope, J., & Gerald, B. (2002). Lack of knowledge of diabetes among Arkansas public elementary teachers: implications for dietitians. Journal of the American Dietetic Association, 102 (8), 1136–1138. Greenhalgh, S. (1997). Improving school teachers’ knowledge of diabetes. Professional Nurse, 13(3), 150–6. He, X., & Wharrad, H. (2007). Diabetes knowledge and glycemic control among Chinese people with type 2 diabetes. International Nursing Review, 54(3), 280–287. Tahirovic, H., & Toromanovic, A. (2006). How much can school staff help children with diabetes type 1 in school? Medical Archives, 60(4), 222–224. Tolbert, R. (2006). Managing type 1 diabetes at school: an integrative review. The Journal of School Nursing, 2(1), 55–61. Wagner, J. (2006). A pilot study of school counselor’s preparedness to serve students with diabetes: Relationship to self-reported diabetes training. Journal of School Health, 76(7), 387–392. Warne, J. (1988). Diabetes in school: a study of teachers’ knowledge and information sources. Practical Diabetes International, 5(5), 210–214. Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care, 27, 1047–1053.