10.1007 s10447 011-9143-3

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International Journal for theAdvancement of Counselling ISSN 0165-0653 Int J Adv CounsellingDOI 10.1007/s10447-011-9143-3

Jordanian School Counselors’ KnowledgeAbout and Attitudes Toward DiabetesMellitus

Adel G. Tannous, Jamal M. Khateeb,Hatem A. Khamra, Muna S. Hadidi &Mayada M. Natour

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ORIGINAL ARTICLE

Jordanian School Counselors’ KnowledgeAbout 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 counse-lors toward diabetes mellitus. A sample of 295 counselors completed a questionnaireconsisting of two parts concerning knowledge and attitudes. The face validity of thequestionnaire was assessed using an informed panel of judges, and its reliability wasestablished using the test- re-test method. Results showed that counselors as a whole hada moderate level of knowledge about diabetes. This level of knowledge was related tocounselor gender (females were more knowledgeable than males) and to knowing a personwith diabetes, but not to counselor age. Results also showed that counselors showedfavorable attitudes toward students with diabetes. Knowing a student with diabetes had noinfluence 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 prevalencerate for all age-groups worldwide estimated at 2.8% (Wild et al. 2004). It is a serious life-longdisease in which the body is unable to use food for energy due to its deficiency in making orproperly using insulin. Although there is no cure for diabetes, it can be managed and serioushealth complications delayed or prevented. Among long-term complications of diabetes areserious problems with eyes, heart and blood vessels, kidneys, nerves, skin and feet, bones andjoints, and teeth and gums.

Diabetes not only has a negative impact on physical functioning, it may also have negativeeffects on psychological, social, and educational functioning. In schools, students with diabetesneed knowledgeable personnel to assist them in managing their diabetes and allowing them toparticipate fully and safely in school activities (Tahirovic and Toromanovic 2006). Studies haveshown that the majority of school personnel have an inadequate understanding of diabetes

Int J Adv CounsellingDOI 10.1007/s10447-011-9143-3

A. G. Tannous : J. M. Khateeb (*) : H. A. Khamra :M. S. Hadidi :M. M. NatourUniversity of Jordan, Amman, Jordane-mail: [email protected]

Author's personal copy

(American Diabetes Association 2001; Tolbert 2006). Consequently, programs must be devel-oped to educate them about the nature of diabetes, ways to manage it, and the role of eachmember of staff in meeting the needs of such students.

In the Hashemite Kingdom of Jordan, studies conducted by Ajlouni and his colleaguesdemonstrate that the prevalence of diabetes is high in that country and is increasing. Whilethe 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 hasalso been an increase in the prevalence of type-1 diabetes, formerly known as juvenile orinsulin-dependent diabetes mellitus (Ajlouni et al. 1999). Considering the high prevalence ofdiabetes as well as unsatisfactory diabetic control among more than half of persons withdiabetes, these researchers recommended formulating and implementing national plans toface this disease and its complications.

In schools, students with diabetes need support to manage their diabetes throughout theschool day. Since school personnel in Jordan do not include healthcare professionals (i.e.,physicians, nurses, dieticians), school counselors and teachers may be expected to initiateprograms aimed at counseling students with diabetes on lifestyle changes required for managingthis disease. Studies have indicated that the majority of school counselors know students whohave diabetes in their schools (Tolbert 2006; Wagner 2006).

Studies related to diabetes in Jordan have focused on medical aspects of the disease, such asincidence, risk factors, and treatment. Little, if any, consideration has been given to psycho-educational and social aspects of this disease. With this background information in mind, thisstudy was carried out to investigate attitudes toward and knowledge of diabetes amongcounselors 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 theirattitudes toward these students.

Method

Participants

According to the Ministry of Education census, it is estimated that there are around 2,300counselors working in both the private and public sector in Jordan, most of them working inthe capital, Amman. The capital city has the largest population with around half the total ofthe country residing there. Accordingly, to achieve acceptable representation of this popu-lation a convenience sample of 350 counselors (15% of the counselor population) workingin both public and private schools was invited to participate in this study. The educationaldirectorates sent out the surveys to the schools with a cover letter explaining the purpose ofthe research. A list of cooperating schools and contact information was forwarded later to theresearchers for follow-up purposes.

After 2 weeks from sending out the survey, (241) copies had been returned to the researchers.Follow-up calls weremade 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 observedthat 22% of respondents were males and 78%were females. Forty seven percent of participantswere between 20 years and 30 years, 43% between 31 years and 45 years, and 9% were abovethe age of 45 years. More than one fourth (0.29%) of counselors knew a student or more thanone with diabetes. This is a relatively high percentage since Jordanian parents generally do notdisclose their child’s diabetes or other illnesses.

Int J Adv Counselling


Instrument

The researchers developed a survey instrument consisting of three parts. The first part involveddemographic data on the respondents. The second part consisted of 22 items exploringcounselors’ attitudes towards diabetes. Participants were asked to rate each item according toa six-point Likert-type scale (6 0 strongly agree, 1 0 strongly disagree). The third part of theinstrument consisted of 40 items assessing knowledge of diabetes. Questions focused on typesof 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 afew ‘yes’ and ‘no’ responses. The itemswere formulated based on a review of relevant literature(He and Wharrad 2007). Means of the item responses were used as measures of the respond-ents’ knowledge or global attitude, with higher scores representing more enlightened knowl-edge and more favorable attitudes. Some of the items related to attitudes were formulated in anegative way, and the scoring direction of these items was reversed because agreement withthem reflected negative attitudes toward diabetes.

To establish face validity of the instrument, a pilot version was given to seven facultymembers from the Faculty of Educational Sciences at the University of Jordan (Counselingand Special Education Department and the Department of Educational Psychology), inaddition to three medical physicians. Comments and feedback were provided from the panelinvolving additions, rephrasing and eliminating some of the items. The panel’s commentswere 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; are-test was administered after two weeks on the same group for reliability purposes. Theircomments were also incorporated into the final version of the instrument. However, this pilotsample was excluded from the actual sample of the study.

Reliability of the instrument was established using the test- re-test method. Correlationcoefficients were calculated for the second part (attitudes) and the third part (knowledge) ofthe survey. The former had a correlation coefficient of .86, and the latter a correlationcoefficient of .92.

Procedure

A letter from the University of Jordan, along with the survey instrument, was sent to theCounseling Department/Ministry of Education. A request was made to send the survey to 350selected counselors either through the internal mail at the Ministry of Education or via fieldtraining students. A letter from the researchers explaining the purpose of the study andrequesting counselor participation was sent, accompanied by a copy of the instrument. Coun-selors were assured that the study was for scientific purposes only and that their responses

Table 1 Distribution of counselors according to age and gender

Age

20–30 years 31–45 years Above 45 years Totals

Males 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%)



would be confidential and anonymous. They were urged to respond to all items to the best oftheir knowledge.

Data Analysis

A variety of statistical techniques were used to analyze the research data. These techniquesincluded: means, standard deviations, one-way analysis of variance (ANOVA), and indepen-dent sample t-test.

Results

Table 2 shows that school counselors in Jordan demonstrated a moderate level of knowledgeof diabetes (M00.66 out of 1.00). The table shows that the items with the highest meanswere related to food portions consumed (0.95), symptoms of diabetes (0.93), quantity offood intake (0.92), protection and hygiene (0.92), and practicing sports (0.91). On the otherhand, 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 differencebetween type-1 and type-2 diabetes (0.25).

Results showed apparent differences in counselors’ knowledge of diabetes according togender, with females showing a higher level of knowledge of diabetes (M00.68, SD0 .01) thanmales (M00.62, SD00.03). These differences were statistically significant [t (293)0−3.03, p00.05]. 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 othermaterials made of carbohydrates and sugar.

0.95 0.23

31 Excessive thirst, frequent urination, weight loss and dizziness are allsymptoms 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 reduceblood pressure and cholesterol level.

0.91 0.29

23 Food, exercise, medication and psychological pressure can affect glucoselevels in the blood.

0.90 0.30

11 Diabetes happens when kidneys do not perform their work in controllingthe level of glucose in urine.

0.40 0.49

18 Nuts and cereals are bad for the body due to the increased levels ofsaturated 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 intensivemuscular effort.

0.26 0.44

8 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

a This number represents the original item in the survey, only the highest and lowest items were included in thetable



p00.5). To find out whether counselors’ knowledge differed due to knowing a student withdiabetes, an independent sample t-test was conducted. Results showed that knowing a studentwith 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 counse-lors had a higher than average mean (M04.05 out of 6). The highest mean ratings wereassociated with statements related to the way people think of diabetes as not a disability (M05.12), the right of having a family life and not being scrutinized just for being diabetic (M04.94), general rights and duties of people with diabetes in comparison to others withoutdiabetes (M04.86), and the need for further knowledge about diabetes and the way ofdealing with it (M04.84). The lowest mean ratings were associated with statements relatedto 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 ofmedications 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 1.56

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 withoutdiabetes.

4.86 1.56

4 I have no problem in having information on how to deal with diabetic episodes whenthey occur.

4.84 1.34

5a Health problems related to diabetes are the issue of physicians only and not teachers. 4.83 1.36

6 Children with diabetes should be educated in the regular classroom. 4.82 1.66

7 Equal employment opportunities must be provided to people with diabetes. 4.53 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 withdiabetes.

4.33 1.44

10a People with diabetes should not be allowed to bear children. 4.32 1.72

11 People with diabetes can maintain a normal quality of life. 4.23 1.16

12 Teachers should have the same expectations from students with diabetes just likestudents without diabetes.

4.12 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 People with diabetes should benefit from health insurance. 3.98 2.19

16a Families of individuals with diabetes do not need any special assistance or support. 3.77 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 distinguishthem from everybody else.

3.32 1.37

20a Diabetes and medications affect the emotional, psychological and academic status ofstudents with diabetes.

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

a Items for which a “disagree” response (scored negatively) indicates a positive attitude



(M03.09)—nevertheless, even though those are the lowest items in comparison to otheritems, they can still be seen as positive responses rather than negative.

An independent sample t-test was conducted to find out whether counselors’ attitudesdiffered due to knowing a student with diabetes. Results showed that knowing a student withdiabetes 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 diabetesmellitus and their attitudes toward students having this disease. The results showed thatcounselors demonstrated a moderate level of knowledge about diabetes. Counselor genderand knowing a person with diabetes had a significant impact on the level of knowledge. Resultsalso 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’ knowledgebut not their attitudes.

These findings are interesting in light of the fact that preparation programs for schoolcounselors in Jordan rarely include elements related to diabetes or other chronic illnesses.Almost all counselors reported that they obtained information about diabetes either from themedia or from parents. None of them reported participating in pre-service or in-service trainingon diabetes mellitus. However, with the exception of a few private schools, school staff inJordan do not include health care providers. In light of this, counselors apparently face thechallenge of dealing with most health problems.

The findings that counselors had a moderate level of knowledge of diabetes and positiveattitudes 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 ofdiabetes in Jordan might have played a role in improving counselors’ understanding andattitudes. Second, counselors’ exposure to students with diabetes in schools might have asignificant impact on their knowledge and attitudes. Furthermore, intensive public educationprograms about diabetes over the past decade could have helped to transform diabetes into amuch better understood and accepted illness.

Nevertheless, there were clear deficits in terms of knowledge of appropriate management ofdiabetes in the school. This was apparent in counselors’ responses to items like the type of dietsused for diabetics, medications useful to control sugar levels, and differences between type-1and type-2 diabetes. Furthermore, having acceptable levels of knowledge of diabetes or positiveattitudes towards it does not necessarily mean that counselors are well prepared or have the timeto provide effective support for students with diabetes (Tolbert 2006; Wagner 2006).

Similarly, the finding that counselors’ attitudes toward students with diabetes were generallypositive may not necessarily reflect counselors’ willingness or preparedness to have a role insupporting these students in school. This was reflected in responses to items such as: childrenwith diabetes might have a negative impact on their peers; health problems related to diabetes isthe issue of physicians only and not teachers; and people with diabetes prefer to live with otherdiabetic persons.

This study has methodological limitations. First, the findings of this study cannot begeneralized to all of Jordan, as the data were derived from Amman city only. Thus, furthersimilar studies in other parts of the country are needed. Second, because this descriptive studywas conducted on a convenience sample of counselors, it does not allow generalizations to allcounselors in the country. Third, school personnel likely to have an effect on this issue include



administrators, teachers, and people in other roles. Thus, further studies investigating knowl-edge and attitudes of these practitioners are also needed in Jordan.

Another limitation of the present study was the questionnaire used. It was a self-reportedquestionnaire and the participants’ responses to the attitude part may have suffered from socialdesirability. This questionnaire was relatively long and focused on theoretical knowledgerelated to diabetes. Future research utilizing different data collection instruments focusing onother kinds of information that may be important in school settings is needed.

Despite these limitations, the results of this study are enlightening. However, more researchis needed to understand the complexity of relationships between knowledge and attitudes.Furthermore, the scarcity of research literature in this country hindered comparison of thefindings and understanding of the implications of the results obtained.

In conclusion, the study showed moderate overall knowledge of diabetes mellitus andgenerally favorable attitudes toward students with this disease among school counselors inJordan. Therefore, the study recommends further research to explore the practical aspects ofdiabetes knowledge needed by counselors to promote improved health outcomes for students.The study also recommends conducting research on practical knowledge and behaviors of otherkey school personnel, such as teachers and administrators.

References

Abdel Gawwad, E. (2008). Teacher’s knowledge, attitudes and management practices about diabetes care inRiyadh’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: Prevalenceand 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 yduring 1992–1996. Acta Paediatrica, 88, 11–13.

Ajlouni, K., Khader, Y., Batieha, A., & El-Khateeb, M. (2008). An increase in prevalence of diabetes mellitusin 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 Arkansaspublic 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

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