The Scale of Attitudes Towards Disabled Persons (SADP): Cross-cultural Validation in a Middle Income Arab Country, Jordan Kozue Kay Nagata, Senior Economic Affairs Officer of the Development Cooperation Branch United Nations Department of Economic and Social Affairs Abstract: The purpose of this pilot study was to assess the level of the existing attitudinal barriers towards disabled persons in four communities of Jordan. Jordan is a middle income Arab country, with a PPP-adjusted GDP/capita of US$ 4320.i The study attempted to determine the present level as a baseline of prejudice against people with a disability in Jordan, and to examine the relationship between the randomly selected participants’ attitudes and their previous exposure to and experience with disability. The Scale of Attitudes towards Disabled Persons (SADP) was selected as the instrument. An Arabic translated version of the Scale was used for 191 participants. The respondents showed overall negative attitudes towards disabled persons, as illustrated by previous documented materials. The result of this survey was highly correlated with the collective opinion expressed by the focus group that was conducted by the author in Amman in January, 2005. Thus, the cross-cultural validity of this instrument has been confirmed, and the major findings of this pilot study could inform future policy directions and public awareness raising strategies to foster positive public attitudes. Key Words: disability, Jordan, attitudes Background The social model of disability is becoming widely accepted by many in academic circles as well as within the community of both developed and developing countries. The author argues that the strength of the social model is due to its examination and analysis beyond specific impairments of individuals. It can encompass socioeconomic, cultural, and legal dimensions of disability from human and civil rights perspectives. This complexity of the model will require coherent action for carrying out research on the existing social barrier level (e.g., the level of acceptance, recognition and discrimination), and campaigning to confront social prejudice and discrimination. For the theoretical framework for this pilot study, however, the World Health Organization International Classification of Functioning, Disability and Health (WHO-ICF, 2001) model was used (WHO 2001), which is based on an integration of two opposing models, the medical model and the social model, and emphasizes a dynamic process between a disabled individual and his or her social environment. Negative attitudes of non-disabled people can inhibit disabled peoples' social integration and their empowerment, including the development of their positive selves, irrespective of the type and degree of impairment. Roush (1986) reported that negative attitudes towards disabled people are common in society, but are not directly voiced. There is agreement that those who have had previous exposure to disabled people, and with proper professional training, tend to have more positive attitudes towards disabled people. Paris (1993) reported that health-care professionals with constant exposure to disabled people have positive attitudes towards people with physical impairments. It is believed that the variation in attitudes towards different categories of disabled people result from cultural values, living environment, age and exposure to disabled people. Therefore it is important for each community to collect its own data. The attitudes towards the disabled have been studied worldwide, but not so in Jordan and the Arab region. A study undertaken in Saudi Arabia in 2003, using the SADP, concluded that Saudi Arabian healthcare professionals displayed positive attitudes towards people with disabilities as do other professionals and caregivers worldwide (Al-Abdulwahab & Al-Gain, 2003). Qaryouti (1984) concluded through his research on special education that the attitudes of Jordanian rural people towards persons with disabilities were generally negative. Turmusani (2003) argued that persons with disabilities (particularly disabled women) in Jordan were treated with cultural prejudice, isolated, and hidden sometimes within the family. He attributed this discrimination to the ambivalence of the Qur’an, which sometimes emphasizes equality and at other times associates persons with disabilities with the wicked of the society. Aims A major objective of this pilot study was to establish the current level of acceptance/recognition of disabled people for future comparison, and to examine the relationships between nondisabled peoples' attitudes with different sociodemographic characteristics and experience of interaction with disabled people, for the purpose of informing possible public awareness policy interventions in the future. In order to establish the concurrent validity, the result of this survey was compared with the collective opinion expressed by the focus group (composed of 30 participants, 21 disabled people and 9 parents) that took place in Amman in January, 2005. The result can also be correlated to the previous documented materials about the cultural barriers existing in Jordan and the Arab region. Methods The Arabic version of the Scale of Attitudes Toward Disabled People (SADP) was personally administered with a total sample of 191 individuals with valid data. The data was collected from four communities of Jordan, namely, Amman (the capital), Karak, Irbed, and Madaba with almost the same proportion, 25% from each community. The research employed a stratified proportional sampling method to balance the residential characteristics of the respondents. The sample size was relatively well spread across different socioeconomic characteristics. For instance, the gender balance was almost equal. The mean age was 33 years with SD of 13.37, similar to the national norm. To eliminate the sampling bias, on the street of each community, people passing by were selected and asked to answer the questionnaire, in a systematic manner, thus maintaining a certain level of random selection The SADP is a reliable self-report scale that consists of 24 items, developed by Antonak (1982, 1998). The 24 items of the SADP are expressed as statements to which respondents answer on a Likert-type scale. A Likert-type scale consists of a series of declarative statements. The subject is asked to indicate whether he or she agrees or disagrees with each statement. Commonly, five options are provided: "strongly agree," "agree," "undecided," "disagree," and "strongly disagree." Other Likert-type scales include four or six steps rather than five, excluding the undecided position. It provides a convenient and effective tool for the evaluation of attitudes towards people with disabilities. In the SADP, the participants were asked to choose the most appropriate number, with 6 scaled options, that best corresponds with how they feel about each statement. There were no "right" or "wrong” answers. There was no time limit. For instance, in Question number 8, which is a negative question, participants were asked to react to the statement, “Disabled people are in many ways like children,” and they could choose their answer ranging from, “I disagree very much,”ii to “I agree very much.” Any incomplete questionnaire was eliminated from the study. The total score ranged from 0, indicative of a very negative attitude, to 144, indicative of a very favorable attitude. An ANOVA and the descriptive statistics of the Kruskal-Wallis Test were used to analyze the data using SPSS statistical software. The reliability alpha showed a moderate level of reliability of 0.56. Results of the SADP Two hundred and five people responded to the SADP as requested, out of which, 191 data sets were complete and valid, with 95 males and 96 females with a mean age of 33 with a SD of 13.37. The respondents had overall negative attitudes towards disabled persons with the mean score of 88.67, with a SD of 14.63, as seen in Table 1.iii There was no significant difference found, based on the demographic and socioeconomic characteristics of the respondents. However, their responses were particularly negative to those questions relating to “misconceptions” and “stereotypes.” The only characteristics to which a difference in attitudes could be attributed were the participants’ residential communities and their personal experience of interaction with disabled family members. With respect to communities, the mean score of the respondents from the capital city, Amman was rated the highest (most positive score, 95.63) in contrast with the equivalent of the town of Karak (82.94), the most suburban and rural community of the four places. The difference was statistically significant at p<0.01, as seen in Table 1. The respondents in interaction with disabled family members scored higher (94.38) than those without (87.53, p<0.01). Those who had watched or participated in some disability awareness programs/campaigns also scored higher (93.01) than those who had not (86.44, p<0.01). All other public education schemes had no impact on their attitudes. Those whose impression about disabled people came from personal experiences with disabled people scored higher (94.38) than those who did not (87.53) (p<0.05). The findings supported the common and global view that disabled people living in rural communities tend to face more serious discrimination and prejudice than those in urban communities. Also, exposure to personal experience with people with disabilities and public awareness programs was associated with positive attitudes towards people with disabilities. Table 1: The Result of the Scale of the Attitudes towards Disabled People (SADP) in four communities of Jordan among 191 non-disabled persons (N=191) (POPULATION ESTIMATED IN 1997) N THE SADP RESULT TURKEY HSD *** SCHEFFE POST HOC **** MEAN * MEAN RANK ** SD Karak (23,466) ***** 47 82.94 75.79 12.77 Karak – Amman Karak – Amman Irbed (327, 543) 46 88.70 95.47 15.22 None None Madaba (87,534) 49 87.20 89.91 13.08 Madaba- Amman Madaba- Amman Amman (capital) (1,331, 028) 49 95.63 121.98 14.80 Amman- Karak Amman- Madaba Amman-Karak Amman-Madaba Total (5,759,732) ***** 191 88.67 14.63 * ANOVA: F=6.846, p<0.01. Significance of mean differences found among the cities. ** Mean rank scores and non-parametric Kruskal-Wallis Test indicated the significance of differences among the cities, p<0.01 *** Post Hoc Turkey HSD found the significance between Amman-Karak and Amman-Madaba **** Post Hoc Scheffe found the significance between Amman-Karak and Amman- Madaba. ***** Population of each city was estimated in 1997 (World Gazetteer, 2007) ****** Total population of Jordan was estimated in 1995 (Yahoo Education, 2007) Results of the Focus Group The following is a summary of the participatory focus group conducted by the author that took place in January, 2005.iv For triangulation and co-validation, three participatory focus group sessions were conducted by the author, assisted by an Arabic-English Jordanian interpreter, who is a social worker and activist with physical impairment, with 30 participants: one group with 10 blind persons and 6 with physical disability, another group with 3 mildly intellectually disabled persons and 9 parents, and a small session of 2 multiply disabled persons of which one has deafness and slight intellectual disability. Respondents with intellectual disability and with multiple disabilities were assisted by their parents and associates and the questions were provided in the most appropriate modes of communication. In addition, a small supplementary focus group session of professionals on disability and Official Development Assistance (ODA) workers was conducted. A few standard techniques of the Participatory Rural Appraisal (PRA) were used, such as semi-structured group questions, drawing a disability chronology, open ended discussion and observation. For example, in the open-ended discussion, questions were asked such as “What kind of proactive measures are most effective to improve public attitudes towards disabled people in Jordan and how can we improve the current public awareness program?” or “Do you think disabled people in rural communities are more discriminated against, and if so, what are the major reasons for this tendency?” The following key points made by the above-mentioned focus groups reply to those questions and co-validate the empirical findings of this study: a) The overall negative elements of Jordanian culture towards disability, particularly towards disabled women and other marginalized disability groups (e.g. intellectually disabled people and those with psycho-social disability); b) Particularly negative attitudes of residents in rural or suburban communities of Jordan, due to their limited exposure to the global development of human rights concepts and the social model of disability as well as Western cultures in general; c) The importance of including disability concerns and the concept of the social model of disability into school curricula; d) The need to promote better understanding of the family of disabled children and adults; e) The importance of direct exposure to and personal experiences with people with disabilities (e.g. disabled peers, disabled colleagues, etc.); f) Jordan’s failing to attempt to utilize pop singers or celebrities on air to boost public awareness; g) The participants’ preference for disability mainstreaming into regular and popular TV programsv, over the current too educational, boring targeted TV programming, which is still based on a charity-based framework; h) The importance of mutual interaction between disabled people and the surrounding society, mandating a dual- track intervention. The dual- track approach is a comprehensive strategy of the empowerment and capacity development of people with disabilities and the removal of all kinds of social barriers (e.g. adoption of universal design, eliminating the legal and institutional barriers) as a means of changing attitudes; i) Diversity among different disabilities (e.g. deaf culture, disabled veteran culture and martyrdom, conflicts between the grass-roots people and English- speaking urban elites). People with intellectual disabilities and/or psychosocial disability, disabled Palestinian refugees, as well as disabled women, are most severely discriminated against. Conclusion The results of this study demonstrate the cultural validity of the SADP instrument that is the most widely used in the USA, Europe, and some Arab Gulf countries. Also, the findings of the present study, both the quantitative and qualitative parts, echoed previous research such as Hong Kong Equal Opportunity Commission (2000), Rosenbaum, Armstrong, and King (1986), Al-Abdulwahab and Al-Gain (2003), and Kabbarah (2005), in that they demonstrate that attitudes should be treated as a multidimensional construct, consisting of the interlocking facets of cognitive and affective process as well as direct exposure to disability. The findings of the focus group also exhibited diversity among disabilities and different types of disabled people. The findings of the present study may inform a new strategy for policy makers, educators, social workers, and mass media experts in careful rethinking of the core messages to be delivered in public awareness programs. In particular, it is important that due attention be paid to the need to improve the current public awareness strategy, which is considered to be too educational and boring. The focus group informed us that it is worthwhile to explore a more innovative and engaging strategy appealing to wider audience, such as mainstreaming of “disabled characters” into ordinary drama series or effective use of pop singers and celebrities to boost awareness. Also, the public awareness effort may target rural or suburban populations who have limited access to global media coverage, thus not knowing the international trend of disability and human rights. Following the findings of this small scale pilot study, a nationwide publicly funded survey with a bigger, less biased and more representative sample should be conducted in both the urban and rural communities of Jordan, and elsewhere in the Arab region. The limitation of this research includes a small sample size, potential sample bias towards voluntary participants in the focus group, lack of randomness, and a question regarding the accuracy of the Arabic translation of the two instruments. The participatory focus groups were conducted partially with an interpreter (Arabic and English, as well as sign language), so a cultural and linguistic shortcoming should be added to the limitation. In order to cover a nationwide disabled population without sample bias, a larger-scale and more systematic follow-up (preferably publicly-funded) study should be conducted, based on the preliminary baseline constructed in this research. Kozue Kay Nagata is a Senior Economic Affairs Officer of the Development Cooperation Branch, Office of ECOSOC Support and Coordination, United Nations Department of Economic and Social Affairs, UN HQ, New York. However, the views expressed in this article are those of the author and do not necessarily reflect the views of the United Nations. This study is a part of the comprehensive doctoral dissertation on disability and development in Jordan and Lebanon, by the author, to be submitted in Japanese language to the Graduate School of International Social Development, Nihon Fukushi Univeristy, Nagoya, Japan. The author lived in Amman Jordan for 7 years. References Al-Abdulwahab, S., & Al-Gain S. I. (2003). Attitudes of Saudi Arabia care professionals towards people with physical disabilities. Asia Pacific Disability Rehabilitation Journal, 14, 63-70. Antonak, R. F. (1982). Development and psychometric analysis of the Scale of Attitudes toward Disabled Persons. The Journal of Applied Rehabilitation Counseling, 13, 22-29. Antonak, R. F., & Livneh, H. (1998). The measurement of attitudes toward people with disabilities: methods, psychometrics, and scales. Springfield, IL: C.C. Thomas. Hong Kong, Equal Opportunity Commission (2000). A baseline survey of students’ attitudes towards people with a disability. Hong Kong: EOC. Kabbarah, N. (2005). A study on the situation of disabled persons and the Arab Decade of Disabled Persons (2004-2013). Retrieved September 28, 2007, from http://www.jica.go.jp/branch/ific/jigyo/report/kyakuin/200506_01.html Paris M. J. (1993). Attitudes of medical students and health-care professionals towards persons with disabilities, California School of Professional Psychology, Berkeley/Alameda. Arch Phys Med Rehabilitation, 74, 818-825. Quryouti, Y. (1984). Special education for Jordan: A present status of needs assessment study, Unpublished doctoral dissertation, University of Jordan. Rosenbaum P. L., Armstrong R.W., & King S.M. (1986). Children’s attitudes toward disabled peers: A self-report measure. Journal of Pediatric Psychology, 11(4), 517-530 Roush S. E. (1986). Health professionals as contributors to attitudes towards persons with disabilities. A special communication, Physical Therapy, 10, 1551-1554. Turmusani M. (2003). Disabled people and economic needs in the developing world: A political perspective from Jordan. Ashgate: UK. World Gazetteer (2007). Jordan: Largest cities and towns and statistics of their population. Retrieved September 28, 2007, from http://www.world- gazetteer.com/wg.php?x=&men=gcis&lng=en&dat=32&srt=npan&col=aohdq&geo=- 110 World Health Organization (2001). International Classification of Functioning, Disability and Health (WHO-ICF). Geneva: WHO. Yahoo Education (2007). Jordan people: Population. Retrieved September 28, 2007, from http://education.yahoo.com/reference/factbook/jo/popula.html Endnotes i UNDP (2005), UNDP Human Development Report 2005, Table 1. ii In this case, as it is a negative question, this choice will be scored as 0, indicative of the most negative attitude, iii The score is lower than the findings of most of the studies conducted globally. For instance the study by Al-Abdulwahab (2003) demonstrated the score of 102 +- 3.5 for Saudi speech pathologists and 102 +- -3.4 for Saudi family medicine physicians. N=3=, F/M=13/17, Blind=10, Physically Disabled=6, Multiply Disabled=2. Intellectually Disabled=2, and Parents=9. v Disabled people themselves do not enjoy the current educational programs on disability awareness, and they do enjoy watching regular entertainment programs. --------------- ------------------------------------------------------------ --------------- ------------------------------------------------------------ 8