Before interventions are implemented, the potential treatment benefit must be determined.
The primary objective of this feasibility study was to assess if peers’ attitudes towards children who stutter (CWS) change one month after the administration of the Classroom Communication Resource (CCR). The secondary objectives of the study were to determine if differences in peer attitudes were related to gender and to previous exposure to a person who stutters.
The study used a cluster randomised control trial design. The study included 211 Grade 7 participants from schools in the Cape Town Metropole. The CCR intervention was administered to 97 participants in the experimental group, whilst 114 participants in the control group did not receive the intervention. The Stuttering Resource Outcome Measure (SROM) used as the outcome measure during pre- and post-test period. STATISTICA was used for in-depth data analysis.
An overall positive direction of change in scores was observed for the experimental group compared with the control group. However, the magnitude of change in the experimental group was not statistically significant (
This result indicated the beginning of positive attitude change which may be attributed to the intervention. Further investigation is warranted.
Social interactions and associations with peers are important for learners who are typically between 10 and 13 years. (Evans, Healey, Kawai
Communication disorders such as stuttering are often not viewed as ‘acceptable’ individual differences (Murphy & Quesal,
The teasing and bullying: unacceptable behaviour (TAB) programme was one of the first formal classroom-based interventions to be developed in Canada. The intervention comprises of a 14-minute video and six units of classroom-based lessons originally designed for Grade 4–6 learners, with the biggest impact occurring in the fourth grade (Langevin,
However, before a new intervention is adopted, it is imperative that it is assessed for potential benefit as part of a feasibility study (Thabane,
There is a dearth of studies which assess the benefits of classroom interventions for stuttering. The literature available in this area is mainly on the TAB and its development. A recent study by Langevin and Prasad (
Historically, research suggests that gender may influence peer attitudes towards CWS. However these results have been inconclusive (Wiesel & Spektor,
A further secondary objective of this study is to ascertain how individuals who are exposed to stuttering compare to those who do not have direct exposure. Langevin & Hagler (
To determine if participants’ attitudes towards CWS change in direction and magnitude one month after the administration of the Classroom Communication Resource (CCR) intervention.
To determine if the changes in attitudes were influenced by the participants’ gender. To determine if the changes in attitudes were influenced by the participants’ previous exposure to a person who stutters.
This study used a cluster randomised control trial design. This design allows for identification of cause and effect relationships within a controlled environment (Leedy & Ormrod,
In South Africa, schools fall within five (5) quintiles based on the National Poverty Distribution Table, with quintile 1 representing the lowest socio-economic strata and quintile 5 the highest (Department of Education,
The participants were required to be Grade 7 learners, in mixed gender classes from English dual-medium schools in Cape Town, falling within quintiles 2 and 3 on the National Poverty Distribution Table. Learners were also required to have adequate English literacy skills to complete the questionnaire, the SROM.
Learners from schools that had on-site speech therapy services and learners from schools that have previously participated in similar studies (prior to 2013) were not included in the study.
According to Lenth (
Using this power analysis as a guideline, this study recruited 211 participants, with 97 in the experimental and 114 in the control group. Of this total sample, 108 were males and 103 were females. The majority of participants (197) reported to have been previously exposed to people who stutter, whilst 44 reported no previous exposure. The average age of participants was 13 years.
Cluster randomisation design was applied with schools as the unit of cluster. A list of all the schools in Cape Town was obtained from the Western Cape Education Department (WCED). From this list, only those schools that fell within quintiles 2 and 3 on the National Poverty Distribution Table and those that were English dual-medium were considered part of the sampling cluster. Three schools (Schools A, B and C) were randomly selected and randomised to either the experimental or control group. Although the classrooms were used as the unit of intervention, it was necessary to randomise schools rather that classrooms to prevent contamination effect (Lindegger,
Three schools were contacted telephonically and then in person to invite them to participate in this study. Written permission from the principals and grade teachers was obtained. Informed consent was obtained from the participants’ parents and assent was attained from the participants themselves.
Prior to the study being conducted, permission was obtained from the Faculty of Health Sciences Human Research Ethics Committee and the Western Cape Education Department (WCED). Ethical research ensures that the rights of the participants involved are preserved through the ethical principles of autonomy, confidentiality, beneficence, non-maleficence and justice, as stated in the Helsinki Declaration (Williams,
A summary of the research process is in
The researchers themselves undertook preliminary analyses of the data, whilst a statistician checked the results and conducted more in-depth analyses. A score was allocated for each response on the SROM, with the response ‘strongly disagree’ reflecting a score of -2 and the response ‘strongly agree’ a score of 2. The response ‘not sure’ corresponded with a score of 0. All negatively worded items were reverse scored. The total scores obtained on the SROM were used for data analysis. The minimum total score obtainable was -40, reflecting a negative attitude, whilst the maximum was 40, indicating a positive attitude. The reliability in terms of internal consistency of items on the SROM was confirmed using Cronbach's alpha.
Descriptive statistics were used to analyse the SROM total scores in both the pre-test and post-test periods for the experimental and control group participants. In particular, the range, mean and standard deviation of total scores were analysed in terms of differences in mean total scores between groups (experimental vs. control), gender (male vs. female) and exposure (yes vs. no).
Inferential statistics were used to determine the effect of the intervention. For this, the distribution of the total score was assessed both visually on a histogram and by means of the Shapiro-Wilk's test, which evaluates normal distribution of a sample (Panik,
Pre-test and post-test scores experimental and control group.
Total score by group, gender and exposure; pre-test vs. post-test.
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Group | Experimental | 97 | -25 | 40 | 9.51 | 14.10 | -16 | 40 | 12.22 | 13.42 |
Control | 114 | -32 | 34 | 7.96 | 11.96 | -21 | 40 | 8.32 | 13.95 | |
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Gender | Male | 108 | -32 | 40 | 8.68 | 12.77 | -21 | 40 | 10.55 | 13.97 |
Female | 103 | -20 | 40 | 8.67 | 13.26 | -17 | 40 | 9.66 | 13.71 | |
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Exposure | Yes | 167 | -32 | 40 | 9.62 | 13.23 | -17 | 40 | 11.47 | 13.71 |
No | 44 | -20 | 33 | 5.07 | 11.42 | -21 | 31 | 4.95 | 13.09 | |
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Min, minimum; Max, maximum; Std. dev., standard deviation
A summary of the ANOVA results when analysing group, gender and exposure over the pre-test and post-test.
Category | Comparisons |
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Group | Experimental vs. Control | 1 | 4.34 | 0.0379 |
Pre-test vs. Post-test | 1 | 1.23 | 0.2683 | |
Interaction | 1 | 0.81 | 0.3678 | |
Gender | Male vs. Female | 1 | 0.03 | 0.8643 |
Pre-test vs. Post-test | 1 | 1.38 | 0.2403 | |
Interaction | 1 | 0.81 | 0.3684 | |
Exposure | Yes vs. No | 1 | 12.58 | 0.0004 |
Pre-test vs. Post-test | 1 | 1.42 | 0.2333 | |
Interaction | 1 | 0.84 | 0.3616 |
The primary objective of this study was to observe if participants’ attitudes towards CWS change in direction and magnitude one month after the administration of the Classroom Communication Resource (CCR). During the pre-test, the experimental group had a statistically significant higher average total score than the control group (
In the post-test the experimental group again had a statistically significant higher average total score than the control group (see
Within the experimental group, there was a higher post-test average total score than pre-test, reflecting a shift in scores in a positive direction. However, the magnitude of the shift was not found to be statistically significant (
In the control group there was no statistically significant change between the pre-test and post-test scores (see
Given that the results of the experimental group changed from pre-test to post-test scores whilst that of the control group did not change significantly, it can be inferred that the intervention had a positive effect but not a significant effect one-month post-intervention (see
Mean shift in item average total scores of the subscales of the SROM between pre-test and post-test: experimental group.
The mean shift scores from pre-test to post-test for the experimental group indicated that the shift occurred predominantly in the positive social distance subscale compared to the verbal interaction and social pressure subscales (see
Pre-test and post-test scores for male and female participants.
In the pre-test scores, there was no difference in attitude between males and females (see pre-test gender means,
Pre-test and post-test scores for participants who had exposure/no exposure to stuttering.
On the SROM pre-test, participants who were previously exposed to stuttering had more positive scores than participants with no exposure (
The results indicated positive scores in participants in the experimental group pre-intervention as compared to the control group. This difference may have occurred, as participants from the experimental group were from a different school than those of the control group. Although these schools were from similar areas in Cape Town, schools themselves are likely to be different and therefore may display varied attitudes. For example, schools may vary in the emphasis they place on issues of teasing and bullying. The strength of randomisation in the research design is that it is aimed at ensuring that each participant has an equal chance of being in experimental or control groups, thereby reducing the selection bias (Lindegger,
Groups also differed from each other post-intervention, with the experimental group again showing statistically significant more positive scores than the control group. Within the experimental group, the difference in average total scores between the pre-test and post-test period was 2.71. Although this difference was not found to be statistically significant with regard to the magnitude of the shift, the CCR appears to influence the change in attitudes in a positive direction. Overall, standard deviations were high in the experimental and control groups, indicating variation amongst participants.
The treatment effect may have been influenced by the time period. The post-test administration of the SROM occurred one month after the intervention of the CCR. Although Langevin and Prasad (
The sample size of the experimental group may have been too small to observe a significant difference in attitude in this study. The experimental group in this study consisted of 97 participants. The Langevin and Prasad study (2012) observed significant effects on a sample of 608 participants. A larger sample size in an RCT may therefore be helpful in observing changes with greater clarity.
The results of the subscale analysis may also help to understand which aspects of attitude shifts occurred post-intervention. The subscale ‘Positive Social Distance (PSD)’ showed the greatest positive shift compared to the social pressure and verbal interaction subscales. Items from the PSD subscale, for example (‘I would like having a child who stutters live next door to me’) refers to neighbourly relations, which may indicate that the CCR has begun to effect attitude change amongst peripheral relations. The same can be argued for ‘I would let a child who stutters hang out with us’ - as PSD is linked to how comfortable the peer is around a CWS (Langevin
The other two subscales showed less positive shifts after intervention. ‘Social pressure (SP)’ showed limited improvement and a slight negative shift in items such as ‘I would not go to the shop with a child who stutters.’ SP is linked to how one feels about what other peers think about CWS (Langevin
Since the shift in the experimental group is comparatively larger than that of the control group, the positive shift may possibly be attributed to the effects of the CCR on the experimental group. This result was consistent with findings by Langevin and Prasad (
The results indicated that exposure to stuttering has an effect on peers’ attitude towards CWS; a statistically significant more positive attitude towards CWS was noted in participants with previous exposure. The literature points towards a positive effect of exposure on attitudes. Children who have been exposed to stuttering may have a greater sense of empathy and understanding of CWS (Wiesel & Spektor,
No change was observed between pre-test and post-test for those with no previous exposure. This result may indicate that a longer time period may be necessary to effect attitude change in individuals who have not been exposed to this communication disorder. Contrary to this study, Langevin and Prasad (
Results indicated that gender did not have an effect on peers’ attitude towards CWS. The study by Langevin and Prasad (
After completing this segment of the study, some limitations were brought to light. The main limitations include:
The SROM being the only measure of attitude change. Participants were of diverse linguistic backgrounds and had varied English language proficiency, which might affect their performance on the SROM. Although the researchers took all available steps to ensure that the items were understood, this factor remains an area of concern. The sample size in the experimental group was smaller than the experimental group due to absenteeism which was beyond the control of the study.
The findings of this study point to the potential effect of the CCR as an intervention which can facilitate positive attitude change. The study raises awareness of the importance of a focus on changing negative attitudes of peers towards CWS, in South Africa. Whilst clinicians commonly work on an individual basis with children, their attention is directed to the impact of negative attitudes of peers. This intervention provides insights into classroom-based interventions as a possible strategy for intervention.
Furthermore, in a context like South Africa, as well as other contexts where under-resourcing is a common problem (Kathard & Pillay,
The study also highlighted that participants who were exposed to children who stutter had more positive attitudes compared to their peers who were not exposed. Therefore, it is vitally important that therapists encourage children in classrooms to interact with CWS – in close proximity activities to facilitate exposure as a strategy to reduce negative attitudes.
As this was a small scale study which considered attitude changes at one month post-intervention, it is essential that attitudes changes in further studies are considered over a longer term period in lower quintile schools. A further study examines attitude changes in higher quintile schools (Walters, A further large-scale study must consider cluster effect to determine the appropriate size of the sample of a future RCT. It is envisaged that further studies would require larger samples to accommodate the cluster effect. Further studies should seek to determine the clinical significance of findings. Whilst this study focused on the statistical significance, a further investigation could consider literature guidelines and clinician guidelines for what can be considered clinically significant results in classroom-based interventions such as the CCR.
The results in this study at one month post-intervention indicated a positive shift direction in treatment effect, indicating improved attitude towards CWS in participants of the experimental group as compared to the control group. The magnitude of the attitude change was not statistically significant. Gender did not appear to influence participants’ attitude towards CWS. Previous exposure to stuttering had a significant positive effect on participants’ pre- and post-test attitudes to CWS. This study concluded that treatment effect of the CCR was small but positive at one month post-intervention, warranting further study.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
H.K. (University of Cape Town) was the primary investigator and first author. F.W. (University of Cape Town) and F.C-S. (University of Cape Town) contributed to the development of the study and are senior authors of this article. K.F. (University of Cape Town), T.M. (University of Cape Town), M.R. (University of Cape Town), R.S. (University of Cape Town), J.W. (University of Cape Town), N.Z. (University of Cape Town) and A.Z. (University of Cape Town) planned and executed the study and contributed actively to writing the article.
The items of the SROM according to subscales
Item Number | Item | Subscale | ||
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1. | I would like having a child who stutters live next door to me. | PSD | - | - |
5. | I would enjoy doing a class project with a child who stutters. | PSD | - | - |
7. | I would introduce a child who stutters to my friends. | PSD | - | - |
8. | I would be happy to have a child who stutters for a friend. | PSD | - | - |
10. | In class I would like to sit next to a child who stutters. | PSD | - | - |
12. | I would like a child who stutters to talk for my group in class. | PSD | - | - |
14. | I would let a child who stutters hang out with us. | PSD | - | - |
15. | I would enjoy being with a child who stutters. | PSD | - | - |
16. | I would be best friends with a child who stutters. | PSD | - | - |
18. | I would like having a child who stutters in my class. | PSD | - | - |
20. | I would spend time at break with a child who stutters. | PSD | - | - |
2. | I would avoid a child who stutters. | - | SP | - |
3. | Children who stutter are like normal children. | - | SP | - |
4. | I would be ashamed to be seen with a child who stutters. | - | SP | - |
6. | Children who stutter are weird. | - | SP | - |
9. | I would not go to the shop with a child who stutters. | - | SP | - |
11. | I would be frustrated listening to a child who stutters. | - | - | VI |
13. | Listening to a child who stutters would annoy me. | - | - | VI |
17. | I would be embarrassed to be with a child who stutters. | - | - | VI |
19. | Children who stutter should not play games that involve talking. | - | - | VI |
PSD, positive social distance; SP, social pressure; VI, verbal interaction.
Flowchart - Procedure