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
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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

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(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.

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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

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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

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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

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(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

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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.
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