INT J LANG COMMUN DISORD, NOVEMBER–DECEMBER VOL.

2013,

48, NO. 6, 703–714

Research Report Public attitudes toward stuttering in Poland Aneta M. Przepiorka†, Agata Blachnio†, Kenneth O. St. Louis‡ and Tomasz Wozniak§ †Institute of Psychology, The John Paul II Catholic University of Lublin, Poland ‡West Virginia University, Morgantown, WV, USA §Maria Curie-Sklodowska University, Poland

(Received March 2013; accepted June 2013) Abstract Background: People who stutter often experience negative judgments and reactions to their stuttering from the nonstuttering majority. Many are stigmatized because of their stuttering and threatened with social exclusion, placing them at risk for compromised quality of life. Aims: The purpose of this investigation was to measure public attitudes toward stuttering in Poland. Methods & Procedures: A sample of 268 respondents (mean age = 29 years; range = 15–60 years) from numerous different geographic and urban-rural settings in Poland filled out a Polish translation of the Public Opinion Survey of Human Attributes–Stuttering (POSHA–S). Outcomes & Results: Polish respondents displayed attitudes toward stuttering and people who stutter that were generally similar or “average” in comparison with other samples around the world from the POSHA–S database. Conclusions & Implications: Although generally typical of other Western societies studied, attitudes of adolescents and adults from Poland were notably different in some ways, such as in the beliefs that emotional trauma or viruses and disease can cause stuttering as well as in the self reaction that they would feel uncomfortable speaking with a stuttering person. Overall, social exclusion and stigma are as likely among Poles who stutter as among most other populations studied. Keywords: stuttering, attitudes, Poland, POSHA–S.

What this paper adds? What is already known on this subject? Previous studies have suggested that people who stutter, regardless of their age, are likely to be negatively affected by stereotypes, stigma, and social exclusion. Stuttering affects social relationships, impedes functioning in society, and has detrimental influence on their quality of life. What this study adds? This study contributes to the knowledge on the attitudes towards people who stutter primarily as a result of using a standard measure, the Public Opinion Survey of Human Attributes–Stuttering (POSHA–S). Using a new Polish translation of the POSHA–S, a broadly-selected sample of Polish adults was compared with previous samples using the instrument. Attitudes towards stuttering in the Polish society were generally similar to other samples around the world. Nevertheless, their attitudes were still far from positive and showed much the same stereotypes and potential stigma reported previously, thus very likely affecting the lives of people who stutter in Poland. Introduction Stuttering is not only a speech fluency disorder: it also has a social dimension, potentially impeding the individual’s functioning in society seriously and potentially lowering the quality of a person’s life (Craig, Blumgart,

& Tran, 2009). In the literature, stuttering is viewed as a complex and multifaceted speech disorder (Wo´zniak, 2008), which is manifest as symptoms not only at linguistic, emotional, or physical levels, but in terms social consequences. This disorder has impact on the

Address correspondence to: Aneta Malgorzata Przepiorka, Institute of Psychology, The John Paul II Catholic University of Lublin, Al. Raclawickie 14, PL 20–950 Lublin, Poland; e-mail: [email protected] International Journal of Language & Communication Disorders C 2013 Royal College of Speech and Language Therapists ISSN 1368-2822 print/ISSN 1460-6984 online  DOI: 10.1111/1460-6984.12041

704 functioning of person who stutters in society, especially on the way the person is perceived. A so-called “stuttering stereotype” has been shown to exist in the nonstuttering majority, wherein people who stutter are assumed to be quiet, taciturn, evasive, introverted, reserved, passive, limited worth, fearful, tense, distrustful, nervous, withdrawn, and timid (Williams, 2006). Such negative stereotypes often result in a stigmatization of these people, which in turn, can affect their lives dramatically (Blood & Blood, 2007). Negative social consequences of stuttering have been widely reported in the literature. Children and adolescents who stutter are negatively evaluated, become the object of jokes and ridicule from their peers, meet with limited acceptance from colleagues and strangers, and are less often perceived as leaders (Blood, Blood, Tellis, & Gabel, 2003; Blood, Blood, Tramontana, Sylvia, Boyle, & Motzko, 2011; Davis, Howell, & Cooke, 2002; Franck, Jackson, Pimentel, & Greenwood, 2003; Langevin & Hagler, 2004; Langevin, Kleitman, Packman, & Onslow, 2009). For example, Langevin et al. (2009) found that about one-fifth of Canadian 3rd to 6th graders held negative attitudes towards their peers who stutter. In Poland, school-age children and adolescents (aged 8–25 years) were more disliked than their fluent peers (Kulas, 1990). Similarly, adults who stutter are viewed negatively, stigmatized, and discriminated against, and stereotyping seems to be omnipresent regardless of education or culture. For example, speech-language clinicians and respondents from the general public (17–81 years) attributed characteristics to people who stutter that were primarily negative, e.g., shy, introverted, tense, reticent, and withdrawn (Woods & Williams, 1976). Teachers from Kuwait surveyed by Abdalla and St. Louis (2012) held similar negative attitude towards people who stutter. As in other studies, the teachers’ knowledge about the cause of stuttering was highly variable and typically not accurate. Hughes, Gabel, Irani, and Schlagheck (2010) studied university students and documented clear negative effects of stuttering on lives of those who stutter and about the possible difficulties they would encounter when they stuttered. In interviews, stuttering participants identified more problems and barriers as a result of their stuttering than positive aspects. Gabel, Blood, Tellis, and Althouse (2004) reported that employers have clear ideas about what stuttering workers can and cannot do, thus “entrapping” them in certain roles or jobs. Even in close-knit rural communities, adults judged a hypothetical person who stuttered more negatively than they judged a person who did not stutter, even though 85% of the participants declared that they knew a person who stuttered and 39% were related to such a person (Doody, Kalinowski, Armson, & Stuart, 1993). We may conclude that even being acquainted with a person who

Aneta M. Przepiorka et al. stutters does not necessarily prevent from stereotyping, although one study did show better attitudes toward known stuttering individuals (Klassen, 2001). Results of a study in Poland by Blachnio (in press) showed that fluent speakers strongly experience emotions of helplessness and care when listening to persons who stutter. Another Polish study documented negative stereotype attribution to people who stutter, especially the belief that they are fearful or distrustful (Grzybowska, Łapi´nska, & Michalska, 1991). The concept of ostracism, a term which is often used interchangeably with social exclusion and rejection, has bearing on the results of research on attitudes towards stuttering (Oaten, Williams, Jones, & Zadro, 2008). Studies of Polish respondents by Tarkowski (2008) indicate that fluent speakers may be divided into two groups with regard to their stereotypes concerning people who stutter. One group believes that people who stutter do not have a disordered personality but merely suffer from a peculiar speech dysfunction. The other group believes that stuttering is a speech neurosis and is connected with neuroticism; these people consider those who stutter to be fearful, sensitive, shy, and taciturn. Tarkowski stressed that the negative reactions of fluent speakers to stuttering stem from a lack of knowledge concerning what the interlocutor who stutters is experiencing. Studies on ostracism demonstrate that being rejected has negative influence on individuals, their selfesteem, and their sense of meaning in life (e.g., Leary, Kowalski, Smith, & Phillips, 2003). Williams, Cheung, and Choi (2000) advanced the position that ostracism poses a threat to four human needs: (a) the need to belong, (b) the need for control, (c) the need for selfesteem, and (d) the need for meaning in life. Ostracism induces negative emotions in a rejected person and triggers a sense of loss. The person’s reaction will depend on which of the needs cannot be fulfilled. Turnbull (2006) points out that negative stereotyping of children who stutter may have negative impact on their degree of interaction in school as well as their self-esteem. She highlighted the beneficial effect of a class presentation delivered to children with speech difficulties that was associated with positive changes in their attitudes. Similarly, Murphy, Yaruss, and Quesal (2007) identified negative reactions that children who stutter experience from peers who tease them and emphasized that education about stuttering can foster reductions in negative societal opinions. Other research shows that social exclusion has negative influences on self-regulation and that these influences are more lasting in people with high levels of social anxiety (Oaten, Williams, Jones, & Zadro, 2008). Although not entirely accepted, recent research has also shown that people who stutter may have elevated social anxiety (Blumgart, Tran, & Craig, 2010).

Polish stuttering attitudes Being somewhat different from others may limit normal functioning in society, which depends to a great extent on the social perception of people with one’s differences. The evidence is clear that lack of tolerance for differences in others can lead to many negative sequelae for those identified as different (Abbey, Charbonneau, Tranulis, Moss, Baici, Dabby et al. 2011). Stuttering can generate stigma in society that reduces “a whole and usual person to a tainted, discounted one” (Goffman, 1963, p. 3). Although negative attitudes toward people who stutter have been commonly reported, because most research studies have used different strategies and measures, the results are not easily comparable. To address this issue, St. Louis and his colleagues inaugurated the International Project on Attitudes Toward Human Attributes (IPATHA), an international project for research on attitudes toward people with various stigmatizing human conditions that would employ standard measures. Most notably, they developed the Public Opinion Survey of Human Attributes–Stuttering (POSHA–S) (St. Louis, 2011), which permits inter-sample comparisons of attitudes. The POSHA–S contains a demographic section; a general section comparing stuttering to four other “anchor” attributes, i.e., intelligent, left handed, mentally ill, and obese; and a detailed stuttering section (St. Louis, 2011). The general section asks for ratings of the five attributes on 5-point Likert scales while the detailed stuttering section ask for “yes,” “no,” and “not sure” ratings that are later converted to 3-point scales where “no” = 1, “not sure” = 2, and “yes” = 3. All attitude ratings are then converted to a -100 to +100 scale where 0 is neutral, with scores for some items reversed such that higher scores reflect more accurate and sensitive attitudes, and vice versa. The −100 to +100 conversion is carried out after mean values for each item are calculated, permitting comparison of the two rating scales on the same scale. In the demographic section following an instruction page, participants are requested to fill in demographic characteristics and to make self-ratings of their physical health, mental health, speaking ability, and learning ability. Additionally, respondents rate various life priorities (e.g., being safe and secure, helping the less fortunate, earning money, and doing my jobs or my duty) as potential future predictors of attitudes. Next, respondents fill out the general section wherein they provide their opinions of stuttering in comparison to four other human attributes ranging from positive (i.e., intelligent), to neutral (i.e., left handed), to negative (i.e., obese, and mentally ill). The purpose of this section is to provide the potential to differentiate samples according not only to attitudes toward stuttering but also to the contexts into which they occur. Finally, respondents rate hypothetical stuttering/people who stutter on a wide variety of items that can be divided according to beliefs about

705 the disorder that do not involve the respondent considering his or her own reactions or behaviour versus self reactions or responses that do involve the respondent’s actions and emotions. Using the converted scores, the POSHA–S is scored such that clusters of various items form components, various components form subscores, and the two subscores for stuttering (Beliefs and Self Reactions) form an Overall Stuttering Score. The IPATHA initiative has generated a database of respondents from dozens of studies using the POSHA–S (St. Louis, 2011, 2012c). The database consisted of 6957 respondents representing in 15 different languages and 23 countries. The POSHA–S has been carefully evaluated for reliability; validity; internal consistency; userfriendliness; translatability; different modes of administration; and sensitivity to attempts to change attitudes, intercultural differences, generational differences, and different types of sampling (e.g., Flynn & St. Louis, 2011; St. Louis, 2012c, 2012c; St. Louis, Reichel, Yaruss, & Lubker, 2009; St. Louis & Roberts, 2010). Research using the POSHA–S has shown important differences between countries and cultures, cf. review in St. Louis (2012c). Three examples serve to illustrate. St. Louis & Roberts showed that attitudes toward stuttering in Cameroon were markedly less positive than attitudes in Canada and the USA, regardless of whether the POSHA–S was administered in English or French. ¨ Ozdemir, St. Louis, and Topbas¸ (2011a, 2011b) demonstrated that public attitudes toward stuttering in Turkey were not as positive as previous samples taken from the “West” and that attitudes of 6th grade schoolchildren were remarkably similar to the attitudes of their parents, grandparents (or adult relatives), and neighbours. In addition, attitudes of adult respondents from Hong Kong and adjacent Mainland China were much more similar than different but, as a group, were less positive than most of the samples in the POSHA–S database taken from North America and Western Europe (Ip, St. Louis, Myers, & An Xue, 2012). Several POSHA–S investigations have also begun to explore predictors of more versus less positive public attitudes. Information about stuttering from an entertaining talk to high school students about stuttering by a young adult male with rather severe stuttering or a professionally developed video for teens featuring the same speaker (plus two other females who stuttered) resulted in significant short-term positive changes in attitudes (Flynn & St. Louis, 2011). One study showed that male and female respondents selected randomly but equally from 50 different samples around the world resulted in virtually identical POSHA–S measured attitudes (St. Louis, 2012a). The need exists to broaden the database to public samples in other countries, especially in areas that have relatively recently undergone dramatic political changes,

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such as in Eastern European nations previously part of the Soviet Union. Poland is one such country. The purposes, therefore, of the current study were two-fold: (a) to describe the attitudes toward people who stutter that are held by adolescent and adult Poles, and (b) to compare the Polish attitudes to those from samples previous analyzed in the POSHA–S database.

and were asked to share their honest opinions about the five different human attributes. Respondents received no financial compensation but were thanked for their participation and reassured about anonymity of their ratings.

Data analysis Method Survey instrument This study was conducted according to procedures approved by the research ethics committee. The current study used a Polish version of the POSHA–S. The first two authors who are native speakers of Polish translated separately the POSHA–S into Polish. Next, they compared the two drafts of their translations in terms of ambiguity and adequacy and jointly chose the most appropriate translation. Following that, their Polish version was verified by a committee of three experts in a speech therapy (one practitioner and two researchers in the field) for correct terminology. Next, the approved Polish version was translated back into English by a professional English translator, and the original English versus back-translated English version were compared. The two English versions, though not worded exactly the same, had no important differences in meaning. The final version of POSHA–S was verified for readability by administering it to a group of ten students to assess whether any inconsistencies or misunderstandings arose for the respondents. They did not report any problems in understanding the items or in the survey procedure. As will be seen below, it is important to note that the respondents knew that the term for stuttering “jakanie” ˛ meant the disorder of stuttering and not normal disfluency “niepłynno´sc´.” Participants The data were collected in different places in Poland, i.e., the provinces of Kielce, Lublin, Poznan, Rzesz´ow, Warsaw, and Wrocław. Even though we used convenience sampling, our goal was to generate a reasonably representative sample of Poles by recruiting respondents from different cities and at different age and education levels across Poland: 15% from rural areas, 14% from small towns (≤20,000 inhabitants), 26% from mediumsized towns (20,000–99,000 inhabitants), 22% from large towns (100,000–500,000 inhabitants), and 23% from cities (≥500,000 inhabitants). The questionnaires were administered to respondents who voluntarily agreed to participate. They were informed that the goal of this project was to explore public opinion about a number of human attributes and characteristics

Data were analyzed according to procedures used in ¨ several recent studies (e.g., Ip et al. 2012; Ozdemir et al. 2011a, 2011b; St. Louis, 2011; St. Louis, 2012a, 2012b, 2012c). These involved reporting converted means (ranging from most negative [−100] to most positive [+100]) for each of the items, components (clusters of items), subscores (clusters of components), and the Overall Stuttering Score (mean of the two stuttering subscores). A radial graph provides a visual display of the components and subscores along with a numerical Overall Stuttering Score. The radial graph shows the middle (median) mean rating of 98 different samples analyzed to data in the POSHA–S database. At the time of this writing (circa January, 2013), the 98 different samples came from single administrations of the instrument or the first of multiple administrations (e.g., preand post-test designs) representing 6957 respondents from 23 countries taking the POSHA–S in 15 different languages. Additionally, the radial graph shows the highest (most positive) mean rating observed to date for each comparison as well as the lowest (least positive) in order that the sample(s) in question can be compared with the extremes and with the median or average sample rating. To provide a more precise sample comparison, percentiles relative to the 98 database means were generated for the means of the Polish sample and divided into quartiles. The percent of all of the Polish mean ratings in the 1st or lowest quartile (0–25th percentile [%ile]), the interquartile range (25th –75th %ile or 2nd and 3rd quartiles), and the 4th or highest quartile (75th –100th %ile) were then calculated. If the large majority of them were in the interquartile range, then it could be assumed that the Polish attitudes were about average. If a substantial percentage were in the lowest or highest quartiles, then the implication would be that the Polish samples had lower or higher attitudes, respectively, than average. Although the POSHA–S database is not yet sufficiently broad and large to make accurate predictions of the relative positivity or negativity of attitudes in most places of the world, the current study went one step further to search for predictors in this Polish sample. We divided the total sample in half based on their Overall Stuttering Scores, a number that is influenced by all of the stuttering items. The highest half was then compared to the lowest half so that we could inspect demographic variables to determine which, if any, of them were

Polish stuttering attitudes significantly different for the half with the “best” versus the half with the “worst” attitudes toward stuttering. Results Demographic information Demographic information is provided in column 2 of Table 1 for the 268 Polish respondents who took part in the study. The Table also compares these results to means of the 98 samples in the POSHA–S database. The median or middle sample mean from the database is shown in column 3. Column 4 shows percentiles for the Polish means generated from the 98 database means. Women constituted 60% of participants, and men, 40%. Respondents’ mean age was 29.2 yr, and they had an average of 12.8 years of formal schooling. Twenty-seven percent were married, and 30% were parents. Thirtynine percent were students, 34% were working while 19% were not, and 8% were retired. Only 22% identified themselves as intelligent (21st percentile [%ile]), and, surprisingly, 11% and 20% identified themselves as stuttering and mentally ill, which placed them relative to the POSHA–S database at the 91st %ile and 99th %ile, respectively. Percentages (and percentiles relative to the POSHA–S database) of the Polish sample reporting knowing no people who stuttered or who were mentally ill were 35% (68th %ile) and 21% (40th %ile), respectively, but were above the 98th %iles for knowing no one who was intelligent, left handed, or obese. Health and abilities were all rated lower than average, with physical health, mental health, and ability to learn all rated in the lowest quartile (0–25th %iles). This adolescent and adult sample of Poles were also somewhat atypical of the samples analyzed previously in that they were in the 4th quartile (75–100th %ile) for wanting to be free and desiring exciting but potentially dangerous experiences but in the 1st quartile for wanting to attend social events, helping the less fortunate, doing their job or duty, and getting things done. Polish attitudes toward stuttering Table 2 lists the 60 POSHA–S standard ratings: items, components, subscores, and Overall Stuttering Score, along with database median and generated Polish percentiles as is Table 1. Figure 1 displays the Polish data graphically in the standard POSHA–S graph format comparing them to the highest, lowest, and median sample means observed to date (St. Louis, 2011). The solid tracing for the Polish data in Figure 1 are very close to the finely dotted median tracing, indicating generally average Polish attitudes. Nevertheless, the Polish means were lower or less positive than the database median values for the Who Should Help (Help) com-

707 ponent, but sometimes more positive for the Knowledge/Experience (Knowledge) and Knowledge Source (Source) components. The Polish Overall Stuttering Score of 18 (52nd %ile) is slightly above the median database score of 15. By quartile, more than three-fourths (78%) the Polish percentiles (Table 2, column 4) for the POSHA–S ratings were in the interquartile range, which is what would be expected if the Polish sample were generally about average. Eleven percent of the ratings were within the 1st quartile and 11% were within the 4th quartile. Beliefs about stuttering reflect impressions and thoughts about stuttering that do not involve the respondent personally. Poles were less likely than average to reject the belief that a person who stutters is “shy or fearful” (69th %ile) than to reject “nervous or excitable” (30th %ile). Nevertheless, the relatively low scores on the −100 to + 100 range for both items reflect the well-known “stuttering stereotype” (Woods & Williams, 1976). Beliefs that were less positive or less accurate than average included component ratings of who should help a person who stutters (22nd %ile), accepting that speech and language therapist should help (7th %ile), and rejecting that a medical doctor should help (7th %ile). By contrast, the Polish respondents held the more positive than average belief that other people who stutter should help a stuttering person (80th %ile). Regarding etiology, Poles failed to reject as much as average samples that stuttering is due to a very frightening event (13th %ile) or a virus or disease (11th %ile). Although the Poles thought a person who stutters can lead a normal life (70th %ile), they did not believe the person could do any job he or she wanted (8th %ile). Fewer respondents than average indicated that they would feel comfortable around a person stuttering (23rd %ile). Self-Reactions are items associated with respondents’ self-appraisals of their own behavior, reactions, or knowledge. Although the mean was about neutral (i.e., 3), Polish respondents indicated more commonly than average that they, themselves, should help a person who stutters (81st %ile). Although within the interquartile range, the respondents were less likely to reject filling in a stuttering person’s words than telling him or her to “slow down” or “relax.” They, like most samples, were more likely to reject making a joke about stuttering. Respondents rated their comfort level with a stuttering person lower than average. Otherwise, items related to the Social Distance/Sympathy component were close to or slightly above average. Although low in terms of the mean ratings, the Poles indicated higher sources of knowledge about stuttering than average (76th %ile), especially relative to stuttering persons known personally (83rd %ile). Poles’ sources of

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Table 1. Demographic characteristics: POSHA–S mean ratings of Polish respondents, median values from the POSHA-S database samples (98 samples circa January, 2013 reflecting first or only POSHA-S administrations for 6957 respondents), and percentiles of those means relative the POSHA-S database Demographic Variable

Polish Respondents

Database Median (50th Percentile)

Polish Sample Percentile

Number in sample Age: Mean (yr) Total schooling: Mean (yr) Sex: Males / females (% total) Student (% total) Working (% total) Unemployed or not working (% total) Retired (% total) Married (% of total) Parent (% of total) Polish as native language (% total) Self-Identification (% responding) Stuttering Mentally ill Obese Left handed Intelligent No Persons Known (% responding) Stuttering Mentally ill Obese Left handed Intelligent Self-Ratings for Health and Abilities (Mean: -100 to +100) Physical health Mental health Ability to learn Speaking ability Self-Ratings for Life Priorities (Mean: -100 to +100) Be Safe/Secure Be Free Spend Time Alone Attend Social Events Imagine New Things Help Less Fortunate Have Exciting by Potentially Dangerous Experiences Practice My Religion Earn Money Do Job/Duty Get Things Done Solve Big Problems Completion time: Mean (min)

268 29.2 yr 12.8 yr 40% / 60% 38% 34% 19% 8% 27% 30% 100%

55 34.9 yr 14.7 yr 35% / 65% 17% 61% 6% 3% 46% 53% —

97 34 18 68 / 32 60 18 78 81 27 34 —

11% 20% 14% 8% 22%

0% 1% 8% 7% 41%

91 99 75 60 21

35% 21% 35% 29% 26%

25% 23% 5% 3% 1%

68 40 98 99 99

32 43 50 61

47 58 62 62

13 6 19 40

80 65 34 16 33 55 -23 24 64 77 77 70 10.6 min

32 77 47 23 58 19 79 33 33 11 21 58 14

knowledge were higher than average from television, radio, and films as well as from the Internet, 79th %ile and 90th %ile, respectively. For the attributes of obesity and mental illness, the Polish sample had a higher than average overall impression of obese people (85th %ile), and although within the interquartile ranges, their desire to be obese or amount known about obesity were more positive than parallel ratings for mental illness. In the preliminary attempt to identify demographic factors related to stuttering attitudes, we sorted the Polish sample sorted according to the Overall Stuttering

74 69 32 7 37 40 -6 12 58 63 66 72 8.8 min

Score into the highest and lowest halves. Predictably, mean ratings for the “best” half versus the “worst” half were higher for all the stuttering attitude ratings. This pattern was also true for all the obesity and mental illness items. We ran t tests for independent samples between all pair-wise “best” versus “worst” means, with a Bonferroni corrected alpha level of (p ≤ .05/12 or .00417) to reduce the likelihood of Type I errors. This specific alpha level used in numerous previous sample comparisons and has provided a satisfactory balance between avoiding Type I errors with solid correction but also avoiding Type II errors with a too-strict correction (e.g., Flynn &

Polish stuttering attitudes

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Table 2. Attitudes: POSHA–S mean ratings of Polish respondents, median values from the POSHA-S database samples (98 samples circa January, 2013 reflecting first or only POSHA-S administrations for 6957 respondents), and percentiles of those means relative the POSHA-S database POSHA-S Variable OVERALL STUTTERING SCORE Beliefs About Persons Who Stutter Traits / Personality Have themselves to blamea Nervous or excitablea Shy or fearfula Stuttering Should Be Helped by . . . Speech and language therapist Other people who stutter Medical doctora Stuttering is Caused by . . . Genetic inheritance Learning or habitsa A very frightening eventa An act of Goda A virus or diseasea Ghosts, demons, spiritsa Potential Can make friends Can lead normal lives Can do any job they want Should have jobs requiring good judgment Self-Reactions to People Who Stutter Accommodating / Helping Try to act like the person was talking normally Person like me Fill in the person’s wordsa Tell the person to “slow down” or “relax”a Make joke about stutteringa Should try to hide their stutteringa Social Distance / Sympathy Feel comfortable or relaxed Feel pitya Feel impatient (not want to wait while the person stutters)a Concern about my doctora Concern about my neighbora Concern about my brother or sistera Concern about mea Impression of person who stutters Want to have stuttering Knowledge/Experience Amount known about stuttering Persons who stutter known Personal experience (me, my family, friends) Knowledge Source Television, radio, films Magazines, newspapers, books Internet School Doctors, nurses, other specialists Obesity/Mental Illness Subscore Overall Impression Obese Mentally ill Want to be Obese Mentally ill Amount Known about Obese Mentally ill a

Polish Respondents

Database Median (50th Percentile)

Polish Sample Percentile

18 31 25 81 17 −22 16 85 28 −65 29 22 33 −48 68 20 80 55 92 91 11 25 4 40 81 3 36 −20 78 62 9 −2 21 54 43 73 −11 −42 8 −66 −25 −12 −76 12 −8 21 −8 6 −19 −40 −32 −13 −9 −17 −81 −78 −84 −1 15 −17

16 34 18 82 7 −4 26 89 11 −15 34 15 18 3 63 53 89 61 93 84 51 40 −2 49 77 −21 51 28 88 69 4 18 22 58 29 67 −31 −50 1 −71 −38 −20 −85 −9 −23 −12 −13 −49 −24 −35 −32 −15 −23 −9 −83 −82 −85 2 11 −10

52 39 62 47 69 30 22 7 80 9 36 67 66 13 62 11 31 31 44 70 8 29 66 31 57 81 31 27 28 33 57 23 48 44 57 59 66 63 62 68 76 62 83 67 66 79 60 90 53 48 59 65 85 34 60 65 54 43 62 35

The signs of the mean ratings for this item are reversed so that higher scores reflect “better” attitudes and lower scores, “worse” attitudes.

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Figure 1. Summary POSHA-S graph for the Polish sample.

¨ St. Louis, 2011; Ip et al. 2012, Ozdemir et al. 2011a, 2011b; St. Louis 2012a, 2012c). Sixty-eight percent (41) of these comparisons statistically favored the “best” half, but in this preliminary predictor analysis those items that did not discriminate the “best” versus “worst” attitudes would be especially interesting. Differences were not significant for 32% (19) of the comparisons: impressions of obese persons, wanting to be obese or mentally ill (items and the combined component), and amount known about mental illness. Non-significant stuttering ratings included: help for stuttering by a medical doctor; genetic, learning, emotional trauma, act of God, and virus/disease etiology; leading a normal life (with stuttering); being suited for jobs requiring good judgement; telling a stuttering person to “relax” or “slow down; joking about stuttering; being concerned if a neighbour stuttered; number of stuttering persons known; and information about stuttering from television/radio/films or from the Internet. Unlike the attitude ratings, none the demographic variables were significant except that the “best” half indicated a significantly higher life priority for “getting things done.” The variables of age, education, income, sex ratio, self-ratings of physical or mental health, self-ratings of abilities to learn or speak, and 11 other life priorities did not differentiate the two halves. General section ratings for intelligence and left handedness do not influence POSHA–S summary scores. Some-

what surprisingly, however, ratings for amount known about these two attributes were significantly different (as was the amount known about obesity and stuttering which were included in the summary scores). Discussion This investigation constitutes an important contribution to the literature in that stuttering attitudes of a broad-based sample of the public from Poland are compared with other public samples around the world. The most important finding of the study was that the Eastern European sample of Polish respondents held attitudes toward stuttering similar to the average of previous convenience and probability samples around the world. Fully 78% of the POSHA–S items, components, subscores, and Overall Stuttering Score were within the interquartile range (25th %ile to 75th %ile) relative to samples of 98 first-time respondents (circa January, 2013) within the POSHA–S database. Average scores would be expected to fall within this range. By contrast, a few significant differences are worth highlighting among the 11% of ratings falling in either the 1st quartile and the 11% in the 4th quartiles. One previous report on Polish attitudes toward stuttering carried out in the period of transition from communism to capitalism wherein the process of globalization has started postulated that their attitudes

Polish stuttering attitudes were generally less positive than those observed in many other countries, for example the USA (Grzybowska et al. 1991). The items relating to sources of help for people who stutter were noteworthy. Below average ratings for the beliefs that either speech and language therapists and medical doctors should help people who stutter are consistent with the result of a Polish report on confidence in doctors and therapists, which reveals that one out of ten Poles do not trust their doctors or therapists (Report Polpharma, 2010). On the other hand, the fact that Poles were relatively more optimistic than average about people who stutter helping others with the same problem bodes well for the potential of self-help groups in Poland. Compared to other samples, the Polish respondents were more likely to accept genetic inheritance as a cause of stuttering and to reject learning or habits and an act of God. They were somewhat to substantially less likely than average to reject emotional trauma, viruses or disease, and ghosts, demons, or spirits. A possible disconnect was observed between the belief that those who stutter can lead normal lives but uncertainty about whether or not they can do any job they want or do a job requiring good judgment. This finding may be related to the fact that rising unemployment characterized the Polish work market at the time of this writing (Report MPiPS, 2013). Comparing the Poles to other samples around the world, we noted a few slight differences in Self-Reactions to people who stutter. The Poles were less likely to reject the option to “Tell the person to slow down or relax” than average. They were more likely to indicate that they should help a stuttering person, much more so than average. Other differences occurred in Social Distance and Sympathy components. For example, the Poles were more likely than average to indicate ‘no’ in response to the question of whether they would feel comfortable and relaxed when talking to a stuttering person. They were about average in other responses related to social distance, i.e., concern about examples of other people who stutter (doctor, neighbour, siblings, and themselves). In the area of knowledge and experience, they assessed their knowledge about stuttering and their personal experience higher than other samples did. They also reported television, radio, films, the Internet, and school more highly as sources of their stuttering knowledge. As noted, it is premature to calculate the predictive value of various descriptors and self-ratings in the demographic section shown in Table 1 on stuttering attitudes. Such predictions will require that the POSHA–S database grow considerably, especially among mainstream populations around the world, so that regression

711 analysis can be performed on these and other items to determine which items, or which combination of items, if any, are predictive of more positive or negative attitudes toward stuttering. Nevertheless, comparing the “best” versus the “worst” halves of the Polish data according to their Overall Stuttering Scores revealed some interesting results. First, mental illness and obesity attitudes were more positive, and some significantly so, when the data were sorted according to stuttering attitudes alone. Apparently, there is some “carry over” of positive attitudes toward stuttering to positive attitudes toward other stigmatizing attributes. This is consistent with a preliminary study by St. Louis and Rogers (2011a) who analyzed the POSHA–S database, then containing 3750 respondents. However, the failure of such socio-economic variables as education and income to predict the “best” versus “worst” attitudes was not consistent with a companion preliminary study of the 3750 respondents (St. Louis & Rogers, 2011b). In fact, none of expected demographic variables made a significant difference in the preliminary analyses reported in this study (Table 1). We cannot explain why only respondents’ priority for “getting things done” and knowledge of left handedness and intelligence did discriminate between the two halves. To be able to offer some meaningful interpretation of that finding would require many more “normal” samples of respondents around the world, not just those that are at the positive and negative extremes. Looking at differences for the total Polish sample (Table 1) for life priorities indicates that Poles rated themselves quite positively on desire for freedom (77th %ile) and for exciting but potentially “dangerous” experiences (79th %ile). We speculate that this may be partly related to their age, since the majority of respondents were young adults. At that age, excitement and freedom may be important (Erikson, 1968). We speculate further that it might also be related to the history of Poland, a country that was under occupation and deprived of independence for a long time. This situation may have affected Polish citizens’ way of thinking. In communism, people with different disabilities were frequently pushed to the margin of society, so that in those years, disabled people were not commonly seen in the streets of Poland, and people who stutter were frequently absent from social life. In a study by Cieciuch and Zaleski (2009) using the Schwartz Portrait Value Questionnaire, freedom and the sense of security were found to be important for Poles as they attempt to compensate for the lack of these in their recent history. This being said, the POSHA–S database is still expanding as new samples are added so that the percentiles may still change. Additionally, we emphasize that this study examined a convenience sample that may not be representative of the Polish population.

712 As noted, the results provide evidence that the attitudes of Poles are generally similar to those of other adult samples of the public around the world. Nevertheless, it is important to bear in mind that many ratings were still negative, and much more negative than the most positive attitudes obtained so far from leaders in the self-help movement for stuttering or from speech and language therapists who were specialists in fluency disorders, who have been advanced as generating a “gold standard” target (St. Louis & George, 2008). Accordingly, the social problems, stigma, and ostracism reviewed in the introduction can also be similarly attributed to people who stutter in Poland, confirming results of other Polish studies (e.g. Grzybowska et al. 1991; Kulas, 1990). The low ratings for people who stutter being nervous, excitable, shy, or fearful are widely regarded symptoms of the “stuttering stereotype” (Blood & Blood, 2007; Woods & Williams, 1976). The social concern about other people who stutter, such as neighbours, reported by some Polish respondents suggests that even something as innocuous as a stuttering neighbour creates a threat. If Tarkowski (2008) is correct, it is possible that those who are concerned about a neighbour who stutters are more likely those who view stuttering as a symptom of neurosis. More obvious and in accordance with Blachnio’ (in press) findings, the Polish respondents reported feeling uncomfortable while talking with a person who stutters. In similar vein to aforementioned research (e.g. Gabel et al. 2004; Klein & Hood, 2004), the failure of Polish respondents to agree that people who stutter can do any job they want suggests that vocational role entrapment does occur in Poland and could easily deprive them of job opportunities and/or hinder desired promotions. We were somewhat surprised at the high levels of self-identification of stuttering and mental illness obtained in the Polish sample. During the translation process, no misinterpretation of the experts in the term for the disorder of stuttering occurred. “Jakanie” does ˛ not mean “normal disfluency.” Even so, 11% of the respondents self-identified themselves as stuttering. High self-identification of stuttering could be influenced by several factors. For example, in colloquial Polish, there is an expression meaning “do not stutter,” used in order to reprimand a person for speaking unclearly and incoherently, regardless of whether they really stuttered or not. This is similar to the English use of the term in some colloquial use. It is possible that, by identifying themselves as people who stutter, respondents meant that they sometimes happen to stutter, e.g., during stressful situations, in which case “stuttering” occurs as an incident but is not a fluency disorder. On the other hand and although we cannot be certain, it is possible that the percentages reflect an unusually high prevalence of stuttering in the sample studied. The Polish sample percentage self-identifying themselves as

Aneta M. Przepiorka et al. intelligent was surprisingly low (21st %ile), and we cannot imagine that respondents misunderstood that term especially since they were at the 58th %ile for their rating of the amount known about intelligence. Eight percent identified themselves as left handed, which is about average (60th %ile). Fourteen percent indicated that they were obese (75th %ile), which is consistent with a recent report of obesity in Poland (Milewicz, J˛edrzejuk, Lwow, Białynicka, Łopatynski, Mardarowicz, & Zahorska-Markiewicz, 2005). Twenty percent of Polish respondents identified themselves as mentally ill, which may well stem from a misunderstanding of the term. Affective disorders such as depression or even personal crises might be interpreted by the respondents to fall under the term “mental illness,” which might be consistent with their 7th %ile self-identification mean rating for mental health. We believe the misinterpretation explanation, though tentative, to be a more plausible explanation of the high prevalence of stuttering and mental illness, although only further research, especially mixed method research, could more satisfactorily answer the question. The obtained results validate the Polish translation of POSHA–S and indicate that the instrument measures attitudes in Polish very similarly to the way it does in other languages. This is consistent with studies using translations into many other languages such as French, Simplified Chinese, and Turkish (Ip et al. 2012; ¨ Ozdemir et al. 2011a; St. Louis & Roberts, 2010). Finally, the data have clinical implications for Polish speech and language therapists as well. The mean ratings have potential usefulness in targeting areas wherein people who stutter may be stigmatized and where the danger of stereotyping is the highest. Also, since stuttering therapy often involves family and friends, educating them about negative public attitudes could be helpful in modifying clients’ environments. Hopefully, such efforts would result in more positive views and kinder treatment of stutterers based on information consistent with the true nature of this disorder rather than on misguided knowledge, beliefs, and reactions. Future Research Clearly, there is much to be done and changed in order to build a society more friendly to people who stutter. These results are a first step in making Polish society more familiar with stuttering itself. A logical next step would be to compare the attitudes of people on the street with those who are or will be charged with treating people who stutter, such as speech and language therapists or psychologists or students training to do so. Additionally, future studies should be focused on changing the perception of the public toward people who stutter

Polish stuttering attitudes through direct contact with stutterers and information about stuttering.

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