The Level of Quality of Life among Individuals who Stutter in Jordan and Its Relationship with Some Demographic Variables

The current study aimed to identify the level of quality of life among Individuals who Stutter in Jordan and its relationship to some demographic variables using the correlative descriptive approach. In order to achieve the objectives of the study, the researchers used the quality of life scale-BRIEF-WHOQQL, prepared by the World Health Organization (WHO), on a sample (N=32) males and females Stutters.The results of the study showed that the level of quality of life among individual who stutters in Jordan was low, as the physical health field ranked first with the lowest level in the quality of life followed by the field of social relations and then the mental health and finally the field of environment. They also showed that there were no statistically significant differences in the level of quality of life among Individuals who Stutter in Jordan attributed to the variables of age, gender, marital status, family income and the degree of stuttering severity. The study concluded with a set of research and educational recommendations.


Quality of life for individuals who shutter
Although several previous studies addressed the concept of the quality of life in general concerning several disorders and diseases, many of them ignored stuttering disorder, despite the fact that stuttering disorder is a communicative and social problem that has negative impacts not only on the emotional and psychological health but also on the lives of individual who Stutter.
One of the studies that addressed the importance of the quality of life and its dimensions among Individuals who Stutter is the study of Kasbi et.al. (2015) who divided the dimensions of the quality of life for stuttering adults into five dimensions, the most important of which are: Public health, emotional health, physical needs, social needs, vital emotional determinants, and pain, and they confirmed that one of the most important roles of a speech and language pathologist is an attempt to improve the quality of life of Individuals who Stutter by reducing functional and organic defects and determinants of communication and daily activities. Maree et.al. (2011) discussed the importance of guidance in improving the value of life design for adult Individuals who Stutter. The study adopted the quality of life approach for adult Individuals who Stutter as a case study. Various pre-strategies were used to engage with adults in discussions about the quality of life and the future they aspire for. After training, the study showed that the adult Individuals who Stutter are more able to make their own desired work decisions, especially with empowerment and personal agency.
Moreover, a group of researchers found that the impacts of the quality of life for adult Individuals who Stutter were often negative. Klompas and Ross (2004) studied the quality of life for adult Individuals who Stutter and found negative impacts of stuttering on emotions, self-esteem, self-image, and professional performance. The study of Kasbi et.al. (2015) addressed the impacts of stuttering on the quality of life of adult Individuals who Stutter. The results of the study showed that stuttering has negative impacts on the various dimensions of the quality of life scale among adult Individuals who Stutter. The study found statistically significant differences among groups concerning the quality of life scale in public and emotional health, physical and social functions resulted from emotional and physical problems. It is also found that there were no significant differences in the dimension of pain among the two groups. The results of the study of Craig (2009) related to the quality of the life of adult Individuals who Stutter and ordinary people showed that stuttering has negative impacts on emotional and social activities, psychological health, the more stuttering is frequent, the worse the emotional aspects are.
By reviewing the quality of the life of Individuals who Stutter and its relationship with some variables, Andrade et.al. (2014) found that simple and severe stuttering had negative impacts on the quality of life, whereas the study of Koedoot et.al. (2011) showed that medium and severe stuttering had negative impacts on all aspects of it. Similarly, Bramlett et. al. (2006) confirmed that stuttering has negative impacts on the quality of life, especially the intensity of stuttering. Moreover, Yaruss et. al. (2010) conducted a comprehensive evaluation for the experiences of speakers with stuttering before and after treatment taking into account that stuttering had negative impacts on the quality of life and showed that the quality of life increased after treatment. Concerning Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.11, No.26, 2020 83 other variables, Mohammadi et. al. (2011) studied the quality of life among 59 Kurdish speakers and compared them to normal cases, who has no stuttering, in relation to the variables of gender, education, work, and social status using the World Health Organization Quality of Life scale-(BREF). They concluded that Individuals who Stutter' scores were less than their people who don't stutter according to the aspects of mental and physical health as well as social interactions, and that there was a negative correlation between the severity of stuttering and the dimensions of health, physical and mental environment. Mansuri et. al. (2013) studied the quality of life in Tehran. The study sample consisted of (25) adult Individuals who Stutter and compared them to 25 people who don't stutter according to the variables of gender, age, and level of education using the World Health Organization Quality of Life scale (BREF). The results of the study indicated that there are significant differences on the overall measure of the quality of life and on the degrees of environmental, mental and physical aspects between adult Individuals who Stutter and non-Individuals who Stutter, while there are no differences attributed to the variable of social relations.
The study of Boyle (2015) aimed to investigate the relationship of social support, empowerment, and the quality of life self-help groups comprised of 240 Individuals who Stutter through a web-based survey. It was noted that increasing the level of self-esteem and the family social support are related to improving the quality of life of adult Individuals who Stutter regardless of the severity of stuttering. It was also found that consideration must be given to exercises that increase the feelings of self-esteem and strengthen the family social support for adult Individuals who Stutter in order to overcome stuttering and improve their quality of life. Nang, et. al. (2018) studied the effect of stuttering on the development of autonomy, relationships, and the quality of life among women Individuals who Stutter. Given the fact that there are few studies on this subject especially that the prevalence of stuttering in males is higher than females. Study found that stuttering has extended impacts on all aspects of a woman's life as it greatly affects how she sees herself, her relationships, her profession capabilities and how others see her in society. As to the women who were interviewed, they showed a negative self-concept, and they felt that the level of their quality of life was affected by stuttering, and they considered that fluency was an essential factor in the development of personality and relationships. Therefore, the study recommended that speech and language specialists should take into consideration treatment plans and their impacts on the aspects of self-enhancement and the quality of life while training female Individuals who Stutter.
The study of Lucey et. al. (2019) aimed to find out whether there is a relationship between the temperament of adult Individuals who Stutter and the frequency of stuttering and its impact on the quality of life. The study found that the temperament of adult Individuals who Stutter is negative compared to ordinary individuals, and that adult Individuals who Stutter have frustration associated with a lack of knowledge of information about stuttering. It also found that there was no relationship between the feature of the temperament and the stuttering frequency and the quality of life.
Therefore, it is noteworthy that there are previous studies that addressed the impact of the quality of life and its correlation with some variables on Individuals who Stutter. Hence, the significance of the current study stems from the fact that it is the first study of its kind in the region -in researchers knowledge limits-since it comprises of Jordanian Individuals who Stutter and addresses the different dimensions that determine the level of the quality of life-physical health, psychological health, social relations, and the environment-according to a number of the most commonly important demographic variables such as age, gender, marital status, family income, and the degree of stuttering severity.

Study problem
Stuttering is one of the most common fluency disorders, and mainly affects the quality of life compared to other communication disorders as a Individuals who Stutter develops negative feelings, the inability to communicate smoothly and easily like others, thus, causing psychological pressure, tension, anxiety, and fear of any verbal situations. The quality of life problems is thus reflected on the psychological health, satisfaction, happiness, low self-esteem, the psychological development of an individual's personality, the feeling of deficiency, and the tendency to avoid others and move away from verbal situations that cause embarrassment. These feelings and frustrations could lead to slow or unsuccessful treatment and training that Individuals who Stutter undergo and, therefore, it is necessary to identify the most important factors that contribute to developing the positive energies of Individuals who Stutter enhance their attitude of themselves, and face verbal situations and life effectively.
In this regards, researchers, who investigate the stuttering disorder especially in Jordanian culture which considers -as many cultures-stuttering as a shame and deficiency sign for a person noticed that most of the programs designed to train individual Individuals who Stutter focus heavily on strategies for developing fluency, and overlook a large part of the focus on the psychological effects of stuttering, such as the effect of the quality of life on Individuals who Stutter. Therefore, there was an urgent need to conduct a study that addresses the concept the quality of life and its impacts on Individuals who Stutter to help them solve their verbal problems within various aspects.
Likewise, through the researchers' study of the literature review, they also noticed a clear and significant deficiency of studies in both the Jordanian and Arabic library databases related to the level of quality of life, especially among Individuals who Stutter. Therefore, this study attempted to provide a theoretical and reference framework for subsequent studies and for the speech and language specialists and others who deal with stuttering disorder to help them identify the most important factors that must be centre of concentration during training and preparing programs to improve the quality of life for Individuals who Stutter as one of the important drivers of success to overcome daily and psychological stuttering disorder problems. Hence, the study problem posed the following questions:

Individuals who Stutter
They are individuals who suffer from stuttering disorder in the intermediate and advanced age stages and who were enrolled in hearing and speech centres and clinics in Amman.

Study limitations
The generalization of the results of the study is determined according to the following:  Time limitations: The study was conducted between September and March 2020.  Spatial limitations: The study was applied in speech and hearing clinics in the capital city of Amman.  Objective limitations: The generalization of the study results is determined according to the study scales used and within the criteria of its validity, reliability and study sample.

Study population and sample
The study population consisted of all clients of hearing and speech clinics in the capital city of Amman. There are (4) clinics that include (52) male and female clients diagnosed as having only stuttering by self-reports. After excluding the piloting sample of the survey, which consisted of (20) male and female clients., the final study sample consisted of (32) clients. The researchers distributed the study tool to them by hand and was recollected.
The results of the study were statistically analyzed, and Table No. (1) shows the distribution of the study sample according to the personal variables:

Study tool
To achieve the aims of the study, the Quality of Life Scale was used as follows: The researchers referred to several quality of life scales, the most important of which is the Brief Quality of Life Scale -BRIEF-WHOQQL-(prepared by the World Health Organization (WHO), 2013). The survey consists of Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.11, No.26, 2020 (100) items distributed on six domains, namely, physical health, psychological health, social relations, the environment, the level of autonomy, and the spiritual health, which was later abbreviated to (Brief-WOQOL) and consists of (26) items within four domains: physical health, psychological health, social relations, and the environment. This scale is used with ordinary, sick, and people with disorders (Skevington, S., Lotfy & O 'Connell, K., 2004). The researchers also took advantage of a number of psychometric tools used to measure stuttering disorder, stuttering attitudes and their reactions to stuttering and the quality of life, including (Franic & Bothe, 2008;Bramlett et.al., 2006;Abu Asaad, 2009;Al-Bdour, 2013;Tashtoush & Al-Qashaar, 2017), to make adjustments in line with stuttering disorder on the (Quality of life scale-Brief scale-WHO, (BRIEF-WHOQQL)). The study tool was then finalized into (26) items distributed on four domains: physical health represented by items (1-7), the psychological health (8-15), the social relations (16)(17)(18)(19)(20), and the environment domain (21-26). Likert five-level scale (Very few, few, medium, large, and very large), where (1) is the assigned to very few and (5) to very large; reflected in the case of the following negative items (1), (13), (14), (19) and (20), where the highest score obtained by the respondent is (130) and the lowest is (26). Consequently, and for the purpose of this study, means were used to judge the level of quality of life for the respondents according to the following equation: the highest weight -the lowest weight divided by the number of categories, 5-1 = 4, 4/3 = 1.33 (5 − 1 ÷ 3 = 1.33) , and accordingly, the total score is less than 2.33 and this indicates a low level of quality of life, and a score between 2.33-less than 3.67 indicates an average level of quality, 3.67 and above indicates a high level quality of life. > 2.33 = 2.33−≥ 3.67 = 3.67 = ℎ ℎ 3.3 Validity and reliability of the study tool 3.3.1 The validity and reliability of the study tool was verified by the following methods  Apparent validity (Reviewers): The validity of the study tool was verified by (8) professors, at Al-Hussein Bin Talal University and the University of Jordan specialized in the fields of measurement and evaluation; psychology; and speech and language disorders, to express their opinion on the accuracy and validity of the scale content, clarity of items, study tool language, and the extent to which items are related to the domains and the scale. The reviewers made a number of observations that were taken into consideration, and (80%) of the agreement between the reviewers was adopted.
 The validity of internal consistency: The validity of the internal consistency of the study tool was verified by calculating the correlation coefficient between the domain and the total score and between the item and the domain to which it belongs and the total score, where the scale was applied to a pilot sample consisted of (20) males/ females samples of the study population and other sample. Table No. (2) shows the results: Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.11, No.26, 2020  The results of Table (2) show that the correlation coefficients between the domain and the overall score ranged from (0.929-0.937). The item's correlation coefficients with the domain ranged (0.554-0.895), and the correlation coefficients of the item with the total score ranged between (0.461-0.857). This indicates that all correlation coefficients are statistically significant and thus the validity of the internal consistency of the study tool.

Tool reliability
The reliability of the study tool was verified using the internal consistency coefficients using the Cronbach's Alpha equation, and Table (3) illustrates the internal consistency factors of domains and the scale.

Study methodology
The descriptive correlational approach was used to describe the reality of the level of the quality of life among Individuals who Stutter with disorder and to explain the nature of its relationship with some demographic variables related to the members of the study sample.

Study variables 3.5.1 Independent variables
 Age: It has two categories (intermediate stage (7-13 years) and advanced stage (14 years or more).  Gender: It has 2 categories (male and female).  Stuttering severity: It has 4 levels (mild, moderate, severe, and very severe/ profound).  Marital Status: It has 3 categories (single, married, separated)  Family income: It has 3 categories (less than 500 JDs) (500-less than 1,000 JDs), (1,000 JDs and more) 3.5.2 Dependent variables: the level of the quality of life 3.6 Statistical analysis: To achieve the aims of the study and to answer its questions, the following were used:  1. Pearson coefficients to verify the validity of the scale.  2. Cronbach Alpha coefficient to verify the scale reliability.  3. Means and standard deviations to answer the first and second study questions.  4. One-way ANOVA to verify whether the apparent differences were significant.

Study results
The results of the first study question "What is the level of quality of life for Individuals who Stutter in Jordan according to physical health, psychological health, social relationships and environment dimensions?
To answer this question, the means, standard deviations, rank, level of domains, and total score were calculated as shown in Table ( (4) shows that the overall mean of the level of the quality of life of Individuals who Stutter in Jordan is (2.04) with a standard deviation of (0.431), and this indicates a low degree of appreciation, and that the level of the quality of Individuals who Stutter' life is low and the domain of physical health ranked first with a mean of (2.23) and a standard deviation of (0.537), followed by the social relations with a mean of (2.06) and a standard deviation of (0.591), and in the third place the mental health with a mean of (1.95) and a standard deviation of (0.481), followed by the environmental domain with a mean of (1.92) and a standard deviation of (0.549).
For more declaration for the Means, standard deviations, rank, and level of the quality of life items among Individuals who Stutter in Jordan in the previous four domains, table (5) show the Means and standard deviations of physical health items. The data of table (5) show that the overall mean of the physical health domain is (2.23) with a standard deviation of (0.537), and this indicates a low degree of appreciation, and that the physical health of Individuals Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.11, No.26, 2020 who Stutter is low. Item (7) ranked first with a mean of (3.34) and a standard deviation of (1.035), followed by item (1) with a mean of (2.88) and a standard deviation of (1.211), then item (2) with a mean of (2.06) and a standard deviation of (0.878), and in the last place is item (3) with a mean of mean of (1.69) and a standard deviation of (0.896). The data of table (6) show that the overall mean of psychological health among Individuals who Stutter is (1.95) with a standard deviation of (0.481). This indicates that there is a low degree of appreciation, and that the physical health level of Individuals who Stutter is low, where item (13) ranked first with a mean of (2.59) and a standard deviation of (1.241), followed in the second place by item (14), with a mean of (2.53) and a standard deviation of (0.950), and in third place, item (11) with a mean of (1.87) and a standard deviation of (0.793), whereas item (9) ranked last with a mean of (1.66) and a standard deviation of (0.553). Table 7. Means and standard deviations of the social relations domain as one of the domains of the quality of life among Individuals who Stutter in Jordan The data of table (7) show that the overall mean of social relations among Individuals who Stutter is (2.06) with a standard deviation of (0.591), and this indicates a low degree of appreciation, and that the level of social relations is a low, where item (19) ranked first with a mean of (2.34) and a standard deviation of (1.096), followed by item (20) with a mean of (2.31) and a standard deviation of (1.256), and in third place item (18) with a mean of (2.16) and a standard deviation of (0.677), followed by items (16) and (17) with a mean of (1.75) for each of them and a standard deviation of (0.672) and (0.567) respectively.  (8) show that the overall mean of environment among Individuals who Stutter is (1.92) with a standard deviation of (0.549), and this indicates a low degree of appreciation, and that the level of environment is a low, where item (22) ranked first with a mean of (2.19) and a standard deviation of (0.931), followed by item (24) with a mean of (2.13) and a standard deviation of (0.871), and in third place item (25) with a mean of (2.09)  Vol.11, No.26, 2020 89 and a standard deviation of (0.893), followed by item (26) with a mean of (1.75) for each of them and a standard deviation of (1.56) and standard deviation of (0.669).

No. Domain
The results of the second study question "Are there statistically significant differences at the level of significance (α≤0.05) in the quality of life of Individuals who Stutter attributed to: age, gender, degree of stuttering severity, marital status, and family income?" To answer this question, One-Way ANOVA analysis of variance was used, and the following tables show the results: Table 9. Means and standard deviations for the variables of age, gender, marital status, family income and degree of stuttering severity on a level of the quality of life.  (9) show that there are apparent differences between the means of the study population concerning the level of the quality of life according to the age, gender, marital status, family income, and the degree of stuttering severity variables. In order to verify whether the differences were significant, One-Way ANOVA analysis of variance used as table (10) show the results: The results of table (10) show that there are no statistically significant differences in the level of the quality of life among Individuals who Stutter in Jordan according to age, gender, marital status, family income and the degree of stuttering severity depending on the calculated (F) values at the level of probability accompanying it, and that they are not statistically significant at the level (α≤0.05).

Discussion
The results of the study indicated that the level of the quality of life among Individuals who Stutter in Jordan was low and the researchers attributed this decrease to the negative impacts that result from stuttering disorders and that they reduce the extent of human satisfaction with one's self in various aspects. Moreover, the physical health domain ranked the first lowest level of the quality of the life of Individuals who Stutter, and specifically for the item that includes the need for more training sessions to treat the problem. Many Individuals who Stutter develop physical behaviors that are not nature or involuntary, such as eye blinking, head, jaw, or body nodding as a reaction to hide the main behaviors of stuttering-repetition, blocks and prolongation-and, therefore, most of their problems were the need for training sessions to get rid of these behaviors and physical features. The second lowest domain was the social relations specifically for the item of a feeling of contempt for those who mocked Individuals who Stutter when speaking, and the researchers attributed this to the fact that human communication is a social need in the first place and among its main components is fluency and, thus, the disfluency or its problems greatly affect the extent of the interaction between an individual and his/her surroundings. Moreover, the repeated failures to communicate with others generate feelings of distance, isolation, and a tendency to avoid mockery of others. The third lowest domain was the psychological health, specifically for the item that shows Individuals who Stutter develop negative feelings such as anxiety and depression when speaking. This is due to the role of the general psychological side in the life of Individuals who Stutter , his/her lack of acceptance of the problem of stuttering, the weak satisfaction with his/her verbal behavior, the negative feelings, anxiety, and depression that the Individuals who Stutter develops while speaking.
The last lowest domain was the environment, specifically the item related to the material aspect of not having enough money to meet the needs of the Individuals who Stutter. The researchers attributed the low quality of life in the environment domain because the environment surrounding Individuals who Stutter does not support and accept the difference in speech between Individuals who Stutter and ordinary individuals, especially with the emergence of material problems including the need for training and guidance sessions, and psychological and social support in order to adapt to the surrounding environment and get rid of the problem. The results of the current study concorded with the study of Kasbi (2015), Craig (2009), Klompass (2004, and Merre (2011) who found that stuttering negatively affects the quality of life, especially in the emotional and social aspects.
The results of the study also showed that there are no statistically significant differences in the level of the quality of life according to a number of variables, the first of which is the age variable, where the quality of life level for each of the intermediate stage (13-6 years) and the advanced (14 years and older) appeared low, and the researchers attributed this to the fact that Individuals who Stutter develop more negative feelings and attitudes towards themselves as they get older and affect their satisfaction with their lives, and develop avoidance behaviors to reduce their stuttering occurrences and make them overcome such stuttering. Nevertheless, they develop great psychological pressures that affect the quality of life. These results differed with those of the study of Mansurre (2013) which found differences on the mental and physical dimensions of Individuals who Stutter according to the age variable.
The results also indicated that there are no statistically significant differences in the level of the quality of life according to the gender variable. They also indicated that the level of the quality of life for both males and females was low. The researchers attributed that despite the fact that many studies have confirmed that the occurrences of stuttering disorder among males have a higher rate than females, both males and females have problems in education, training, care and openness to the surrounding community, and suffer from a lack of opportunities for social and language interaction as a result of verbal disorder. Moreover, the results of the study concorded with Nang's (2018) study which focused on that stuttering affects all aspects of women's life.
Furthermore, the results of the current study indicated that there are no statistically significant differences in the level of the quality of life according to the variable of the marital status, as both the single and married have problems and a decrease in the quality of life. The single individual suffers from problems of emotional stability and the obsession of forming a family, as well as the married person suffers from problems, connections, needs, pressures, and some restrictions imposed by the nature of marriage including many social and financial relationships. The results concorded with Boyle's (2015) and Mohandi's (2011) studies, which emphasized the importance of the role of the family and self and social support groups in improving the quality of life.
In addition to this, the results showed that there are no statistically significant differences according to the family income or economic situation in the level of the quality of life of Individuals who Stutter regardless of their low, medium, or high incomes. All of them suffer from financial and economic problems that negatively affect the life of the individual, create a sense of the lack of satisfaction and stability and the difficulty of taking training and rehabilitation sessions, which are often costly. Therefore, Individuals who Stutter have less chance of improvement and recovery from disorders, thus, leading to a lower level of quality of life, particularly in the environmental domain. The results of the current study concorded with those of Yaruss' (2011) which emphasized the improvement in the quality of life after treatment and training.
Finally, concerning the degree of stuttering severity variable, the results showed that there are no statistically significant differences in the low level of the quality of life (mild, moderate, severe, and very severe/profound degrees). The researchers attributed this to the problems and symptoms experienced by Individuals who Stutter including fear, anxiety, and avoidance of verbal situations. However, this degree of severity varies and develops and consequently the quality of life is affected and decreased regardless of the degree of stuttering severity. Moreover, the results of the study differed from those of Kodot's study which emphasized that the moderate stuttering degree highly affects the quality of life, and concorded with the studies of Braraellet (2006), Andrade (2008), and Mohamdi, et.al. (2011) who confirmed that the more severe stuttering, the more the level of the quality of life of Individuals who Stutter is affected negatively.

Conclusion and recommendations
The study examined an important psychological aspect, which is the concept of the quality of life in its various dimensions, and its impact on the most common fluency disorders, stuttering disorder, and its relationship to some important demographic variables such as age, gender, marital status, family income, degree of stuttering severity. The concept of the quality of life is a contemporary concept addressed by several recent studies and tackles with the extent of the individual's satisfaction with his/her life in several aspects. It was found that the World Health Organization (WHO) focused on this concept and developed measures for a number of diseases and disorders to shed light on this aspect that greatly affects the concept of self-esteem and psychological well-being for individuals, as those with stuttering disorder, and contributes significantly to increasing the extent of improvement in treatment and training.
The results of the study showed that the level of the quality of life of Individuals who Stutter in Jordan was not satisfactory but rather low, especially the domain related to the lower physical dimensions. Stuttering disorder, according to the researchers, is a problem in the quality of life in the first place, and negatively and significantly affects several areas and aspects of Individuals who Stutter, such as social relations, psychological health, and the environment.
The quality of life of Individuals who Stutter did not differ statistically according to several variables, consequently, the level of the quality of life was low regardless of ag (advanced, intermediate) or gender (male, female) or marital status (single, married and separated) or economic income (high, medium and low) or stuttering severity ( mild, moderate, severe, and very severe/ profound).
Accordingly, the researchers recommend a set of recommendations that would enhance the level of the quality of life of Individuals who Stutter, the most important of which are:  Creating self-support, and community and family support groups of Individuals who Stutter.  The training programs should include strategies to enhance the dimensions of the physical, psychological, and social concept, and environment.  Preparing a guidebook in cooperation with the World Health Organization that includes the most important dimensions of the concept of the quality of life speech and language pathologist need to assess and train of Individuals who Stutter.  Conducting further studies and research related to the psychometric measures of the quality of life of Individuals who Stutter.  Promoting positive attitudes and developing the quality of life concept programs of Individuals who Stutter.