Attitudes of Pakistani Community Members and StaffToward People with Intellectual Disability

Mazna Patka, Christopher B. Keys, David B. Henry, and Katherine E. McDonald

Abstract

The acceptance and inclusion of persons with intellectual disability can vary across cultures,and understanding attitudes can provide insight into such variation. To our knowledge, noprevious study has explored attitudes toward people with intellectual disability amongPakistani community members and disability service providers. We administered theCommunity Living Attitudes Scale (Henry et al., 1996), a measure of attitudes towardpeople with intellectual disability developed in the United States, to 262 communitymembers and 190 disability service providers in Pakistan. Confirmatory factor analysisfound a 4-factor solution (empowerment, similarity, exclusion, and sheltering) fit thePakistani sample. More positive attitudes were observed in staff serving people withintellectual disability, females, Christians, Hindus, Sunnis, and people with greatereducation. We discuss implications for research, theory, and practice.

Key Words: intellectual disability; Pakistan; attitudes

The evaluations, attitudes, and/or beliefs (Fazio,2007; Yuker, 1988) held by those who share acommon culture affect the lives of people withintellectual disability (Gaad, 2004). Understandingattitudes in a particular cultural context can assist intransforming the value and position of marginal-ized groups (Vilchinsky & Findler, 2004). Negativeattitudes may foster exclusion of people withintellectual disability from community life andaffect access to educational, residential, and em-ployment opportunities. Positive dimensions ofattitudes are a foundation for social inclusion. Notonly are attitudes of community members impor-tant but also the attitudes of those who serve andsupport people with intellectual disability becausethey can directly affect the quality and natureof services (Henry, Keys, Jopp, & Balcazar, 1996).This study—the first of its kind to the authors’knowledge—examines attitudes of communitymembers and disability service providers (referredto as ‘‘staff’’ hereinafter) in Pakistan. Thus, it seeksto offer perspective and advance the understandingof attitudes in a new, diverse cultural milieu.

Intellectual Disability Within

Pakistani Culture

A good standard of living for the population atlarge may be a prerequisite for improving theposition of people with disabilities (Parmenter,2001). In Pakistan, a South Asian country thatwas created and gained independence in 1947,high poverty contributes to significant numbers ofpeople with intellectual disability; approximately28% of Pakistani children with severe malnutri-tion develop intellectual disability within a yearof birth (Yaqoob et al., 2004). Pakistan has takenlegal measures to protect the rights of people withdisabilities. The Disabled Persons Ordinance,enacted in 1981, promotes the employment,rehabilitation, and welfare of people with dis-abilities (Masood, Turner, & Baxter, 2007). TheNational Institute of Special Education, formed in1986, established 46 special education centers(Masood et al., 2007). However, there is a shortageof special education teachers, an absence of clearqualifications for special education teachers, and a

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

32 Pakistani community and staff

lack of support for people with disabilities of anykind attending college (Khatoon, 2003). Of allpeople with disabilities, individuals with intellec-tual disability may be the least understood inregard to the nature of their disabilities and theirneeds (Miles, 1998). There is very little empiri-cal research on intellectual disability in Pakistan(Miles, 2001). Pakistanis have limited access toliterature, which is produced mostly in Westerncountries (Berkson, 2004; Fujiura, Park, & Rut-kowski-Kmitta, 2005; Miles, 2001). Rehabilitationprofessionals are virtually nonexistent in Pakistan,other than a minimal presence of physicaltherapists (World Health Organization, 2011).

Worldwide, 70% to 80% of individuals withdisabilities live in developing countries such asPakistan (United Nations Enable, n.d.). Accordingto the most recent Pakistani census (1998), 2.49%of the population is reported to have a disability.Among people with disabilities, 8.15% of thepopulation in urban areas and 7.32% of thepopulation in rural areas have intellectual disabil-ity (Pakistan Census Organization, 1998). How-ever, statistics on the prevalence of intellectualdisability are questionable because the PakistanCensus Organization does not provide a defini-tion of intellectual disability or the questionsused to assess its presence. According to Durkin,Hasan, and Hasan (1998), the prevalence ofintellectual disability in Karachi, Pakistan, inchildren between the ages of 2 and 9 years old,based on screening with 10 questions (Durkin,Hasan & Hasan, 1995), is 19.0 per 1000 children.This 1.9% rate is near the upper limit of reports ofprevalence in developing countries, which typi-cally range between 5.3 per 1,000 for all people(e.g., India) to 20 per 1,000 children (e.g., inBangladesh; Fujiura et al., 2005).

Research on Pakistani Attitudes

Notwithstanding living in collectivist cultures thatvalue family connections and support (Ghosh &Magana, 2009), Asian parents of children withintellectual disability often experience stigma andshame, limiting familial support. Pakistani parentsof children with intellectual disability reportexperiences of others’ negative attitudes towardtheir children and feelings of shame (Ansari, 2002;Bywaters, Ali, Fazil, Wallace, & Singh, 2003). Topromote their inclusion, many parents may pushchildren with intellectual disability to assumesocially expected roles. In one case the mother of

a Muslim Bangladeshi woman with moderateintellectual disability hoped that her daughterwould ‘‘grow out’’ of her disability, and her fa-ther believed that her ‘‘illness’’ was treatable.When she changed very little over time, theparents arranged a marriage for their daughter,believing that she would be forced to change bytaking on domestic tasks and observing codes ofmodesty (Hepper, 1999).

Pakistani and Bangladeshi parents, whetherliving in their native lands or not, may have littleknowledge of the etiology of intellectual disabilityand explain a child’s disability as being causedby God, an evil possession, or childhood illness(Bywaters et al., 2003; Hepper, 1999; Hulme, 2004;Mirza, Tareen, Davidson, & Rahman, 2009).Ansari (2002) found that Pakistani parents reportedshowing more warmth toward children who aredeaf, blind, or have a physical disability than tochildren with intellectual disability. Parents’ self-reported levels of warmth toward children withintellectual disability and children without disabil-ities did not differ (Ansari, 2002). Ansari suggestedthat the difference may be due to parents feelingmore comfortable and accepting of children whoare deaf, blind, or have a physical disability than achild with an intellectual disability. Also of note,mothers reported greater rejection of children withany type of disability than did fathers. A reviewof research of families of Asian descent with amember with intellectual and developmental dis-abilities observed that it is common for mothers tobe blamed by others and to blame themselves fortheir child’s disability (Ghosh & Magana, 2009).

To date, only parents’ attitudes and perspec-tives toward people with intellectual disabilityhave been formally studied. The extent to whichsimilar attitudes are present among Pakistanis ingeneral and staff in particular is the focus of thecurrent study.

Demographic Variables and AttitudesA variety of studies have investigated the influ-ence of demographic variables on attitudes towardpeople with intellectual disability. Most relevantto the current study are whether respondents arecommunity members or staff, have a friend orrelative with a disability, as well as the respon-dents’ gender, age, level of education completed,and religion.

Studies in the United States and Australiahave found that staff holds more positive attitudes

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 33

toward people with intellectual disability thancommunity members, and that this differencemay be related to the extent of their contact withpeople with intellectual disability. Such priorexperience has been found to be associated withmore positive attitudes toward people with in-tellectual disability (Horner-Johnson et al., 2002;Yazbeck, McVilly, & Parmenter, 2004).

Other demographic variables have not alwaysbeen consistently associated with differences inattitudes toward people with intellectual disabil-ity. Women hold more positive attitudes thanmen in some countries (Granello & Wheaton,2001; Hunt & Hunt, 2004; Panek & Jungers, 2008;Werner & Davidson, 2004); in others, includingDenmark, India, and Israel, men hold morepositive attitudes than women (Yuker & Block,1986). Furthermore, no gender differences werefound in attitudes toward individuals with intel-lectual disability among Japanese students (Hor-ner-Johnson et al., 2002). A consistent theory toexplain interactions between gender and culturein attitudes has not been advanced (Chen,Broadwin, Cardoso, & Chan, 2002). Youngerpeople tend to have more positive attitudes(Cuskelly & Gilmore, 2007; Yazbeck et al.,2004), but more years of education are alsoassociated with more positive attitudes towardpeople with intellectual disability (Olkin, 1999;Yazbeck et al., 2004; Yuker, 1994).

Religious beliefs are also important forunderstanding attitudes toward people with intel-lectual disability in Pakistan. Religious organiza-tions may provide positive support or help forchildren with disabilities (Glidden, Roger-Dulan,Hill, 1999), and people tend to understanddisability through the lens of their religion. Incountries influenced by Chinese Confucianthought as well as Hindu and Buddhist traditions,ancestral or parental sins are advanced as expla-nations for intellectual disability. Muslims tendto attribute intellectual disability to God’s will orto possession by a spirit. Christians may reportintellectual disability as being God’s gift or will(Ghosh & Magana, 2009).

The Community Living Attitudes ScaleMost prior efforts to measure attitudes towardpeople with intellectual disability have portrayedpeople with intellectual disability as relativelypassive objects of others’ attitudes and largely didnot focus on issues valued by people with

intellectual disability (Keys, Balcazar, Bartunek,& Foster-Fishman, 1996). To address these short-comings, Henry et al. (1996) consulted U.S.-basedadvocates with intellectual disability to developthe Community Living Attitudes Scale—MentalRetardation Form (CLAS-MR). They created afour-factor measure of contemporary attitudes im-portant to advocates with intellectual disability.The four dimensions of these attitudes include (a)empowerment, the degree to which people withintellectual disability are permitted to make theirown decisions; (b) similarity, the degree to whichindividuals believe that people with intellectualdisability share a common humanity with others;(c) exclusion, the degree to which individualsdesire to segregate people with intellectual dis-ability from community life; and (d) sheltering,the degree to which individuals believe peoplewith intellectual disability require protection fromharm (Henry et al., 1996). We use this measure tobreak new ground in an exploratory study ofattitudes toward people with intellectual disabilityamong Pakistani community members and staff.

Research Questions

The present study contributes to existing knowl-edge by including community members andstaff, studying relationships between attitudesand demographic variables, and adding a newcultural context of Pakistan to previous attitudinalresearch. We investigate the following researchquestions: (a) Is the factor structure of Pakistaniattitudes comparable to the structure for attitudesin the United States? and (b) How do demo-graphic differences affect attitudes among com-munity and staff samples in Pakistan?

Methods

ParticipantsThe total sample was 452 Pakistani nationals inKarachi, Pakistan, including 262 (58%) commu-nity members living in one of seven neighbor-hoods and 190 staff (42%) from two participatingorganizations serving people with intellectualdisability and their families. Participants included214 males (47%) and 238 females (53%) aged18 years or older. Neighborhoods in Karachi wereselected to obtain variety based on neighborhoodtype and socioeconomic status and to providesafety and accessibility for the data collector. Thesettings in which data were collected included

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

34 Pakistani community and staff

four katchi abadis (‘‘squatter settlements’’), twoneighborhoods of apartment buildings, and oneneighborhood of bungalows. In the staff sample,56 (29%) individuals worked at an orphanageserving children and adults with intellectualdisability who had been abandoned or givenaway. Another 134 staff members (71%) worked atan organization serving people with intellectualdisability and their families through, for example,parent empowerment programs and vocationaltraining. At both organizations, most paid staffalso volunteered their time outside of workinghours such as on the weekends; moreover, somestaff members were unpaid due to limitedfunding.

MaterialsAll participants were asked demographic ques-tions including whether they have a friend orrelative with a disability, gender, age, level ofeducation completed, and religious affiliation. Forthe demographic variable of level of educationcompleted, participants identified as being edu-cated through the Pakistani or British system ofeducation. We combined equivalent groupstogether. Primary school included grades 1 to 8.Secondary school included both metric andhigh school, which consisted of grades 9 to 12.‘‘Metric’’ is part of the Pakistani system ofeducation, which is for a duration of 2 years aftergrade 8. Two-year degrees consist of two types ofpostsecondary degrees, vocational and juniorcollege.

As noted, Form A of the CLAS-MR, a 40-itempsychometrically sound measure, was used toassess attitudes toward people with intellectualdisability. We also used an alternative form of theCLAS-MR (Form B) to determine the degree towhich the two forms of the same instrumentconverged. No significant differences were foundbetween the two forms. We, thus, focused onresults from the original form (Form A). TheCLAS-MR addresses topics important to advo-cates with intellectual disability in the UnitedStates across four dimensions: empowerment (13items), similarity (12 items), exclusion (8 items),and sheltering (7 items). The CLAS-MR uses aLikert-type scale (1 5 disagree strongly to 6 5 agreestrongly) with positive and negative statementsabout people with intellectual disability. Highmean scores indicate high endorsement of thesubscale. The CLAS-MR subscales have shown

good internal consistency in U.S. samples (Henryet al., 1996) and an Israeli sample (Henry,Duvdevany, Keys, & Balcazar, 2004). Validitystudies suggest the measure is free of socialdesirability bias and show good convergent anddiscriminant validity (Henry et al., 1996; McDon-ald, Keys, & Henry, 2008). The instrument alsohas a stable cross-cultural structure in Japan(Horner-Johnson et al., 2002), Israel (Henry etal., 2004), Australia (Yazbeck et al., 2004), HongKong (Scior, Kan, McLoughlin, & Sheridan,2010), and the United Kingdom (Scior et al.,2010).

ProcedureWe translated research materials into Urdu(Pakistan’s national language) using establishedprocedures to ensure cultural and linguisticequivalence (Liang & Bogat, 1994). First, individ-uals fluent in both Urdu and English translatedmaterials into Urdu. The translated Urdu materi-als were then back-translated into English bytwo individuals who did not conduct the initialtranslation. We then compared the originalEnglish versions and the English back-translationsto determine whether the content retained itsmeaning or not. We determined that onetranslated item was not equivalent to its originalmeaning. To address this discrepancy, we reex-amined the item. We retranslated it from theoriginal English version to Urdu and then back-translated the item into English; the content inUrdu then retained the meaning of the originalitem in English. Four Pakistani natives reviewedthe materials for cultural relevance.

After receiving institutional review boardapproval from DePaul University for the study,we surveyed community members’ door to door,requesting one member of each household toparticipate. A table of random numbers was usedto select households for the community sample,skipping houses in each community according-ly. However, houses intended to be skipped wereoften included as most community memberswanted to participate. The first author obtainedpermission from two intellectual disability–focused organizations in Karachi, Pakistan, torecruit staff members during work. All staffmembers were eligible to participate; those whovolunteered to participate were interviewed in aseparate room or in a private corner of a roomduring breaks. We had a 100% response rate, most

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 35

likely because of the rarity of being asked toparticipate in research in Pakistan. Participantswere not provided any incentives. For moreinformation on the data collection process, seePatka (2009).

Because adult literacy in Pakistan is approxi-mately 54% (United Nations Statistics Division,2008), the first author conducted all researchprocedures orally in Urdu. The first author readan information sheet to each participant andobtained his or her informed consent. Participantswere offered the information sheet. Most partici-pants refused to keep the information sheet,particularly the male participants. Then, the firstauthor asked their nationality and age to assesseligibility; eligibility criteria required all participantsbe Pakistani citizens and 18 years of age or older.Eligible individuals were then asked other demo-graphic questions followed by the CLAS-MR.

Results

We report the results of two sets of analyses. Oneanalysis assessed the conceptual structure of theCLAS-MR. The second examined variation inattitudes associated with differences in demo-graphic characteristics of the sample. The demo-graphic composition of the sample is reported inTable 1.

1. Is the factor structure of Pakistaniattitudes comparable to the structure forattitudes in the United States?A confirmatory factor analysis tested threeessentially tau-equivalent factor models (Graham,2006) for the CLAS-MR. We used LISREL version8.0 (Joreskog & Sorbom, 2002) to conduct thisanalysis. These models fix all factor loadings to1.0 so that the only parameters allowed to varybetween models are the parameters that define thefactor structure. One model was a single-factormodel (with all items scored so that higher scoresindicated more positive attitudes). The secondwas a two-factor model (one factor for positiveattitudes and the other for negative attitudes). Thefinal model tested was the four-factor modelrepresenting the structure of the original measure(Henry et al., 1996). Likelihood ratio tests used tocompare the models showed that the originalfour-factor model fit the Pakistani data better thaneither the single-factor model, Dx2[7, N 5 448] 5

12,102.35, p , .01, or the two-factor model,

Dx2[9, N 5 448] 5 1,162.17, p , .01. We, thus,used the four-factor model to calculate scores foreach of the four attitude domains. Table 2 reportsthe means, standard deviations, and correlationsamong the four CLAS-MR scales for the commu-nity and staff samples.

2. How do demographic differences affectattitudes among community andstaff samples?The present analyses sought to examine howcommunity and staff attitudes differ along the

Table 1Demographics for Community and Staff Samples

Demographic

Community and staff

sample (n 5 452)

% (n)

Participant role

Community 57.96 (262)

Staff 42.04 (190)

Friend/relative with disability

No 79.87 (361)

Yes 20.13 (91)

Gender

Male 47.35 (214)

Female 52.65 (238)

Age (years)

18 to 20 15.27 (69)

21 to 30 32.08 (145)

31 to 40 23.01 (104)

41 to 50 14.38 (65)

51 to 60 10.18 (46)

61+ 5.09 (23)

Education

None 10.40 (47)

Primary school 11.28 (51)

Secondary school 34.07 (154)

2-year college 17.48 (79)

4-year college 15.04 (68)

Graduate school 11.73 (53)

Religion

Sunni Muslim 78.54 (355)

Shiia Muslim 6.86 (31)

Hindu 5.75 (26)

Christian 8.85 (40)

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

36 Pakistani community and staff

CLAS-MR dimensions of empowerment, similar-ity, exclusion, and sheltering. They also exploredhow demographic differences affect attitudeswithin community and staff samples utilizingSPSS 19 software. A multivariate analysis ofvariance was performed to examine differenceson four dependent variables: empowerment, simi-larity, exclusion, and sheltering. Independentvariables were participant role, having a friendor relative with a disability, gender, age, level ofeducation completed, and religion. There were nomissing data. The dependent variables werecorrelated above .55, as can be seen in Table 2.

Our initial model tested for the presence ofinteractions. This model found no significantinteractions between participant role (community–staff) and having a friend or relative with a disability,gender, age, level of education completed, orreligion. These findings indicate that the interpret-able effects are main effects rather than role-moderated effects. Thus, in the final model wecombined data from community members andstaff. We reported significant multivariate effects,followed by univariate effects (if the multivariateeffect was significant), and post hoc Tukey meanscomparisons below and in Table 3.

Statistically significant multivariate effectswere found for all six demographic variables,which included participant role, having a friend orrelative with a disability, gender, age, level ofeducation completed, and religious affiliation. Anadjusted alpha of .002 (.05/436) was used tocorrect for multiple tests at the univariate level.

There were statistically significant multivari-ate effects for participant role. Examination of theunivariate effects and cell means indicated thatcompared to the community sample, staff hadsignificantly higher endorsement of empower-ment, F(1,450) 5 75.07, p , .001, gp

2 5 .14, andsimilarity, F(1,450) 5 36.00, p , .001, gp

2 5 .07,and significantly lower endorsement of exclusion,

F(1,450) 5 25.17, p , .001, gp2 5 .05, and

sheltering, F(1,450) 5 140.39, p , .001, gp2 5 .24.

There were significant multivariate effects forhaving a friend or relative with a disability. Noneof the univariate effects was significant.

There were statistically significant multivariateeffects for gender. Compared to males, females hadsignificantly higher endorsement of empower-ment, F(1,450) 5 62.50, p , .001, gp

2 5 .12, andsimilarity, F(1,450) 5 78.61, p , .001, gp

2 5 .15,and significantly lower endorsement of exclusion,F(1,450) 5 51.28, p , .001, gp

2 5.10, andsheltering, F(1,450) 5 22.21, p , .001, gp

2 5 .05.There was a significant multivariate effect for

age. Individuals between the ages of 18 and20 years had significantly higher endorsement ofsheltering, F(5,446) 5 6.38, p , .001, gp

2 5 .07,than individuals between the ages of 21 and 50.

There was a significant multivariate effect forlevel of education. Univariate effects and cellmeans found significance for empowerment,F(5,446) 5 8.80, p , .001, gp

2 5 .09. Individualswith 2-year, 4-year, and graduate degrees endorsedempowerment significantly more than individualswho completed no education and primary school.Examination of univariate effects and cell meansindicated a significant education effect for simi-larity, F(5,446) 5 8.98, p , .001, gp

2 5 .09. Incomparison to individuals reporting no complet-ed education and individuals who completedprimary school, individuals with 2-year, 4-year,and graduate degrees endorsed similarity signifi-cantly more. Additionally, in comparison toindividuals who completed secondary school,individuals with graduate degrees had significantlyhigher endorsement for similarity.

Examination of univariate effects and cellmeans indicated a significant education effect onexclusion, F(5,446) 5 8.56, p , .001, gp

2 5 .09. Incomparison to individuals reporting no educationcompleted and individuals who completed primary

Table 2Means, Standard Deviations, and Correlations for Community and Staff Samples

Scale Community M (SD) Staff M (SD) Empowerment Similarity Exclusion Sheltering

Empowerment 3.01 (1.56) 3.94 (1.10) — .85 2.67 2.57

Similarity 3.53 (1.18) 4.20 (1.16) .89 — 2.75 2.58

Exclusion 3.17 (1.30) 2.54 (1.34) 2.75 2.91 — .60

Sheltering 4.38 (1.21) 3.00 (1.23) 2.91 2.86 .79 —

Note. Correlations above the diagonal are for the community sample, and correlations below the diagonal are for the staffsample.

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 37

school, individuals with 2-year, 4-year, and gradu-ate degrees had significantly lower endorsement ofexclusion. In comparison to individuals whocompleted secondary school, individuals withgraduate degrees had significantly lower endorse-ment for exclusion. Examination of univariateeffects and cell means indicated a significant

education effect for sheltering, F(5,446) 5 4.60,p , .001, gp

2 5 .05. In comparison to individualswho completed no education and those whocompleted primary school, individuals with grad-uate degrees endorsed sheltering significantly less.

And finally, there were statistically significantmultivariate effects for religion. Examination of

Table 3Community Living Attitudes Scale (CLAS) Subscale Means and Standard Deviations byDemographic Variable

Demographic

variable n

Subscale score

Empowerment

M (SD)

Similarity

M (SD)

Exclusion

M (SD)

Sheltering

M (SD)

Participant role: Wilks’ l 5 .72, F(4,447) 5 42.66, p , .001, gp2 5 .28

Community 262 3.01a (1.16) 3.53a (1.18) 3.17a (1.30) 4.38a (1.21)

Staff 190 3.94b (1.10) 4.20b (1.16) 2.54b (1.34) 3.00b (1.23)

Friend/relative with disability: Wilks’ l 5.98, F(4,447) 5 2.62, p , .05, gp2 5 .02

No 361 3.36a (1.22) 3.75a (1.22) 3.00a (1.36) 3.87a (1.38)

Yes 91 3.55a (1.22) 4.04a (1.19) 2.53a (1.23) 3.53a (1.43)

Gender: Wilks’ l 5.16, F(4,447) 5 21.48, p , .001, gp2 5 .16

Male 214 2.95a (1.24) 3.32a (1.21) 3.36a (1.39) 4.12a (1.30)

Female 238 3.81b (1.05) 4.25b (1.04) 2.49b (1.17) 3.51b (1.42)

Age (years): Wilks’ l 5.87, F(20,1784) 5 3.06, p , .001, gp2 5 .03

18–20 69 3.25a (1.05) 3.65a (1.15) 3.15a (1.35) 4.49a (1.14)

21–30 145 3.61a (1.20) 3.95a (1.22) 2.75a (1.32) 3.52b (1.37)

31–40 104 3.57a (1.28) 3.98a (1.26) 2.61a (1.38) 3.59b (1.50)

41–50 65 3.29a (1.32) 3.72a (1.25) 2.95a (1.33) 3.67b (1.41)

51–60 46 3.02a (1.10) 3.52a (1.07) 3.28a (1.21) 4.07a,b (1.27)

61 + 23 2.90a (1.21) 3.46a (1.21) 3.54a (1.32) 4.28a,b (1.17)

Education: Wilks’ l 5.88, F(20,1784) 5 2.93, p , .001, gp2 5 .03

None 47 2.82a (1.16) 3.26a (1.19) 3.52a (1.35) 4.12a (1.28)

Primary school 51 2.81a (1.22) 3.21a (1.08) 3.42a (1.29) 4.34a (1.22)

Secondary school 154 3.36a,b (1.25) 3.74a,b (1.31) 3.04a,c (1.46) 3.89a,b (1.40)

2-year college 79 3.62b (1.06) 4.03b,c (0.97) 2.67b,c (1.11) 3.71a,b (1.38)

4-year college 68 3.59b (1.19) 4.06b,c (1.17) 2.62b,c (1.26) 3.47a,b (1.42)

Graduate school 53 4.02b (1.03) 4.42c (1.02) 2.18b (1.01) 3.28b (1.40)

Religion: Wilks’ l 5.93, F(12,1341) 5 2.63, p , .01, gp2 5 .02

Sunni Muslim 355 3.41a (1.23) 3.84a (1.20) 2.83a (1.31) 3.76a (1.41)

Shiia Muslim 31 2.81a (1.36) 2.98b (1.40) 4.05b (1.56) 4.45a (1.43)

Hindu 26 3.51a (1.03) 3.98a (0.97) 2.89a (1.15) 3.88a (1.27)

Christian 40 3.70a (1.05) 4.10a (1.09) 2.63a (1.23) 3.58a (1.23)

Note. For the attitudinal findings for each demographic variable, means with the same subscript within columns do notdiffer significantly from one another at p , .002. Means with differing subscripts within columns are significantly differentat p , .002 according to post hoc Tukey tests.

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

38 Pakistani community and staff

the univariate effects and cell means indicatedthat Sunnis, Christians, and Hindus had signifi-cantly higher endorsement of similarity, F(3,448)5 5.97, p , .001, gp

2 5 .04, and significantly lessendorsement of exclusion, F(3,448) 5 8.80, p ,

.001, gp2 5 .06, than Shiias.

Discussion

To our knowledge, this is the first study ofcommunity member and staff attitudes towardpeople with intellectual disability in Pakistan. Thisexploratory study sheds initial light on therelationships between demographic variables andattitudes. This study also may encourage futureresearch to further examine Pakistani attitudestoward individuals with intellectual disability.

Our findings indicate that the factor structureof these attitudes in a Pakistani sample is similarto the structure found in the United States andother countries, including Australia (Yazbecket al., 2004), Israel (Henry et al., 2004), Japan(Horner-Johnson et al., 2002), Hong Kong (Scioret al., 2010), and the United Kingdom (Scioret al., 2010). This finding further supports theutility of using the CLAS-MR to examineattitudes toward people with intellectual disabilityfrom different cultures. We also acknowledge thatit may be important to capture additionaldimensions of attitudes important to specificcultural contexts.

Results also suggest that specific demographiccharacteristics and experiences, including partici-pant role, relationships with people with intellec-tual disability, gender, age, level of educationcompleted, and religious affiliation affect Pakis-tani attitudes toward people with intellectualdisability. Consistent with research conducted inAustralia (Yazbeck et al., 2004) and the UnitedStates (Henry et al., 1996), Pakistani staff hadmore positive attitudes than community mem-bers. Relatively favorable attitudes may suggestpositive relationships between people with intel-lectual disability and service providers, resultingin high quality of service. Additionally, positivestaff attitudes may also support present andprevious findings reporting that experience withpeople with disabilities is associated with morepositive attitudes (Fichten, Schipper, & Cutler,2005). Similar to Fichten et al.’s (2005) sample,the organizations sampled for the present studylargely serve children. Most paid workers put inadditional hours as volunteers, and some staff are

unpaid. Contact with individuals with intellectualdisability over time may have a positive effect onattitudes through the reduction of fear andanxiety (Scior, 2011), experiences more typicalfor staff than for community members. Moreover,positive contact may be related to the willingnessfor social contact, and negative experiences mayincrease social distance (Scior, 2011). Thus, staffmay have held more positive attitudes prior toseeking a job working with people with intellec-tual disability.

Participants who reported having a friend orrelative with a disability did have significantlydifferent attitudes than individuals without afriend or relative with a disability. However, thisdifference cannot be attributed to any singleaspect of attitudes. Rather, it appears that a moregeneral tendency to favor inclusion of peoplewith intellectual disability is contributing to thismodest effect. Prior research in Pakistan hasreported that parents of children with intellectualdisability have to pay for medical, educational,and other specialized services, which may createfinancial hardship (Ali & Al-Shatti, 1994). Exclu-sion from community living may result in familiesexperiencing increased financial responsibility forresidential facilities or private schools. It isimportant for future research to examine thefriendships and family relationships of Pakistaniswith people with intellectual disability separatelyand to examine the extent and nature of contactwith people with intellectual disability in theserelationships.

Pakistan shares some religious and culturaltraditions with India, making it reasonable toexpect that, as in India, men would have heldmore positive attitudes than women when Yukerand Block (1986) conducted their study. Ourresults suggest that, if such attitude differences didexist over 25 years ago, there have been historicalshifts. Now Pakistani attitudes are more consistentwith research findings in the West (Granello &Wheaton, 2001; Hunt & Hunt, 2004; Panek &Jungers, 2008; Werner & Davidson, 2004), wherefemales hold more positive attitudes towardindividuals with intellectual disability (Scior,2011). However, there remains evidence Pakistanimothers report greater rejection toward their childwith a disability than fathers (Ansari, 2002). Theremay be subpopulation differences that were notexamined in this study.

In other studies, younger individuals havebeen found to endorse more positive attitudes,

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 39

and older participants more negative attitudes(Scior, 2011; Yazbeck et al., 2004). However, inthis study, Pakistanis between the ages of 18 and20 years endorsed sheltering more than individ-uals between the ages of 21 and 50, with shelteringmeans increasing again after age 50, althoughmeans for individuals over the age of 50 were notsignificantly different with other age groups. Theimplications of such age differences are unclear,because we do not know if there is an age effect ora historical effect. We have found that youngerindividuals hold more negative attitudes. Thehistorical effect may be that at this time in history,attitudes among young people are less positivethan expected. A historical effect may be becauseof religious extremism. Muslims fought for thebirth of Pakistan as an Islamic state, and at presentPakistan struggles with a resurgence of religiousextremism. The progress evident with the Dis-abled Persons Ordinance in 1981 for schoolingand rights for those with disabilities (Masood etal., 2007) may be threatened by the new wave ofIslamic extremism. This extremism may befostering negative attitudes toward people withintellectual disability in younger people.

Consistent with findings in the United States(Henry et al., 2004), Hong Kong (Scior et al., 2010),and the United Kingdom (Scior et al., 2010), higherlevels of education were associated with morepositive attitudes. Thus, better educated Pakistaniswere found to hold more positive attitudes towardpeople with intellectual disability.

The absence of significant differences amongChristians, Sunnis, and Hindus may be explainedby overlapping beliefs that intellectual disabilityresults from God’s will (Ghosh & Magana, 2009).Among religious groups, Shiias endorsed themore negative attitudes than Sunnis, Hindus,and Christians. It is unclear why Shiias hold morenegative attitudes. Based on both historical andcurrent events, Shiias have experienced discrimi-nation and marginalization within Muslim com-munities. We found no previous research thatprovides insight on attitudinal differences be-tween sects of Islam. Researchers tend to groupMuslims together without taking into account thediversity within Islam. The results of this studysuggested that researchers need to examinedifferences within Muslim communities moreclosely. Researchers may usefully recognize diver-sity among Muslims by reporting results by sectsor groups as well as, or instead of, simply by theIslamic religion overall.

Limitations and Conclusion

Like any research endeavor, this study includeslimitations to consider when interpreting findings.First, it is possible that a self-report measure ofattitudes based on American values misseddimensions of attitudes, including some of thoseimportant to the Pakistani cultural milieu studi-ed herein. Qualitative research can aid in thediscovery of such aspects of attitudes. Second,previous administrations of the CLAS-MR haveemployed a written format (Henry et al., 1996;Henry et al., 2004; Horner-Johnson et al., 2002;McDonald et al., 2008; Scior et al., 2010; Yazbecket al., 2004). The present study administered theCLAS-MR in an oral format because of lowliteracy levels. Talking with a researcher face-to-face may have led participants to provide whatthey thought were socially desirable responses.All participants were assured confidentiality andanonymity, which may have helped reduce socialdesirability bias. However, the presence of suchbias cannot be fully ruled out. Also, we did notemploy random sampling, yet our high responserate of 100% from a set of diverse neighborhoodsand two disability service agencies may helpbolster confidence in the findings for thepopulations sampled. Moreover, it is importantto note that the attitudes of those residing inKarachi, with 21 million inhabitants (Khan, 2012,April), may be different from those living insmaller cities and in rural areas. Additionally,women in Pakistan are considered adults upontheir initial menstruation, which is likely to occurbefore the age of 18, the age of legal adulthood onmany dimensions in the United States. Theinclusion criteria of adult participants based onthe norms of Pakistani society should be consid-ered in future research, as adulthood is notsignified simply by one’s age.

We employed a measure of attitudes valuedby advocates with intellectual disability in theUnited States (Henry et al., 1996), therefore, weconclude with a reminder of the importance ofpursuing culturally based theoretical research.Such research may be used to help establish thesignificance of observed attitudes on people’slives. The findings of such empirical work may beused to help promote community inclusion andaccess to opportunities and resources for Pakistanipeople with intellectual disability. Future researchmay usefully seek to explore community andstaff attitudes valued by people with intellectual

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

40 Pakistani community and staff

disability in Pakistan. Examining the attitudinaldimensions important to Pakistanis with intellec-tual disability is a critical step in creating aninstrument grounded within Pakistani culture.Recent research in Hong Kong sought to extendthe cultural relevance of the CLAS-MR by addingsix items that may be relevant to Asians (Scioret al., 2010). The addition of such items capturedculturally based attitudes, which may importantin Hong Kong and other cultures yet less relevantwithin mainstream U.S. culture.

Given that measures assessing attitudes to-ward people with intellectual disability groundedwithin Pakistani culture do not exist, the presentinvestigation makes a substantial initial contribu-tion to our knowledge of Pakistani attitudesthrough the CLAS-MR. This measure has beenused internationally with multiple cultures toexamine, often for the first time, how demo-graphic variables are associated with attitudinaldifferences. The present results and discussionalso point out recommendations for futureresearch to improve our understanding of howdemographic variables and experiences are re-lated to attitudes toward people with intellectualdisability. Additionally, examining attitudes to-ward people with intellectual disability canilluminate how a society perceives this marginal-ized group and can point to areas for interventionor action to promote these individuals’ access toopportunities and resources. For example, differ-ences between staff and community membersindicate that further work within communitiesmay promote positive attitudes. Similarly, indi-viduals and communities with lower levels ofeducation reported less favorable attitudes, sug-gesting the need to promote educational advance-ment among Pakistani community members.

The CLAS-MR allowed an exploratory un-derstanding of Pakistani attitudes toward individ-uals with intellectual disability. The present resultsprovided an understanding of Pakistani attitudesabout specific dimensions of attitudes, whichincludes the empowerment, similarity, exclusion,and sheltering of individuals with intellectual disabil-ity. This work contributes to attitudinal researchwithin Pakistan concerning staff and communitymembers of which little is currently known. Thepresent results also encourage future investigation toidentify further attitudinal dimensions important toPakistanis with intellectual disability for thecreation of culturally grounded instruments andinterventions.

References

Ali, M. R., & Al-Shatti, A. (1994). Parents ofmentally retarded children: Personality char-acteristics and psychological problems. SocialBehavior and Personality, 22, 41–52.

Ansari, Z. A. (2002). Parental acceptance–rejectionof the disabled children in non-urban Pakistan.North American Journal of Psychology, 4(1),121–128.

Berkson, G. (2004). Intellectual and physicaldisabilities in prehistory and early civilization.Mental Retardation, 42(3), 195–208.

Bywaters, P., Ali, Z., Fazil, Q., Wallace, L. M., &Singh, G. (2003). Attitudes towards disabilityamongst Pakistani and Bangladeshi parents ofdisabled children in the UK: Considerationsfor service providers and the disability move-ment. Health and Social Care in the Community,11(6), 502–509.

Chen, R. K., Broadwin, M. G., Cardoso, E., &Chan, F. (2002). Attitudes toward people withdisabilities in the social context of dating andmarriage: A comparison of American Taiwa-nese, and Singaporean college students. Jour-nal of Rehabilitation, 68(4), 5–11.

Cuskelly, M., & Gilmore, L. (2007). Attitudes tosexuality questionnaire (individuals with anintellectual disability): Scale development andcommunity norms. Journal of Intellectual andDevelopmental Disability, 32(3), 214–221.

Durkin, M. S., Hasan, Z. M., & Hasan, K. Z.(1995). The ten questions screen for child-hood disabilities: Its uses and limitations inPakistan. Journal of Epidemiology and Commu-nity Health, 49, 431–436.

Durkin, M. S., Hasan, Z. M., & Hasan, K. Z. (1998).Prevalence and correlates of mental retardationamong children in Karachi, Pakistan. AmericanJournal of Epidemiology, 147(3), 281–288.

Fazio, R. H. (2007). Attitudes as object–evaluationassociations of varying strength. Social Cogni-tion, 25, 603–637.

Fichten, C., Schipper, F., & Cutler, N. (2005).Does volunteering with children affect atti-tudes towards adults with disabilities? Aprospective study of unequal contact. Reha-bilitation Psychology, 50(2), 164–173.

Fujiura, G. T., Park, H. J., & Rutkowski-Kmitta, V.(2005). Disability statistics in the developingworld: A reflection on the meanings in ournumbers. Journal of Applied Research in Intel-lectual Disabilities, 18, 295–304.

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 41

Gaad, E. (2004). Cross-cultural perspectives onthe effect of cultural attitudes towards inclu-sion for children with intellectual disabilities.International Journal of Inclusive Education, 8(3),311–328.

Ghosh, S., & Magana, S. (2009). Research onAsian families of persons with intellectual anddevelopmental disabilities. International Re-view of Research in Mental Retardation, 37,179–212.

Glidden, L. M., Rogers-Dulan, J., & Hill, A. E.(1999). ‘‘The child that was meant?’’ or‘‘Punishment for sin?’’: Religion, ethnicity,and families with children with disabilities.International Review of Research in MentalRetardation, 22, 267–288.

Graham, J. M. (2006). Congeneric and (essential-ly) tau-equivalent estimates of score reliabili-ty: What they are and how to use them.Educational and Psychological Measurement, 66,930–944.

Granello, D. H., & Wheaton, J. E. (2001).Attitudes toward persons with physical dis-abilities and mental illness. Journal of AppliedRehabilitation Counseling, 32(3), 9–16.

Henry, D., Duvdevany, I., Keys, C. B., & Balcazar,F. E. (2004). Attitudes of American and Israelistaff toward people with intellectual disabili-ties. Mental Retardation, 42(1), 26–36.

Henry, D., Keys, C., Jopp, D., & Balcazar, F.(1996). The community living attitudes scale,mental retardation form: Development andpsychometric properties. Mental Retardation,34(3), 149–158.

Hepper, F. (1999). ‘‘A woman’s heaven is at herhusband’s feet’’? The dilemmas for a com-munity learning disability team posed by thearranged marriage of a Bangladeshi client withintellectual disability. Journal of IntellectualDisability Research, 43(6), 558–561.

Horner-Johnson, W., Keys, C., Henry, D.,Yamaki, K., Oi, F., Watanabe, K., … Fugji-mura, I. (2002). Attitudes of Japanese studentstoward people with intellectual disability.Journal of Intellectual Disability Research, 46(5),365–378.

Hulme, D. (2004). Thinking ‘‘small’’ and theunderstanding of poverty: Maymana andMofizul’s story. Journal of Human Develop-ment, 5(2), 161–174.

Hunt, C. S., & Hunt, B. (2004) Changingattitudes toward people with disabilities:Experimenting with an educational interven-

tion. Journal of Managerial Issues, 16(2), 266–280.

Joreskog, K.G., & Sorbom, D. (2002). LISREL 8for Windows [Computer software]. Lincoln-wood, IL: Scientific Software International.

Keys, C. B., Balcazar, F. E., Bartunek, J. M., &Foster-Fishman, P. G. (1996). Groundingresearch in the culture of persons withintellectual disabilities: Dilemmas and direc-tions. British Journal of Developmental Disabil-ities, 42(Suppl.), S16.

Khan, A. S. (2012, April 2). Sindh population surgesby 81.5pc, households by 83.9pc. The Interna-tional News. Available at http://www.thenews.com.pk/Todays-News-13-13637-Sindh-population-surges-by-81.5-pc,-households-by-83.9-pc

Khatoon, A. (2003). A historical and evaluativestudy of special education in Pakistan. Availableat http://eprints.hec.gov.pk/719/1/505.html.htm

Liang, B., & Bogat, G. A. (1994). Culture, controland coping: New perspectives on socialsupport. American Journal of Community Psy-chology, 22, 123–145.

Masood, A. F., Turner, L. A., & Baxter, A. (2007).Causal attributions and parental attitudestoward children with disabilities in the UnitedStates and Pakistan. Exceptional Children, 73(4),475–487.

McDonald, K., Keys, C., & Henry, D. (2008). Thegatekeepers of science: Attitudes toward theresearch participation of adults with intellec-tual disabilities. The American Journal onMental Retardation, 113, 466–478.

Miles, M. (1998). Development of community-based rehabilitation in Pakistan: Bringingmental handicap into focus. InternationalJournal of Disability, Development, and Educa-tion, 45, 431–448.

Miles, M. (2001). Studying responses to disabilityin South Asian histories: Approaches persona,prakrital, and pragmatical. Disability and Society,16(1), 143–160.

Mirza, I., Tareen, A., Davidson, L. L., & Rahman,A. (2009). Community management of intel-lectual disabilities in Pakistan: A mixedmethods study. Journal of Intellectual DisabilityResearch, 53(6), 559–570.

Olkin, R. (1999). What psychotherapists should knowabout disability. New York, NY: Guilford.

Pakistan Census Organization. (1998). Censusreport of Pakistan. Available at http://www.pap.org.pk/statistics/population.htm#tab1.4

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

42 Pakistani community and staff

Panek, P. E., & Jungers, M. K. (2008). Effects ofage, gender, and causality on perceptions ofpersons with mental retardation. Research inDevelopmental Disabilities, 29, 125–132.

Parmenter, T. (2001). The contribution of sciencein facilitating the inclusion of people withintellectual disability into the community.Journal of Intellectual Disability Research, 45(3),183–193.

Patka, M. (2009). Collecting data in Pakistan toassess attitudes towards people with intellec-tual disabilities. The Community Psychologist,42(3), 10–11.

Scior, K. (2011). Public awareness, attitudes andbeliefs regarding intellectual disability: Asystematic review. Research in DevelopmentalDisabilities, 32, 2164–2182.

Scior, K., Kan, K., McLoughlin, & Sheridan, J.(2010). Public attitudes toward people withintellectual disabilities: A cross-cultural study.Intellectual and Developmental Disabilities, 48(4),278–289.

United Nations Enable (n.d.). Factsheet on personswith disabilities. Available at http://www.un.org/disabilities/default.asp?id518

United Nations Statistics Division (2008). Indicators onliteracy. Available at http://unstats.un.org/unsd/demographic/products/socind/literacy.htm

Vilchinsky, N., & Findler, L. (2004). Attitudestowards Israel’s equal rights for people withdisabilities law: A multiperspective ap-proach. Rehabilitation Psychology, 49(4), 309–316.

Werner, P. & Davidson, M. (2004). Emotionalreactions of lay persons to someone withAlzheimer’s disease. International Journal ofGeriatric Psychiatry, 19, 391–397.

World Health Organization. (2011). World reporton disability. Geneva, Switzerland: WHO Press.

Yaqoob, M., Bashir, A., Zaman, S., Ferngren, H.,von Dobeln, U., & Gustavson, K. (2004).Mild intellectual disability in children inLahore, Pakistan: Aetiology and risk factors.Journal of Intellectual Disability Research, 48(7),663–671.

Yazbeck, M., McVilly, K., & Parmenter, T. R.(2004). Attitudes toward people with intellec-tual disabilities: An Australian perspective.Journal of Disability Policy Studies, 15(2), 97–111.

Yuker, H. (1988). The effects of contact onattitudes toward disabled persons: Someempirical generalisations. In H. E. Yuker(Ed.), Attitudes toward people with disabilities(pp. 262–272). New York, NY: Springer.

Yuker, H. E. (1994). Variables that influenceattitudes toward people with disabilities:Conclusions from the data. Journal of SocialBehavior and Personality, 9, 3–22.

Yuker, H., & Block, J. (1986). Research with theattitude toward disabled persons scale (ATDP)1960–1985. Hempstead, NY: Hofstra Univer-sity, Center for the Study of Attitudes TowardPersons with Disabilities.

Received 7/29/2011, accepted 9/24/2012.Editor-in-Charge: Sandra Magana

Authors:Mazna Patka (e-mail: MPatka@pdx.edu), Port-land State University, Psychology Department,P.O. Box 751, Portland, OR 97201, USA;Christopher B. Keys, DePaul University; DavidB. Henry, University of Illinois at Chicago; andKatherine E. McDonald, Syracuse University.

AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

2013, Vol. 118, No. 1, 32–43

EAAIDD

DOI: 10.1352/1944-7558-118.1.32

M. Patka et al. 43