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1. INTRODUCTION
Stuttering has an estimated prevalence of about 1% of the world’s adult population [1], and is a speech disorder that affects many aspects of one’s life [2]. People who stutter (PWS) experience negative impacts due to stuttering such as difficulty in communicating in important situations, reduced life satisfaction and ability to achieve goals in life [3], having low income due to low pay jobs [4], psychological impacts, depression, or personality disorders [5, 6]. Negative social reactions such as teasing, discrimination have worsened the stuttering condition of PWS [7]. Many qualitative studies have described experiences of adults PWS including both positive and negative experiences that affected school performance, teacher-student relationships, job performance, or self-image [8-10]. Those information have helped readers better understand the impacts of stuttering on life of PWS, however, those findings may not be true for PWS in Vietnam, because of cultural, social, and environmental differences. Until now, there has been no study exploring the impact of stuttering on adult Vietnamese PWS, therefore, the aim of this study was to explore the experiences and impacts of stuttering in adult Vietnamese PWS across their lifespan and on different areas of their lives.
2. MATERIALS AND METHOD
The study was carried out online and nationwide from February 1, 2021 to April 30, 2021 in adult Vietnamese PWS.
This is a qualitative descriptive study. Qualitative descriptive researches focus on directly describing the characteristics of things and phenomena, giving readers an understanding and meaning of a thing or phenomenon [11]. Information of the study, including the consent form, was posted on the web site of a Vietnamese stuttering community, namely ECHO Vietnam, with the corresponding facebook page at https://www.facebook.com/groups/133766986662954. This is a non-governmental self-help group of Vietnamese PWS, and is a gathering place for PWS to exchange and share experience in scientific practice methods in stuttering treatment. ECHO members were encouraged to contact the researcher via e-mail or phone number, and if interested, they would provide consent to participate. Inclusion criteria were Vietnamese people from 18 years old and above, diagnosed as developmental stuttering, able to read and write Vietnamese, and agreed to participate in the study. Stuttering diagnosis was based on seven stuttering behaviors [12], regardless of the severity of stuttering or previous treatment, and was made by the consensus between the study subject and an independent Vietnamese speech therapist, who was a doctor trained in the Speech Therapy program of Pham Ngoc Thach Medical University, and was recognized by international specialists. A subject was excluded when diagnosed as acquired stuttering or psychological stuttering, or not having lived in Vietnam continuously for 12 months or more in the past 10 years. Convenience and snowball sampling were used to select study participants. Not all the participants’ personal information was collected, but only name (then coded with letters), place of residence (city), age, and marital status. A summary of the characteristics of the study participants is provided in Table 1.
Semi-structured interview was used for data collection with the questionnaire adapted from Klompas et al (2004) [9], in which some questions and words were changed to fit the culture and environment of Vietnam, as well as to make it more understandable to the participants. A summary of the interview questions is attached in Appendix 1. One interview was face-to-face (for a subject lived close to the researcher), and six others were online via Facebook messenger for distant subjects. The average duration of an interview was 54 minutes (ranging from 32 minutes 7 seconds to 1 hour 15 minutes 33 seconds), and varied depending on the content of the answers of the study participants.
Data were analyzed with thematic analysis method. Thematic analysis widely used in qualitative study is a flexible method that can highlight similarities and differences in a data set, and suitable for semi-structured interviews [13]. The analysis procedure comprises 6 steps according to Braun and Clarke (2006) [13]. In step 1 (acquaintance), the analyzer listened to the video several times, and all the information heard were decoded and transcribed into text. The transcripts were sent back to the study subjects to check the accuracy of information collected through interviews, and study subjects were also allowed to provide more information, or change an opinion if they deemed it necessary. The transcribed data were encoded (step 2, generating the original code), and this activity was done by the principal investigator and the study supervisors. In step 3 (topic search), the researcher collated the codes into potential themes, and gathered all data relevant to each potential theme.
The repetition process in step 4 (review topic) reviewed the topics to check whether the main topics, and the subtopics were appropriate according to many synthesized codes, and then created a single copy thematic map for analysis. In step 5 (defining and naming topics), ongoing analysis was performed to refine the specifics of each theme and the overall story the analysis tells, and generated clear definitions and names for each theme. Finally, the researcher wrote the report (step 6, writing the report) by selecting examples of vivid, attractive quotations that the study subjects answered and putting them in the form of sentences, or short paragraphs of text that went together with subtopics.
3. RESULTS
Analysis of the transcripts revealed 6 main themes including: impacts of stuttering on learning, reactions of family members, self-isolation due to being teased for stuttering, impacts of stuttering on social relationships, impacts of stuttering on work, and experience of stuttering therapy in Vietnam. These themes will be explored in more detail below.
Six subjects described how stuttering affects self-confidence and psychological well-being throughout the school years from childhood to adulthood. In childhood, the fear of stuttering was answered by having anxiety when afraid of being called by the teacher, feeling stressed in class, timid and losing confidence.
“… I felt stressed because every time I got called up, I couldn’t answer normally… “ (N4)
“… felt sad, I’m sorry, sometimes I had negative thoughts that made me more timid in myself” (N2)
“When I went to the board, I was nervous and lose confidence …”(N2)
However, there were also subjects (N7) who had no memory of stuttering or had not noticed stuttering (N5) in childhood.
When stuttering, PWS felt quite embarrassed and expressed more loss of confidence when studying at university because public speaking or group work skills required more verbal fluency.
Some PWS talked about doing better in logical subjects than verbal subjects. In primary school, learning was not much affected because the subjects were quite simple. N2 and N5 said that “… all the exams were on paper”. Stuttering impacts were more serious in secondary school.
“When I was in grade 8 or 9, I stammered, and was afraid to speak … my friends raised their hands but I didn’t. I knew but I didn’t dare to raise hand …” (N4)
“… teacher, please call others, not me” (N7)
“Math, physics, or chemistry exercises were done on paper, no need for oral presentation. But things were different with English …” (N6)
Stuttering affected the study of some subjects but not much on the overall academic result because “in Vietnamese education system the examinations were mainly written” (N6)
In college oral presentations were common, and PWS had to find the ways to avoid them.
“ … I left the presentations to my friends …” (N1)
Stuttering had affected the choice of majors at university, and so PWS chose majors that did not require much communication, but still among the fields of their interest or strength.
“I did not like the disciplines requiring much speaking. At that time, I liked robots, automated machinery that I watched on TV, so I chose it ... it did not require smooth speaking at all. Things would be different if at that time I liked English or pedagogy. Lucky for me!” (N4)
However, some said that stuttering did not affect university choice.
Most of the study subjects reported that during the school time from childhood to adulthood, there was little or no support from teachers at school, and that was probably because stuttering was not common and teachers did not realize how stuttering affected a student, or teachers were busy with teaching load.
“The teacher taught a lot of students, and didn’t care much about stuttering, only checked whether you had well learned a lesson, but not trained you to speak fluently. Teachers even didn’t really understand what stuttering was” (N6)
N1 was the only one reported the support from teachers at university “…the teacher also shared and encouraged me a lot.”
When finding out their children stuttered, some parents reacted quite negatively, leading to psychological impacts of the PWS. They had the experience of being reprimanded, or sometimes violated by their parents to make them correct their verbal disorders.
“ … do not stutter anymore … my dad yelled at me “Speechless, stuttering”. I’ve got an inferiority complex” (N1)
“When I was 11, 12 years old, my mother used to threaten me when I stuttered … she asked me to pronounce over and over again, and hit me too” (N7)
N5 and N6 said their parents neither paid attention to their stuttering nor encouraged them.
Besides negative reactions, a few subjects reported that family members were very sympathetic to their children and encouraged them.
“My relative understood me, so he sympathized with me, and encouraged me to overcome stuttering” (N2)
The parents of N3 considered stuttering normal and let him join a self-help group to improve the condition.
All of the subjects, except N7, reported that they were teased a lot for stuttering in childhood, but the teasing was less as they got older, and no more in adulthood. In childhood up to teenage, friends “laughed at, mocked at, and parodied” us, and made us “turned into the laughingstock of the class”.
“Friends imitated my voice, made fun of me …. when I stuttered. Sometimes I wanted to punch them (laughed)” (N1)
PWS preferred in class rather than outdoor activities, and therefore sometimes judged negatively by classmates.
“When I was at school, I really wanted to go on stage for some performance but when looking at the crowded audience I was mentally inhibited that could neither speak nor sing.” (N2)
“… for everyone, I was a quiet person, not sociable and some people did not like that. People said that I was not sociable and looked down upon others.” (N6)
When going shopping PWS made trouble for others because of their long lasting speak.
“ … they listened to me but I stuttered a lot, made them wait a long time, they felt tired. I hadn’t finished my words yet but they said no as if they didn’t want to sell it to me…” (N2)
However, when the stuttering condition improved they could normally participated in school activities as holding the position of group leader, writing wall papers.
“At university I felt no more stuttering, and became very confident, and participated in many activities, went on stage to sing and dance … or spoke in front of more than 100 people without any trouble” (N2)
Some subjects said that still had normal social relationships, and possibly because of a mild stuttering.
“… my social relationships were still normal, not participating in social activities because of stuttering was just an excuse of laziness” (N7)
Stuttering caused timidity, self-deprecation that the PWS dared not to say love to an opposite sex, or to progress deeply a love relationship. It also indirectly affected career path of the PWS leading to a rejection of the partner’s family.
“Still no lover. No problem if just a friendship, but going further was really embarrassing. Stuttering made me shy with my girlfriend ... “ (N3)
However, it was interesting to find that love had a positive impact on a ‘stutterer in love’ as he felt more comfortable and less stuttering with his lover.
“… that gave me a launching pad to ease myself and be no longer afraid of stuttering.”(N2)
Two subjects were married and found no significant influence of stuttering on their marital relationship, however, they had concerns that stuttering could be passed on to their children.
“…I’m just afraid that my child will be like me.”(N6)
All study subjects reported good relationship with their best friends since childhood, and almost never stuttered when communicating with close friends because of feeling comfortable, so they kept on such relationship until now.
“I had few friends since childhood but they were close friends, and this meant that I just made friends with the ones understanding me…” (N6)
“For my best friend, I didn’t stutter, because I felt comfortable” (N1)
Stuttering affected career choice so PWS chose professions not requiring much verbal communication as accountant, office worker, electronic technician, etc., but not teacher.
“I only worked with computer and rarely talked to other colleagues” (N3)
“Because of stuttering, I had to change from a more verbal job to a less verbal one.”(N1,N2)
“Being scared of contacting clients made me bored, so I gave up. I applied for a design job, just draw and not much talk” (N1)
Even with a less communicative job, PWS still had to talk, but they were not able to express fully or clearly their ideas, and had to be brief instead. Lacking of opportunities to learn from, or share experience with friends and colleagues has limited the development of career path.
“… if I didn’t stutter, my work would progress faster. My level would improve because when I dared to talk, I dared to learn other things. If I wanted to learn something I could ask directly, but when I stuttered I dared not to ask and just told myself that that was it, no need to ask.” (N6)
“Job promotion became more difficult.” (N5)
“… whether my boss will offer me a higher position when I stutter like this” (N4)
However, there were subjects believed that job promotion was depended on work performance but not because of stuttering; and things were not always bad, sometimes they still got help from colleagues to correct their speech or expression.
Some PWS have not learned about therapy or never tried any therapy before, some sought therapy in a variety of ways, some searched for information about stuttering as well as therapy on social networking sites, however, unofficial information were not always reliable.
“… there was no clarity in the treatment methods” (N6) “… knowing of some treatment facilities, but we didn’t trust them yet” (N2)
Some PWS had the opportunity to participate in workshop on stuttering therapy assisted by foreign experts, and found that the prolonged speech treatment method had positive effect.
“I started my first treatment in 2015 at the Ear, Nose and Throat Hospital, and found that the prolonged speech treatment method was effective and my condition improved over time. The thing was we had to know the methods and practiced regularly”(N2)
There are many difficulties in practicing treatment methods because of “too busy with work” (N1, N2, N4, N5, N6), or “feeling tired with the practice” (N1), and the consequences were no more interest with the treatment, and stuttering condition returned. One subject was even teased by friends when practicing the prolonged speech method.
A number of replacement methods was used to express ideas such as texting, using pen and paper to draw, using synonyms easier to pronounce, or even body language. One subject advised the PWS to use some measures to improve stuttering such as “breath slowly, confidently, speak slowly” (N2).
“Speaking Vietnamese I got stuttered, but speaking English made me stuttered more. So I used texting, writing or drawing out something for people to understand. As for Vietnamese, if I can’t speak this word, I will replace it with another word ...” (N4)
In addition, one subject shared the experience of using alcohol to overcome stuttering, and said it worked right then and there.
“I’ve heard people said that drinking alcohol made one stop stuttering. There was one day I drank, and I talked a lot, and didn’t feel shaky when I spoke “ (N1)
Participation in some self-help groups such as the ECHO was really helpful. When participating in this community, PWS felt confident because they knew they were not the only ones having difficulty with stuttering, they received empathy, encouragement to practice the therapy, or to help each other progressed.
“When joining the ECHO group, I felt more comfortable because I saw that I was not the only one who stuttered, and that feeling made my stuttering seemed lighter.” (N3)
“It was lucky for me to join that group. I found more motivation.” (N4)
All subjects expressed the wish to be treated, and the treatment had to be common in terms of the treatment place, and the methods applied. They hoped the future generations of PWS would have more support and better experiences. In addition, they wished to have more studies on stuttering in Vietnam so that information about stuttering could be more widely shared to the next generation of PWS.
“I would like to share my experience in overcoming stuttering, and those information would be used in studies of stuttering.” (N2).
4. DISCUSSION
The study explored the experiences and impacts of stuttering in Vietnamese PWS across their lifespan and on different areas of life. Results of the study have shown the impacts of stuttering in 6 areas: impacts of stuttering on learning, reactions of family members, self-isolation due to being teased for stuttering, impacts of stuttering on social relationships, impacts of stuttering on work, and experience of stuttering therapy. Beside the negative impacts, there were still favorable experiences, though just shared by a few subjects, but showed the opportunities to minimize the negative impacts of stuttering. Stuttering treatment was also a content that the PWS were interested in.
PWS were afraid to speak, avoided verbal communication situations, had low self-confidence, low self-esteem, so they tended to turn inward, and limited themselves to social relationships [9, 10, 14, 15]. Recent studies even showed that PWS had low self-esteem and were more prone to depression [6], and were considered less romantic [16], less attractive [17] than others. Such limitations have disadvantaged PWS.
The experience of stuttering on friendships was found to be similar to the findings from Klompas (2004) [9]. Starkweather and Givens-Ackerman in 1997 pointed out that teasing caused children to deviate from social norms, and behaved badly [18]. Conversely, people with communication difficulties were most likely to have been teased, or simply not listened to [19]. The limited support from teacher was already explained by the subjects as the teachers were busy with work load, or even did not know how stuttering affects their students. Lack of understanding of teachers was also reported in the study of Klompas (2004) [9], and the negative reactions of parents had made the children who stuttered worried, frustrated, and self-blame [20].
Impacts on education and work as the selection of less communicative subjects at universities were found in our data. Meredith (2015) found that stuttering influenced the choice of university and many of those choices had to take into account the need for high verbal skills [15]. Klompas noted the negative impacts of stuttering on academic performance [9], however, in this study, although there was an influence of stuttering on learning activities, all subjects had a high level of education, being undergraduate or postgraduate. This was already explained by the participants that learning assessment was mainly written, so the overall academic performance was not so bad.
Stuttering affected job selection, work performance, and job promotion of PWS, as also noted in previous studies [8, 9, 21, 22]. Furthermore, Hurst and Cooper reported that PWS had less chance of being employed [23].
There were still favorable experiences from home, school, and work environment; PWS received support from parents, relatives, teachers, and colleagues [20, 24] . In this and previous studies, the number of PWS who have had favorable experiences was small, but there are lessons we can learn from those situations. In explaining the lack of help from teachers, PWS in this study said the teachers had not understood the impact of stuttering on their students. In Langevin’s study [20] parents of PWS spent time listening, talking to their children, or waiting for them to speak. Why did they do such things? They did not do unless they understood the impacts of stuttering on their children, and they had love and empathy for their disabled children. Health education through mass media is indeed necessary and helpful to provide knowledge about stuttering to the community.
Changing words and phrases when speaking, speaking slowly, and using body language were the ways to improve speech that found in this and previous studies [9]. Many study subjects said they had no time to participate in stuttering treatment. This might be true because most of them were young and busy with work. However, one important thing noted was that they lacked motivation, and lacked adherence to treatment because stuttering treatment was long-term. Starke explained in his study that this lack of motivation was a reflection of impatient with or distrust of the effectiveness of treatment [25]. One subject in this study reported that his social relationships were normal, and that a low social participation was more due to laziness than to stuttering. Just a single opinion, and about social relation but not treatment, but it was really a good sign.
PWS had low access to stuttering treatment mostly because difficulty in finding official information on stuttering treatment. Speech therapy in Vietnam has just been developed recently with a few formally trained linguists, and information on the treatment of stuttering is still rare. In addition to formal treatment facilities, maintaining and developing more self-help groups is also desirable because of the therapeutic and emotional benefits they have been providing for PWS. The wrong kind of treatment like using alcohol to overcome stuttering is not only the fault of the PWS but also of the authorities.
The sample size was quite small, and did not include other related subjects as relatives, friends, lovers of the PWS, and treatment specialists, etc., so the information was only one way from the PWS. Online interview might limit the interaction between researcher and study subjects, and the depth of information to be shared.
Conclusion
This study provided preliminary information about the experiences and impacts of stuttering in Vietnamese adult PWS. Further studies with larger sample sizes, using appropriate methods are needed to obtain deeper and more comprehensive information. What we can do right now is through mass media, especially the internet, to provide information about treatment facilities, or organizations that PWS can join to get counseling about treatment.
