Journal Pre-proofs

Level of knowledge and evaluation of perceptions regarding pediatric diabetes

among Greek teachers

Panagiota Chatzistougianni, Eleni Tsotridou, Meropi Dimitriadou, Athanasios

Christoforidis

PII: S0168-8227(19)31163-5
DOI: https://doi.org/10.1016/j.diabres.2019.107952
Reference: DIAB 107952

To appear in: Diabetes Research and Clinical Practice

Received Date: 13 August 2019

Revised Date: 20 November 2019
Accepted Date: 27 November 2019

Please cite this article as: P. Chatzistougianni, E. Tsotridou, M. Dimitriadou, A. Christoforidis, Level of
knowledge and evaluation of perceptions regarding pediatric diabetes among Greek teachers, Diabetes Research
and Clinical Practice (2019), doi: https://doi.org/10.1016/j.diabres.2019.107952

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 Level of knowledge and evaluation of perceptions regarding

pediatric diabetes among Greek teachers

Panagiota Chatzistougianni, Eleni Tsotridou, Meropi Dimitriadou,

Athanasios Christoforidis

1st Department of Pediatrics, School of Medicine, Faculty of Health Science, Aristotle University of

Thessaloniki, Ippokratio General Hospital, Thessaloniki, GREECE

Corresponding author:
Athanasios Christoforidis, MD, PhD
1st Department of Pediatrics, School of Medicine, Faculty of Health Science,
Aristotle University, Hippokration General Hospital, Thessaloniki
Address: 49 Konstantinoupoleos str, 54642, Thessaloniki, Greece,
Telephone: +302310892491, FAX: +302310992784,
e-mail address: christoforidis@auth.gr

1
Abstract

Aim. To assess the knowledge and attitudes of nursery school, preschool and primary

school Greek teachers regarding pediatric diabetes.

Methods. Our anonymous questionnaire was comprised of three parts: the first part

was regarding sociodemographic characteristics; the second part was assessing basic

knowledge about diabetes and the third part was about personal perceptions regarding

diabetes management in the school setting. A total of 375 fully completed

questionnaires were collected (22,67% from males).

Results. Males had a higher percentage of correct answers than females (80.71 ±

10.58% versus 80.17 ± 11.77%), but without reaching statistical significance (p= 0.763).

Teachers aged over 45 years, tertiary education graduates and teachers in the public

sector proved to be more knowledgeable about the disease. Question scoring the

lowest percentage of correct answers were those dealing with the management of

diabetic emergencies, such as the course of action in case a diabetic pupil is found

unconscious. One out of four participants incorrectly declared that a delay in the

diagnosis of diabetes mellitus cannot possibly be life-threatening whereas, an

embarrassing 7.47% of the participants stated that diabetes is a contagious disease and

another 6.67% declared that diabetic children should stop school.

Conclusions. It is evident that there is an urgent need for providing further information,

as well as practical training to schoolteachers with emphasis being placed on the initial

symptoms of diabetes and also in the detection and management of diabetic

emergencies.

Keywords: type 1 diabetes mellitus; children; teachers; school; nursery; questionnaire

2
Funding: This research did not receive any specific grant from funding agencies in the

public, commercial, or not-for-profit sectors.

Conflict of interest: None

3
Introduction

Type 1 Diabetes Mellitus (T1DM) constitutes a growing epidemic and one of the

most significant public health issues worldwide. It is estimated that the number of

children and adolescents (0-19 years old), who live with T1DM rises up to 1,110,100 and

the number of new cases per year to 128,900, while an increase regarding the incidence

of the disease especially in children and adolescents younger than fifteen has been

observed in many countries during the past decades with an overall annual increase of

approximately three percent [1].

According to the Diabetes Control and Complications Trial (DCCT) achieving

optimal glycemic control plays a significant role in delaying the development and

slowing down the progression of long-term complications, such as retinopathy,

nephropathy, and neuropathy, which are leading causes of morbidity and mortality in

patients with T1DM [2]. Since these young patients spend a great deal of their time at

school, it is crucial to ensure that the school provides a safe environment, where they

can monitor blood sugar levels, administer insulin when needed, have healthy meals or

snacks and take part in physical education (PE) classes, as well as in extracurricular

activities, such as field trips. When taking into consideration that children spend a great

deal of time away from home from a very early age, when they are not capable or

mature enough to be fully responsible for the management of diabetes, a very

important question arises: Are nursery schools, preschools and primary schools

equipped in the sense of at least having a refrigerator for the storage of glucagon and

the teachers knowledgeable enough, so as to assist them and create the safe

environment needed? According to the American Diabetes Association (ADA) trained

and knowledgeable staff is crucial for the diabetic students’ immediate safety when

4
acute hypo- or hyperglycemia occur, for the protection against chronic complications

and in order for them to reach their full academic potential [3].

Despite these recommendations, several previous studies have shown that

parents raise concerns regarding the safety of their diabetic children at school [4–6] and

that teachers in different educational stages are not knowledgeable enough about the

disease and its management [7–15]. The aim of our study was to assess the knowledge

and attitudes of nursery school, preschool and primary school teachers about diabetes

and its management in the school setting in Greece. To our knowledge no similar study

has been conducted in the Greek population.

Material and methods

A cross-sectional descriptive study was conducted among nursery, preschool

and primary school teachers in Greece, the majority of whom work in schools located

in Northern Greece. Approval for this study was obtained by contacting the

headmasters and headmistresses of the schools, in order to obtain their informed

consent and their permission to contact the teachers during school hours and on school

grounds. All teachers working in the randomly selected schools were considered eligible

for participation in the study and were handed an anonymous questionnaire to evaluate

their knowledge and attitudes towards diabetes. Exclusion criteria included leave of

absence or refusal to fill in the questionnaire. A total of 375 questionnaires were

completed in the presence of researchers.

Our research tool was an anonymous questionnaire developed for this

particular study, which was comprised of three parts. The first part included four

questions regarding sociodemographic characteristics i.e gender, age, educational

5
status and having friends or family members with diabetes. The second part included

twenty questions aimed at assessing basic knowledge about the disease i.e affected age

groups, signs and symptoms, management and control, diet, ability to take part in PE

classes and extracurricular activities and finally detection of hypo- or hyperglycemia.

The third part included thirteen questions about personal attitudes and beliefs

regarding diabetes management in the school setting. The distributed questionnaire is

shown in Appendix 1.

For statistical analysis and graphical demonstrations, the Microsoft® Excel® for

Mac 2011 version 14.0.0 and the IBM® SPSS® Statistics version 20 were used. Shapiro-

Wilik and Kolmogorov-Smirnov tests were used to assess normality of the data. For

quantitative variables student’s t-test was performed to test the equality of means of

two samples and Anova to compare the means of more than two samples for normally

distributed data. Mann-Whitney U and Kruskal-Wallis tests were used respectively for

non-normal data. Chi-square test was used in order to compare qualitative variables

between groups. The level of statistical significance was p<0.05.

Results

In total we collected 375 fully completed questionnaires. Eighty-five

questionnaires (22.67%) were completed by males and the remaining 290 (77.33%) by

females. All age groups were represented with the greatest participation (30.93%)

being observed in the group of teachers over 45 years of age and the lowest among the

youngest ones (<25 years old), who comprised 5.07% of the study sample. There were

no males in the age group 25-30 years, while there were significantly more males than

in the total population in the age groups <25 years and 40-45 years (p=0.003 and

6
p=0.046 respectively). The majority of study participants were university-educated

(64.26%), while 24.27% had a master’s degree or a doctorate. The sex distribution in

each educational status group did not show statistically significant differences, except

for the group of high school graduates, where there were significantly more male

participants than in the totality (p=0.001). Two hundred and thirty-nine questionnaires

(63.73%) were completed by primary school teachers, 72 (19.20%) by preschool

teachers and 64 (17.07%) by nursery school teachers. 246 teachers (65.60%) worked in

the public sector, while 129 (34.40%) worked in the private sector. Two hundred and

seven (55.20%) participants reported having a friend or family member with diabetes.

There were significantly more males in the group, which responded positively. The

sociodemographic characteristics of the study participants are shown in Table 1.

With regards to the second part of the questionnaire the mean percentage of

correct answers was 80.29 ± 11.50%. Males had a higher percentage of correct answers

than females (80.71 ± 10.58% versus 80.17 ± 11.77%), but without reaching statistical

significance (p= 0.763). Furthermore, nursery school teachers had a higher percentage

of correct answers than pre- and primary school teachers, but this difference was also

not statistically significant (82.11 ± 10.57% versus 81.74 ± 11.17% and 79.37 ± 11.78%

respectively, p=0.128). When the percentages of correct answers in the different age

groups were compared, statistically significant differences arose. The age group >45

years scored best, while the group 35-40 years had the worst performance with a mean

percentage of correct answers of 84.01 ± 10.00% and 75.38 ± 9.84% respectively. These

differences are shown in Figure 1. The differences between the mean percentages of

correct answers of the different educational status groups approached statistical

significance (p=0.072, Figure 2). The group of tertiary education graduates had the

7
highest mean percentage of correct answers (81.78 ± 9.90%), followed by the group of

teachers who held a master’s degree or a doctorate (78.57± 13.02%) and the graduates

of post-secondary education (78.16 ± 15.47%). Secondary education graduates had the

worst performance (73.64 ± 14.41%) and the difference between this group and the

group of tertiary education graduates showed statistically significant (p=0.021, Figure

2). Finally, there was a statistically significant difference in the percentage of correct

answers between teachers working in the private and the public sector, with a better

performance of the latter being observed (82.56 ± 9.71% versus 75.97 ± 13.32%,

p<0.001).

The lowest percentage of correct answers observed in the study was 45% found

in six questionnaires, which were all completed by females. On the other hand, seven

participants, also females, achieved the perfect score of 100%. The most frequently

observed score was 90% (73 questionnaires) followed by 85% (72 questionnaires). The

characteristics of the participants who achieved the highest (100%) and lowest (45%)

scores are summarized in Table 2. It is particularly interesting that the question with

the lowest percentage of correct answers (37.33%) was the one regarding the necessary

actions in case a diabetic student is found unconscious. Other questions with relatively

low percentages of correct answers were the ones concerning the treatment of

diabetes mellitus in children and the route of insulin administration (48.27 and 56.80%

respectively). The difference between the percentage of correct answers in these three

questions and the overall mean percentage of correct answers was statistically

significant (Figure 3).

The majority of participants (n=337, 89.87%) correctly reported that it was

possible for a child to suffer from diabetes. There were significantly more males and

8
younger participants in the group which gave an incorrect answer to this question, but

no other statistically significant difference was detected between the two groups. In

response to Question 4 approximately one out of four participants incorrectly declared

that a delay in the diagnosis of diabetes mellitus cannot possibly be life-threatening.

The participants who reported having a friend or family member with diabetes, the

participants over 45 years of age and university graduates had a higher percentage of

correct answers to this question unlike high school graduates and, surprisingly the

participants who held a master’s degree or a doctorate. Six-point sixty-seven percent

of participants declared that diabetic students should stop school. Higher percentages

of incorrect answers were observed among males, teachers working in the private

sector, high school graduates and post-secondary graduates. In response to the

question whether diabetes is a contagious disease, 28 participants accounting for 7.47%

of the study sample surprisingly responded positively. Higher percentages of incorrect

answers were observed among younger participants, participants with lower

educational status and those working in the private sector.

With regards to the third part of the questionnaire, which included personal

attitudes and beliefs regarding diabetes management in the school setting, the answers

given are summarized in Table 3 and the percentages of correct answers in part 2

among those who answered positively or negatively to each individual question of part

3 are shown in Figure 4. Quite unexpectedly a higher percentage of correct answers in

part 2 was observed among the teachers who stated that they had never taught a

diabetic student and the teachers, whose school did not take special measures for the

management of diabetes (81.78% versus 75.71%, p=0.001 and 81.33% versus 78.91%,

p=0.010 respectively). Another unexpected finding was the lower percentage of correct

9
answers among the teachers who reported having received special training on diabetes

(76.21% versus 82.41%, p<0.001). The teachers who stated that they were eager to

support a diabetic pupil, as well as those who supported that providing further

information about diabetes mellitus to the public could help the integration of diabetic

pupils into the school class achieved significantly better scores (81.59% versus 72.22%,

p<0.001 and 81.26% versus 72.44%, p=0.001). Finally, a significantly higher percentage

of correct answers was achieved by the participants who declared that they would be

eager to learn how to measure blood glucose levels and administer glucagon

intramuscularly (after specific training) in case of an emergency (80.93% versus 75.85%,

p=0.006 and 80.74% versus 78.83%, p=0.040 respectively).

Discussion

Our study is the first to assess the knowledge and attitudes of school teachers

regarding diabetes and its management in Greece. According to our results teachers in

nursery, pre- and primary schools in Greece had fair general knowledge about diabetes

with a mean percentage of correct answers of 80.29 ± 11.50% with teachers aged over

45 years, tertiary education graduates and teachers in the public sector proving to be

more knowledgeable about the disease. However, lack of knowledge regarding the

management of diabetes emergencies and the administered treatment was observed.

Furthermore, despite the generally favorable attitudes of the study participants, there

were high percentages of teachers who had not received any specific training about

diabetes management and schools with no specific measures for diabetes

management, such as the presence of a school nurse.

10
 The higher percentage of correct answers observed in the age group >45 years

could be attributed to the fact that teachers with more years of teaching experience

were more likely to have had diabetic students in class and are thus more likely to be

better informed about the disease and its management in the school setting. However,

earlier studies have not demonstrated a positive correlation between the years of

teaching experience and the level of knowledge about diabetes [14,15] or that younger

teachers were in fact more knowledgeable about the subject [7,16]. The overall level of

general knowledge about diabetes in our study was higher than the one found in

previous studies. Bradburry and Smith conducted a study in 1983 in order to evaluate

the level of knowledge of school teachers of diabetic pupils in Liverpool, United

Kingdom [15]. Only 25% of participants had adequate knowledge, the source of

information being mostly parents and students. In another study from the United

Kingdom, Warne reported that only one third of the teachers of diabetic students

included had adequate knowledge about diabetes, the mean score achieved being 10.5

out of 17 [14]. An updated form of the questionnaire developed by Bradbury and Smith

has recently been adopted by Januszczyk et al. in order to assess the knowledge of

trainee teachers in the United Kingdom [13]. Only 60% of participants had a satisfactory

level of knowledge, defined as at least 75% correct answers, with the mean score being

60%. Studies conducted in other countries including Spain, Turkey, Riyadh, the United

States of America and the Hashemite Kingdom of Jordan also reveal a lack of a

satisfactory level of knowledge [7,8,10,11,17].

A key finding in our study was the low percentage of correct answers regarding

the management of diabetic emergencies, such as the course of action in case a diabetic

pupil is found unconscious. This in accordance with the findings of earlier studies. In a

11
study conducted in Riyadh, which included 177 primary and intermediate

schoolteachers, recognizing the signs and symptoms of hypo- and hyperglycemia

proved to be the least known subject [10]. In another similar study from Turkey, 17.9%

of participants stated that they did not know what to do in case of emergency and some

stated that they would give salt-added yoghurt or would slap the child’s face in case of

hypoglycemia [8]. Gomez-Manchon et al. report that, although 97% of the teachers of

diabetic students aged 3-18 years old in Madrid, Spain knew what hypoglycemia was,

only 67% of them were able to recognize its signs and symptoms and only 57% knew

the necessary course of action [9]. The same contrast has also been highlighted by

Bradbury and Smith [15]. However, another recent study in Spain conducted by

Gutierrez-Manzanedo et al. reveals a much higher percentage of correct answers to the

same question regarding the necessary measures in case a diabetic student is found

unconscious with 74.5% of the 756 teachers included in the study answering correctly

[7]. Sixty-three point six percent of parents of 220 diabetic pupils in a study in Italy

reported that their child had experienced at least one episode of hypoglycemia at

school and the majority of these episodes had been managed by the parents

themselves [5], while approximately half of the teachers taking part in a recent study in

Spain conducted by Carral San Laureano et al. admitted that their schools were not

prepared for the management of diabetic emergencies [16]. These findings raise

concerns about the immediate safety of diabetic students in case an emergency occurs.

Singh et al. conducted a study aimed at assessing the knowledge of a more specialized

group, of final year medical students, in Southern India about diabetic ketoacidosis

(DKA) and demonstrated that even in this study group there was a lack of awareness

regarding the characteristics and management of this important complication [18].

12
 Another rather alarming finding, which has also been highlighted in previous

studies, is the lack of specific pre- or in-service training about diabetes and its

management. British school teachers admit that the presence of a diabetic student in

class makes them feel nervous or scared [15,19] and this insecurity, which was also

observed in other studies was attributed mainly to the lack of specific instructions

regarding the management of the disease [9] and the lack of practical rather than

theoretical training [10]. Only 0.63% of 318 teachers in Riyadh [10], 0.8% of 756

teachers in Spain [16], 1.3% of 1500 teachers in Turkey [8], 10% of 722 teachers in

Arkansas, United States of America [11], 20% of 39 trainee teachers in the United

Kingdom [13], 40.4% of 52 teachers in Italy [5] and 0% of 350 school counselors in

Jordan [17] had specific training. Even in the study conducted by Pinelli et al., where a

higher percentage (40.4%) of teachers had received training, 61.9% of them declared

that they had been trained by parents and only 33.3% by specialized diabetic personnel

[5].

Another major problem identified was the lack of special measures at schools,

such as the presence of a school nurse. The lack of school nurses and specially trained

teachers, who could effectively support the diabetic pupils, was the most common

concern of parents in the study by Pinelli et al. [5]. Consequently, the students

themselves or the parents were responsible for the administration of insulin during

school hours. Another noteworthy finding of this study was that 50% of the parents

included stated that the school personnel refused to store and administer glucagon if

needed. Gomez-Manchon et al. report that health personnel was present only in 8% of

the school units included in their study and that in 50% of the times a relative had to

administer insulin [9]. Abdel Gawwad reported that 64.4% of the 177 teachers included

13
in his study declared that providing care to diabetic students during school hours was

the family’s responsibility [10], while according to the findings of Driscoll et al. the

parents’ presence was usually necessary during extracurricular activities [20]. These

problems and shortcomings could on the one hand burden parents, who feel anxious

about the safety of their children and are forced to be responsible for their care even

during school hours, and on the other hand could lead to negative experiences for

diabetic students. School rules are sometimes inflexible thus hindering self-care of

diabetes [4,6]. In a study conducted by Wang et al. Taiwanese adolescents with T1DM

admitted that teachers often thought signs and symptoms related with high or low

levels of blood glucose to be excuses for absences or disobedience [21].

Additionally, schoolteachers could play a significant role in recognizing the first

signs and symptoms of diabetes thus contributing to earlier diagnosis and reduction of

the percentage of children presenting with DKA at diagnosis. Towson et al. have already

proved the feasibility of a community-based intervention aimed at increasing

awareness of T1DM and achieving earlier diagnosis. Parents of diabetic and non-

diabetic school children, teachers and nursery schools managers, general practitioners

and nurses were included in the study [22]. The Kids and Diabetes in School Project

(KiDS Project) by the International Diabetes Federation is the first international project

directed to caregivers and school personnel with free online material available in fifteen

languages, which provides information about T1DM and the special needs of young

patients at schools. A pilot evaluation of this project in Brazil conducted by Bechara et

al. proved its success in improving parents’ and teachers’ knowledge, as well as in

establishing a better and safer environment at school [23]. Apart from strengthening

teachers’ knowledge about diabetes and the needs of diabetic students, courses of in-

14
service practical training in collaboration with the local diabetic units could offer a lot

improving the school-lived experiences of diabetic students.

Our study is not exempt from limitations. The answers of participants to the

questions about their personal attitudes and beliefs regarding diabetes management in

the school setting could be affected by social desirability. Furthermore, we did not

record students and parents’ experiences and the extent to which the schools cater to

their needs. However, and despite these limitations, our study supports the evident

that there is an urgent need for providing further information, as well as practical

training to schoolteachers with emphasis being placed on the detection and

management of diabetic emergencies. Knowledgeable and trained staff could

effectively support diabetic students not only practically in the sense of providing help

with everyday practices, such as glucose measurements and insulin administration, but

also by establishing an environment based on the understanding of their needs.

15
Table 1. Sociodemographic characteristics of the study participants.

Sex:
Male, n (%) 85 (22,67)
Female, n (%) 290 (77,33)
Age group: n (%) Male (%) p Educational status: n (%) Male (%) p
<25 years 19 (5.07) 52.6 0.003 MD or PhD 91 (24.27) 28.57 N.S.
25-30 years 80 (21.33) 0 <0.001 Tertiary 241 (64.26) 18.67 N.S.
30-35 years 80 (21.33) 23.75 N.S. Post-secondary 19 (5.07) 10.53 N.S.
35-40 years 52 (13.87) 28.85 N.S. Secondary 22 (5.87) 54.55 0.001
40-45 years 28 (7.47) 39.29 0.046 Other 2 (0.53) 0 N.S.
>45 years 116 (30.93) 25.86 N.S.
School unit: n (%) Sector: n (%)
Primary school 239 (63.73) Public 246 (65.60)
Preschool 72 (19.20) Private 129 (34.40)
Nursery 64 (17.07)
Friend or Family member with diabetes: 207 (55.20)

16
Table 2. Characteristics of participants scored highest (100%, n=7) and lowest (45%,
n=6).
Scored worst Total Scored best
Parameter n, (%) p n, (%) n, (%) p
N 6 375 7
Males 0 (0) 0.244 85 (22.67) 0 (0) 0.208
Age group
<25 years 0 (0) 0.582 19 (5.07) 0 (0) 0.552
25-30 years 6 (100) 0.004 80 (21.37) 0 (0) 0.222
30-35 years 0 (0) 0.259 80 (21.37) 0 (0) 0.222
35-40 years 0 (0) 0.362 52 (13.87) 0 (0) 0.325
40-45 years 0 (0) 0.504 28 (7.47) 0 (0) 0.470
>45 years 0 (0) 0.174 116 (30.93) 7 (100) 0.023
Educational level
MD or PhD 3 (50) 0.303 91 (24.27) 1 (14.29) 0.618
Tertiary 0 (0) 0.050 241 (64.26) 6 (85.71) 0.607
Post-Secondary 3 (50) <0.001 19 (5.07) 0 (0) 0.552
Secondary 0 (0) 0.553 22 (5.87) 0 (0) 0.552
Other 0 (0) 0.858 2 (0.53) 0 (0) 0.847
Friend or family member
3 (50) 0.889 207 (55.20) 2 (28.57) 0.406
with diabetes
School unit
Primary school 5 (83.33) 0.670 239 (63.73) 4 (57.14) 0.863
Preschool 0 (0) 0.284 72 (19.20) 2 (28.57) 0.622
Nursery 1 (16.67) 0.983 64 (17.07) 1 (14.29) 0.869
Public sector 3 (50) 0.702 246 (65.60) 7 (100) 0.432

17
Table 3. Percentages of positive and negative answers in part 3 questions.

Question YES n,(%) NO n,(%)

1. Have you ever had a diabetic student in your class? 92 (24.53) 283 (75.47)
2. Are you willing to have and support a diabetic student
323 (86.13) 52 (13.87)
in your class?
3. Are there special measures for the support of diabetic
students at your school (such as the presence of a school 161 (42.93) 214 (57.07)
nurse)?
4. Have you received pre- or in-service special training on
128 (34.13) 247 (65.87)
diabetes?
6. Do you believe that diabetic students feel inferior or
221 (58,93) 154 (41.07)
different to their peers?
7. Do you believe that providing further information
about diabetes to the public could help improve the 334 (89.07) 31 (8.27)
integration of diabetic students into the school class?
8. Do you believe that the presence of the parents is
necessary in order for a diabetic child to take part in 118 (31.47) 257 (68.53)
athletic activities (curricular or extracurricular)?
9. Would you allow a diabetic student to measure blood
329 (87.73) 46 (12.27)
sugar in class?
10. Would you be willing to learn how to measure blood
329 (87.73) 46 (12.27)
sugar levels?
11. In case of hypoglycemia, would you allow a diabetic
370 (98.67) 5 (1.33)
student to have a snack in class?
12. Is there a refrigerator for the storage of glucagon at
341 (90.93) 34 (9.07)
your school?
13. Would you be willing to administer glucagon
intramuscularly (after special training) in case of a diabetic 304 (81.07) 71 (18.93)
emergency?

18
Figure 1. Percentages of correct answers across the different age groups. Teachers
aged >45 years scored best, while the group 35-40 years had the worst performance.

19
Figure 2. Percentages of correct answers across the different educational status
groups. Tertiary education graduates had the highest mean percentage of correct
answers whereas secondary education graduates had the worst performance.

20
Figure 3. Percentages of correct answers for each one of the 20 questions consist part
2 of the questionnaire. A full list of the questions can be found in Appendix 1.

21
Figure 4. Percentages of correct answers in part 2 questions among those who
answered positively or negatively to each individual question of part 3.

22
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