Name of Applicant (Last, First, Middle):
Earl, Allison, Nancy
A. STATEMENT OF HYPOTHESES AND SPECIFIC AIMS
Although HIV rates are rising internationally (WHO, 2007), recent work suggests that people who are at
highest-risk for HIV infection (e.g., with infrequent prior condom use) are least likely to participate in preventive
programs (Earl, Albarracín, Durantini, Gunnoe, Leeper, & Levitt, 2008; Noguchi, Albarracín, Durantini &
Glasman, 2007). Furthermore, relative to people who use condoms consistently, those at highest risk report
that HIV-prevention programs are less useful, less necessary, and unlikely to facilitate condom use for them
(Earl et al., 2008). This situation is troubling because preventive efforts target groups at highest risk for HIV
infection (Boyer et al., 1997; Gold & Rosenthal, 1995; Kalichman et al., 1993, 1995, 1996; NIMH Multisite HIV
Prevention Trial Group, 1998; Simbayi et al., 2004). This application aims to understand some of the
determinants of this low attention by high-risk individuals based on a model that explicates anticipated beliefs
and emotions that may reduce an audience’s attention to HIV-relevant information.
According to preliminary data, HIV-negative individuals fear that attention to HIV-relevant information can
create the impression that they are HIV-positive (Albarracín, Durantini, Earl, Gunnoe, & Leeper, 2006).
Participants in a prior study (Albarracín et al., 2006) reported often avoiding publicly reading or collecting an
HIV brochure to preclude the impression that they are infected with HIV. This finding is ironic given that these
programs are designed to prevent infection with HIV among people who are not currently infected. The
anticipated stigma of HIV, as well as the shame and fear of being stigmatized, may serve as powerful barriers
to attention to HIV-relevant information.
The proposed project will address stigma-related barriers to attention to HIV-relevant information.
Specifically, the application is organized around a model of attention to HIV-relevant information that predicts
when potential participants will pay attention to HIV-relevant information. According to the model, type of
information (HIV-relevant versus control) and delivery context (larger versus smaller group) predict attention by
eliciting specific beliefs (expectations about the consequences of attending to the information) and emotions
(shame and fear of being stigmatized) that likely affect attention intentions and automatic approach to the
information (Ajzen & Fishbein, 1980, 2005; Albarracín, Johnson, Muellerleie, & Fishbein, 2001; Fishbein &
Ajzen, 1975). First, HIV-relevant information is expected to elicit less attention than comparable information in
health domains (e.g., Leukemia) that are perceived as less stigmatizing (Chan, Stoové, Sringernyuang, &
Reidpath, 2008). The mediators of the hypothesized difference include greater anticipated stigma (a belief),
and greater shame and fear of being stigmatized (two emotions), for HIV-relevant information versus non-HIVrelevant information. Second, as the presence of a group can heighten stigma anticipation (Dovidio, Major, &
Crocker, 2000; Goffman, 1963), HIV-relevant information available in a larger group setting may elicit less
attention than the same information offered in a smaller group (including individually, i.e., a group of one). By
the same token, if anticipated stigma, shame, and fear of being stigmatized are barriers to attention, people
with past experiences of social rejection (e.g., members of traditionally stigmatized groups, such as ethnic
minorities, Brooks, Etzel, Hinojos, Henry, & Perez, 2005; the obese, Puhl & Brownell, 2001; or those with nonnormative grooming or hygiene, Jones et al., 1984) who chronically anticipate stigma (Downey & Feldman,
1996; Feldman & Downey, 1994; Mendoza-Denton et al., 2002) may be overall less likely to attend to HIVrelevant information than people from other groups.
The present application outlines two studies to examine the roles of anticipated stigma, shame, and fear of
being stigmatized as barriers to attention to HIV-relevant information. In both studies, participants will be
recruited from the Champaign-Urbana Public Health District. The population in attendance is 52% white, 51%
male (Champaign County Community Health Plan, 2006), with elevated risk of Gonorrhea and Chlamydia
relative to the national average (for Gonorrhea: 341.6/100,000 versus 162.0/100,000; for Chlamydia:
872.3/100,000 versus 371.2/100,000; Champaign-Urbana Public Health District, 2004). In addition, Champaign
County has some of the highest levels of HIV infection in downstate Illinois (9/100,000 versus 7/100,000;
Champaign-Urbana Public Health District, 2007). Thus, given the availability of effective HIV-relevant
information, the need understanding the reasons why people decide to attend to HIV-relevant information is
high. In the first proposed study, participants’ attention to information will be unobtrusively observed in a
waiting room setting. In this case, participants will be unaware that their public behavior is being observed
while they have the option to read brochures or watch videos available at the facility. Similar to presentation
schedules currently used at health facilities, the content of the information present at a particular time will be
randomly assigned to include brochures and videos about either HIV or Leukemia. The number of other people
in the waiting room, as well as their distance from the target participant, will be measured as another key
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predictor from the theoretical model. Afterwards, participants will be approached and asked questions about
anticipated stigma, shame, and fear of being stigmatized when attending to the information.
The second proposed study will use self-report and psychophysiological measures to obtain further
evidence that HIV-relevant information creates anticipated stigma, shame, and fear of being stigmatized
(Albarracín, et al., 2006). Furthermore, this study will test the hypothesis that viewing HIV-relevant information
(relative to control health information) in a larger (versus smaller) group delivery context will activate
anticipated stigma, shame, and fear of being stigmatized, therefore reducing the amount of attention allocated
to the health information. This objective will be accomplished by having high-risk participants read HIV-relevant
information, as well as other health-relevant information that is non-stigmatizing (e.g., information about
Leukemia; Chan et al., 2008). In addition, to manipulate delivery context, participants will be instructed to
imagine viewing information either with others (larger group delivery context) or alone (smaller group delivery
context) in the waiting room of the Champaign-Urbana Public Health District at the beginning of each block of
trials. Pictures of the waiting room reflecting either larger or smaller group delivery context will also be used to
facilitate visualization during presentation of stimulus information. To measure the amount of attentional
resources allocated to health information, while simultaneously having a more objective measure of emotional
experience while participants are paying attention to the information, participants will view this information
while connected to an Electroencephalogram (EEG). This provides the opportunity to obtain Event Related
Brain Potentials (ERPs) as a measure of psychophysiological reactions to the information. This measure is
non-invasive but can give additional insight into participants’ cognitive (e.g., attention) and emotional (e.g.,
shame and fear of being stigmatized) responses to information. Participants will be also respond to a series of
questions about the information to measure anticipated stigma, shame, and fear of being stigmatized. In
addition, to test for mediation, half of the participants will complete the questions about anticipated stigma,
shame, and fear of being stigmatized before they view information to measure expectations about the content
of information. By splitting the sample in this way, we can examine the influence of expectations on attention to
the information.
The proposed research will be developed in the context of the training program detailed in section 20,
which involves additional learning opportunities in the area of public health, social psychology and
psychophysiological methods. The principle mentor is Dr. Dolores Albarracín, and Dr. Monica Fabiani is the
secondary mentor. These two researchers have expertise in all areas relevant to the proposed project, namely
selective exposure, HIV in stigmatized groups, health communication, and ERPs. In addition, to increase the
candidate’s interaction with other researchers, the mentoring team also includes Drs. Robert Ruiter, Marta
Durantini, and Catherine Cottrell. Altogether, this mentoring team offers expertise in HIV-prevention, behavior
change, ERPs and psychophysiological methods, field work including unobtrusive observation, and stigma.
The specific aims of this application are as follows:
Specific Aim 1: Unobtrusively observe 240 clients of the Champaign-Urbana Public Health District to
measure attention as a function of the type of information available (HIV versus control), delivery
context (larger versus smaller group), and group membership (traditionally stigmatized versus nonstigmatized). Use retrospective self-report to measure anticipated stigma, shame, and fear of being
stigmatized as a function of type of information available, delivery context, and group membership.
Specific Aim 2: Recruit 50 clients of the Champaign-Urbana Public Health District and use ERPs to
gauge attention, shame, and fear of being stigmatized as a function of type of information available
(HIV versus control), delivery context (larger versus smaller group), and group membership
(traditionally stigmatized versus non-stigmatized). Use prospective self-report to measure anticipated
stigma, shame, and fear of being stigmatized as a function of type of information available, delivery
context, and group membership.
The specific hypotheses of this application are as follows:
Specific Hypothesis 1: Viewing HIV-relevant information (relative to control information) in a larger
(versus smaller) group delivery context will activate anticipated stigma, shame, and fear of being
stigmatized.
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Specific Hypothesis 2: Anticipated stigma, shame, and fear of being stigmatized will be deterrents to
attention to HIV-relevant information in a larger (versus smaller) group delivery context.
Specific Hypothesis 3: Members of traditionally stigmatized groups (ethnic minorities, the obese, or
those with non-normative grooming or hygiene) will show the negative effects of anticipated stigma,
shame, and fear of being stigmatized, to a greater extent than other people.
B. BACKGROUND AND SIGNIFICANCE
B.1.1. Anticipated Stigma, Shame, and Fear of Being Stigmatized as Barriers to Attention to HIVRelevant Information in a Larger Group Delivery Context. Much past work has been directed toward
designing programs that promote HIV-risk-reduction for high-risk individuals. However, the efficacy of these
efforts is limited if the target participants do not attend to the information. It is clear that more work is necessary
to understand factors that hinder attention to HIV-relevant information (Earl et al., 2008; Noguchi et al., 2007).
As a result, this application aims to understand some of the barriers of attention to HIV-relevant information by
high-risk individuals. The relevant theoretical model is presented in Figure 1, and describes how the presence
of HIV-relevant information in a larger group delivery context may decrease attention to HIV-relevant
information. In addition, the model postulates that the relation between type of information and delivery context
with attention may be mediated by anticipated stigma, shame, and fear of being stigmatized. Finally, this
application will test the hypothesis that the effects of anticipated stigma, shame, and fear of being stigmatized
will be amplified for members of traditionally stigmatized groups. We predict that this amplification of
anticipated stigma, shame, and fear of being stigmatized will further reduce attention to HIV-relevant
information in a larger group delivery context.
According to the model, people’s expectations about
how attention to information will be perceived by others
HIV-Relevant
Non-HIV-Relevant
Type of
Information
Information (Control)
will subsequently affect attention to information.
Information
Specifically, the model predicts that anticipated stigma,
Available
shame, and fear of being stigmatized may be powerful
deterrents to attention to stigmatizing (i.e., HIV-relevant)
Group
Group
information in a larger group delivery context. In this Smaller
Larger
Delivery
Delivery
Smaller
Larger
Group
Context
Context
case, anticipated stigma is a belief in expected social Group
Group
Group
disapproval as a result of one’s personal association with
a negative attribute or outcome that is against cultural
+ Anticipated Stigma,
norms (Goffman, 1963). Shame entails a consciousness
Shame, and Fear of
Being Stigmatized
or awareness of dishonor, disgrace, or condemnation
(Dovidio et al., 2000) and fear of being stigmatized
entails an emotional reaction to impending danger
¯
(Ekman, 1993), in this case stigmatization. In addition,
according to the model, these negative reactions are due
+
+
Attention to
Information
to presenting stigmatizing information (i.e., HIV-relevant
information versus control health information) in a larger
(versus smaller) group delivery context.
When information is offered to participants in an smaller group delivery context, participants should form
intentions about whether or not they will attend to information (e.g., “I will pay attention to information”). These
intentions are likely to be the most immediate determinant of attention decisions (Albarracín et al., 2001; Ajzen
& Fishbein, 2005; Fishbein & Ajzen, 1975). However, when information is offered to participants in a larger
group delivery context, additional factors are likely to impact the decision to attend to information. For instance,
the presence of a larger group may activate norms about attention to information (Goffman, 1963; Shah, 2003).
These norms may in turn influence intentions to attend to information (Ajzen & Fishbein, 2005; Fishbein &
Ajzen, 1975). Ultimately, these intentions should predict attention (Ajzen & Fishbein, 2005; Fishbein & Ajzen,
1975). Unfortunately, in the case of HIV-prevention, norms about attention to information may include
normative beliefs that viewing HIV-relevant information implies that one is HIV-positive, or that attending to
information will result in stigmatization (Albarracín et al., 2006). Subsequently, anticipated stigma may elicit
shame and fear of being stigmatized as negative emotional evaluations of attention (Allport, 1954; Pineles,
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Street, & Koenen, 2006; Schmader & Lickel, 2004). As a result, participants may be less likely to attend to HIVrelevant information (Albarracín et al., 2001; Ajzen & Fishbein, 2005; Fishbein & Ajzen, 1975).
Although HIV infection has long been stigmatized, most work has focused on the effects of HIV-relevant
stigma for those who are currently infected (Crandall, 1991; Herek, 1999; Pryor, Reeder, & Landau, 1999; Rao,
Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007). However, HIV-positive people may not be the only targets
of HIV-relevant stigma. For instance, family and friends of HIV-positive people (Herek, 1997; NIMH Research
Workshop of AIDS and Stigma, 1998), or even those who provide treatment to HIV-positive people (Snyder,
Omoto, & Crain, 1999) may be affected by HIV-relevant stigma. Moreover, any person who reads an HIVrelevant brochure or watches an HIV-relevant video may anticipate the backlash of HIV-relevant stigma
(Albarracín et al., 2006). As a result, people may avoid HIV-relevant information as a way of distancing
themselves from the anticipated stigma of HIV. This effect may be exacerbated for members of traditionally
stigmatized groups, who are often more aware of the potential for stigma in any event or situation (Downey &
Feldman, 1996; Feldman & Downey, 1994; Mendoza-Denton et al., 2002). In this case, chronic awareness of
stigma may interact with situational cues to trigger stigma anticipation.
Anticipated stigma may also have several emotional consequences. One potential outcome is shame.
Shame can often arise following stigma (Allport, 1954; Pineles et al., 2006; Schmader & Lickel, 2004).
Furthermore, stigmatized individuals are also more likely to experience shame (Buss, 1980; Fossum & Mason,
1986). Because both stigma and shame are responses to perceived social sanctions (Clore, Schwarz, &
Conway, 1994; Dovidio et al., 2000; Goffman, 1963), the presence of a larger group may amplify shame
(Smith, Webster, Parrott, & Eyre, 2002). As a result, potential participants may be less likely to attend to HIVrelevant information in a larger group delivery context as a way of avoiding the potentially negative outcome of
being stigmatized and shamed due to association with HIV-prevention efforts. Then again, similar to stigma,
shame may be averted by reducing attention to HIV-relevant information.
Fear of being stigmatized may be another potential emotional consequence of anticipated stigma. Much
past work has addressed the effects of fear in HIV-prevention. For instance, several theoretical models have
postulated various relations between fear and behavior change (Janz & Becker, 1984; Fisher & Fisher, 1992;
2000; Floyd, Prentice-Dunn, & Rogers, 2000; Rogers, 1975; Rosenstock, 1974; Rosenstock, Strecher, &
Becker, 1994). In addition, many studies have examined the role of fear of HIV infection in behavioral
interventions (Belcher & Kalichman, 1998; Carey et al., 1997, 2000; St. Lawrence et al., 1995). Recently, metaanalytic work suggests that fear of HIV may decrease learning and behavior change following attention to HIVrelevant information (Earl & Albarracín, 2007). By the same token, fear of being stigmatized may serve as a
powerful impediment to attention to HIV-relevant information (see also Janis & Feshbach, 1953; McGuire,
1968, 1972). Furthermore, people who are chronically aware of stigma may expect, and subsequently react to,
anticipated fear of being stigmatized even in ambiguous situations such as a public health department waiting
room (Downey & Feldman, 1996; Feldman & Downey, 1994; Mendoza-Denton et al., 2002). As a result,
members of traditionally stigmatized groups may pay less attention to HIV-relevant information than other
information, especially when presented in a larger group delivery context. Decreased attention to HIV-relevant
information would be troubling because some traditionally stigmatized groups such as African-Americans are
at high risk for HIV (Boyer et al., 1997; Gold & Rosenthal, 1995; Kalichman et al., 1995, 1996; NIMH Multisite
HIV Prevention Trial Group, 1998).
B.1.2. Multi-Method Measures of Participants’ Reactions to Information. This proposal will use several
methods to measure participants’ reactions to information, including self-report, unobtrusive observation, and
psychophysiological measures. By including multiple methods, we will be able to correlate reports across
several types of measures as a way of examining the reliability of measures of attention, anticipated stigma,
shame, and fear of being stigmatized. First, participants’ self-reported experience of anticipated stigma,
shame, and fear of being stigmatized will be recorded in both proposed studies. In Study 1, self-report
measures will be collected after participants have the opportunity to attend to information in the waiting room of
the Champaign-Urbana Public Health District waiting room. In Study 2, half of participants will complete these
self-report measures before the opportunity to attend to information, and the other half will complete these
measures after. In this respect, these studies will be able to examine expectations both before and after
attention to information. In addition, self-report will also be used to measure participants’ attention to
information. In line with the model presented in Figure 1, we predict that self-reported anticipated stigma,
shame, and fear of being stigmatized will be highest, and self-reported attention will be lowest, when HIVrelevant information is presented in a larger group delivery context.
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In addition, Study 1 contains unobtrusive observational measures of attention to information. Using
unobtrusive observation will allow us to examine what participants are actually doing in the waiting rooms of
health care facilities without the known presence of observers influencing the decision whether or not to attend
to information. For instance, the presence of a known observer may change how participants attend to
information, particularly if participants want to make a good impression on the observer or be a “good”
participant (Schlenker, 1980). As such, unobtrusive observation offers a method of measuring attention in a
naturalistic setting free of biases in self-report. In this case, coders will be present in the waiting room during
the time when participants have the opportunity to attend to brochures and videos to measure if participants
pay attention to the information.
One crucial component of this application is the use of psychophysiological measures to examine
participants’ attention and emotional reactions to health-related information. This is an important step,
especially given concerns over the validity of self-report measures in public health (Schroeder, Carey, &
Vanable, 2004a; Schroeder, Carey, & Vanable, 2004b; Schwarz, Groves, & Schuman, 1998). In the second
proposed study, participants will view health-related information (HIV and Leukemia) in both a group and
individual delivery context while connected to an Electroencephalogram (EEG) machine to measure EventRelated Potentials (ERPs). In this case, participants will be asked to attend to the health-related information
while monitoring the environment for infrequent high-pitched tones (1,000 Hz; Hillyard et al., 1995; Ruiter et al.,
2006). Degree of attention to the message will be measured by examining the amplitude of N100 and P300
ERPs in the context of a dual-task paradigm (Kessels, Ruiter, Brug, & Jansma, 2008; Ruiter, Jansma,
Wouters, & Kok, 2008; Ruiter, Kessels, Jansma, & Brug, 2006). Theoretically, differences in attention levels to
the message should be detectable by differences in the amplitude of N100 and P300 ERPs as well as delayed
response latencies to the high-pitched tones. N100 is an early-onset (peaking approximately 100ms poststimulus presentation), negative-going potential that has a frontal distribution and has been linked to orienting
and automatic stimulus processing (Luck, 2005). P300 is a more late-onset (peaking approximately 300ms
post-stimulus presentation), positive-going potential that has a central-parietal distribution and has been linked
to context updating and controlled processing of information (Luck, 2005). As a result, P300 is often used as
an index of controlled attention allocation (Coull, 1998; Hillyard et al., 1995; Ruiter et al., 2006). Because
response time and N100 and P300 ERPs are time-locked to the auditory oddballs, higher amplitudes of these
ERPs indicate more attention allocated to the auditory oddball task and less attention allocated to the
information. As such, we predict faster response latencies and higher amplitudes when participants view HIVrelevant information in a larger group delivery context. Furthermore, we are interested in testing emotional
responses to information, including shame and fear of being stigmatized, as potential mediators of the
proposed attentional attenuation to stigmatizing (i.e., HIV-relevant) information in a group delivery context. As
such, we will also measure the amplitude of the Late-Positive Potential (LPP). The LPP is a late-onset (peaking
approximately 520ms post-stimulus onset) positive-going potential that has been linked to evaluation of
information (Cacioppo, Crites, Gardner, & Berntson, 1994; Ito, Thompson, & Cacioppo, 2004), particularly
emotional evaluation (Schupp, Cuthbert, Bradley, Cacioppo, Ito, & Lang, 2000). Similarly, we predict higher
amplitude of the LPP ERP when participants view HIV-relevant information in a larger group delivery context.
Differentiation between shame and fear of being stigmatized will be accomplished by examining self-reported
emotional experience.
B.2. Significance. It has become increasingly clear that attention to information is an essential component
of intervention effectiveness. Recently, meta-intervention methods have been designed to increase attention
by means of empowering potential audiences. A meta-intervention is a supplemental program designed to
increase participation in a pre-existing preventive program (Albarracín, Durantini, Earl, Gunnoe, & Leeper, in
press). Meta-interventions have been successfully used by Albarracín and colleagues (in press) to increase
acceptance of an HIV-relevant video as well as enrollment in an HIV-prevention counseling session. In this
case, if anticipated stigma was found to be a barrier to attention, meta-interventions could address this issue.
Similarly, targeted meta-intervention labels could be designed if shame and/or fear of being stigmatized were
found to reduce attention. Thus, this work provides a critical first step to reduce barriers to attention to HIVrelevant information by target audiences.
C. PRELIMINARY STUDIES
This research proposed is based, in part, on several preliminary studies.
C.1. Field Study Examining Participation Decisions with Clients of the Alachua County Health
Department. A relevant study directed by my advisor (Earl et al., 2008; n = 350) examined who is most likely
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to participate in HIV-prevention programs. Ironically, but perhaps not surprisingly, those with low (versus high)
motivation to use condoms, condom-use behavioral skills, and prior condom use were less likely to participate
in a brief HIV-prevention counseling session. Furthermore, participants with low (versus high) motivation,
behavioral skills, and prior condom use were less likely to think that the counseling session would be useful,
necessary, or helpful to increase their condom use. Thus, these analyses established that participants who
need HIV-prevention programs most are frequently the ones who do not participate. Some of the methods to
be used in the proposed work were developed in the context of this study.
C.2. Qualitative Field Study with Clients of the Alachua County Health Department. My advisor’s team
(Albarracín et al., 2006) conducted focus groups with clients to gauge their responses to several HIVprevention programs, as well as barriers to participation. During the course of this study, participants reported
that reading a brochure or watching a video in the health-department waiting room is potentially stigmatizing,
as others in the waiting room may infer that the reader/watcher is HIV-positive and/or engages in behavior that
puts them at risk for HIV infection. Participants also reported that they normally know many of the other people
in the waiting-room, and that reports of their behavior would likely spread throughout their tight-knit community.
Participants reported that they were not afraid of preventive information, but rather did not want to be
associated with the stigma entailed by reading brochures or watching a video. This study provided the basis for
the hypotheses of the proposed study.
C.3. Meta-analysis of the Short- and Long-term Outcomes of Fear-Inducing Arguments and HIV
Counseling and Testing in HIV-Prevention. In collaboration with my graduate advisor, I recently published a
meta-analysis of the immediate and longitudinal impact of fear appeals and HIV-counseling and testing
sessions on knowledge about HIV, perceived threat of HIV, and condom use (Earl & Albarracín, 2007). These
analyses suggested that intervention programs that include fear appeals are more likely to boost perceptions
that participants are at risk for HIV-infection. However, counter to other predictions (Janz & Becker, 1984;
Floyd et al., 2000; Rogers, 1975; Rosenstock, 1974; Rosenstock et al., 1994), these fear appeals were also
linked to decreases in HIV-relevant knowledge, as well as less condom use relative to treatments that did not
include this component. This work suggests that negative emotions such as fear, and potentially also shame,
decrease attention to preventive programs.
C.4. Observational Study of Self-education in the Alachua County Health Department Waiting
Room. In collaboration with Laura Bruder and Dolores Albarracín (Bruder, Albarracín, & Earl, 2007), I
examined whether participants (n = 40) spontaneously read HIV-relevant brochures or watch a HIV-relevant
video while waiting to see a practitioner at the local health department. This study demonstrated that
participants’ reading and watching behavior could be successfully observed and coded without being
conspicuous. Of the forty participants, none reported being suspicious of the coders while they were being
observed. In addition, all participants who were approached agreed to the brief interview after the observation.
This study serves as a pilot study for the proposed project, which employs this methodology.
D. RESEARCH DESIGN AND METHOD
D.1. Study 1 Overview and Design
In Study 1, we will measure participants’ spontaneous attention to health information while they wait for
services at the Champaign-Urbana Public Health District. Specifically, we will examine if participants choose to
read brochures or watch a video, as well as how deeply participants process this information. Unobtrusive
observation will be used to code for attention with respect to strategically-placed information while minimizing
participants’ awareness that their behavior is being observed. In line with the theoretical model, we predict that
type of information (HIV versus Leukemia) and delivery context (larger versus smaller group) will influence
attention to information. Furthermore, we predict that group membership (traditionally stigmatized versus nonstigmatized) will amplify the negative effects of presence of a larger group on attention to health information. In
this study, type of information will be randomized by a day and time schedule with one participant recorded at a
time. Delivery context will be measured by recording the total number of others in the waiting room, as well as
their physical distance from the participant. These measures will allow us to determine if the presence of more
people in the surroundings, as well as the proximity of these people, decreases attention to HIV-relevant
information. Group membership will also be unobtrusively recorded by coding observable stigmatizing features
such as ethnicity, obesity, and non-normative grooming or hygiene. After participants have the opportunity to
view information, we will ask them to retrospectively self-report their reactions to the information, including
anticipated stigma, shame, and fear of being stigmatized.
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The design of the study is thus a 2 (information type: HIV versus control) X continuous (delivery context:
larger versus smaller group) X 2 (group membership: traditionally stigmatized versus non-stigmatized). In line
with the theoretical model, we predict an interaction between these three factors, such that attention will be
lowest when HIV-relevant information is presented in a larger group delivery context to members of a
traditionally stigmatized group.
D.1.1. Participants. To have adequate power (.80) to detect a small effect for the two- and three-way
interactions, f = .25, and an alpha level of .05, a total of 240 participants are needed (Faul, Erdfelder, Lang, &
Buchner, 2007). Participants will be community members who will be selected if they are sitting in predetermined seats in the main waiting room of the facility. Participants will not be aware of the observation, as is
standard in scientific observations of public behavior (Leary, 2004; Whitley, 2002).
D.1.2. HIV-Relevant Information. HIV-relevant information will include six brochures, and a health video.
Although this information has been successfully pre-tested by the team while in Florida, to confirm applicability
in Champaign-Urbana, all information will be pre-tested again with 20 participants.
D.1.2.1. Brochures. Six brochures will be used in this study: “Women & HIV: Think about It”, “Men &
HIV: Think about It”, “Safer Sex Self-Test”, “Condoms: Think about It”, “HIV: Think about It”, and “101 Ways to
Avoid HIV”. These brochures have been used successfully in past research (Albarracín et al., in press; Bruder
et al., 2007; Earl et al., 2008).
D.1.2.2. Video. The video, a segment from “Just Like Me” (AIDS Risk Reduction Project, 1997),
contains informational and motivational arguments. It comprises a series of vignettes featuring people
describing how they contracted HIV or what living with HIV entails. The video is quite moving to most viewers.
D.1.3. Control Information. Control information will include six brochures and a video on issues related to
Leukemia. This information will be comparable to the experimental information, and will be pre-tested with 20
participants to ensure equal levels of attractiveness, relevance, and educational quality.
D.1.4. Protocol. Before participants arrive, the brochures and the video will be set up in the waiting room
of the health district. Seats that allow participants to watch the video and are in clear view of the brochures will
be selected and numbered. Participants who sit in the pre-selected seats will be observed. Random
assignment to the type of information available will be based on times and days, rather than by participants.
Coders will sit in seats that allow a clear view of the participant as well as being unobtrusive. Coders will code
for the measures specified on the coding sheet, including if participants read each of the brochures or watch
the video, as well as how long they view information, and the number and physical distance of other people in
the waiting room. To have complete data for supplementary analyses, coders will also record membership in a
traditionally stigmatized group by coding for observable stigmatizing features such as ethnicity, obesity, and
non-normative grooming or hygiene, and their impression of whether the target participant is friends with the
people around them. Participants will be observed one at a time during their entire wait time. When the
participant is called into the clinic, a nurse will escort these participants to an additional waiting room where
they will wait for their practitioner. During this time, participants will be approached and offered the
questionnaire. The questionnaire will ask participants to retrospectively self-report their intentions to read each
of the brochures or watch the video, if they read each of the brochures or watched the video, recognition
questions from the information, and their reactions to the information including anticipated stigma, shame and
fear of being stigmatized.
D.1.5. Measures of Intentions, Attention, Anticipated Stigma, Shame, and Fear of Being Stigmatized.
To measure attention to the health information, participants will be observed while waiting in the waiting room
of their local health district. To measure intentions, anticipated stigma, shame, and fear of being stigmatized,
participants will be asked to self-report on a questionnaire following the opportunity to read brochures and
watch the video. This will be a retrospective self-report and participants will be instructed to complete the
measures of what they were thinking during the time that they had the opportunity to view information (see also
Earl et al., 2008). Finally, participants will be asked about membership in traditionally stigmatized groups.
D.1.5.1. Coding Sheet. The coding sheet has been rigorously piloted and used in several studies
conducted by Albarracín and colleagues (Albarracín et al., in press; Bruder, et al., 2007; Earl, et al., 2008). It
includes multiple measures of attention to both the brochures and videos. Specifically, to measure attention to
the brochures, coders will be asked to record if the participant: (a) reads a brochure, (b) which brochures (if
any) the participant reads, (c) seems attentive to the brochure, (d) reads each brochure, (e) puts down each
brochure, (f) comments on the content of each brochure, or (g) takes each brochure home, as well as (h) how
long participants spend reading brochures. Measures of attention to the video will include if the participant (i)
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watched the video, (j) seems attentive to the video, (k) glances at the video, (l) casually watches the video, (m)
watches the video intently, or (n) comments on video content, as well as (o) how long participants spend
watching the video. Coders will also record behavior not specifically related to reading the brochures or
watching the video, but may be useful to understand what participants are doing in the waiting room, including
if the participant (p) eats or drinks, (q) talks or plays with a cell phone, (r) sleeps, (s) reads non-health related
information (e.g., newspaper or novel), (t) talks with other participants, or (u) remains quietly seated. In
addition, to measure membership in traditionally stigmatized groups, coders will record (v) variables related to
traditionally stigmatized group membership (e.g., ethnicity, obesity, and non-normative grooming or hygiene).
D.1.5.2. Questionnaire. The questionnaire will assess participants’ retrospective self-report of
intentions to attend to information, attention to the brochures and video, and anticipated stigma, shame and
fear of being stigmatized experienced during the time that they had the opportunity to view information.
Specifically, participants will be asked how strong their intentions were to (a) read the brochures and (b) watch
the video, on a seven-point scale ranging from “Very Weak” to “Very Strong.” Participants will also be asked:
(c) did you read a brochure, (d) which brochures (if any) did you read, and (e) did you watch the video. In
addition, participants will be asked how much attention they paid to the (f) brochures and (g) video on a sevenpoint scale ranging from “Paid No Attention” to “Paid Very Close Attention.” To further assess attention to
information, participants will also be asked (h) recognition questions from the information. Specifically,
participants will be asked to judge if a series of statements was or was not present in the information they read.
These measures were successfully piloted (Bruder et al., 2008; Earl et al., 2008). Participants will also be
asked about their expectations about stigma, as well as shame and fear of being stigmatized for seeking the
information, on a seven-point scale ranging from “Not at All” to “Extremely.” Specifically, participants will be
asked to indicate the extent to which (i) HIV/Leukemia-relevant brochures and videos are stigmatizing, (j) if
viewing HIV/Leukemia-relevant brochures and videos would damage valued relationships or their status in
their community, (j) if viewing HIV/Leukemia-relevant brochures and videos would damage their reputation, (l)
if others would think that they have HIV/Leukemia if they view HIV/Leukemia-relevant brochures and videos,
(m) if others would treat them differently if they view HIV/Leukemia-relevant brochures and videos, (n) if they
feel ashamed when viewing HIV/Leukemia-relevant brochures and videos, and (o) if they feel afraid when
viewing HIV/Leukemia-relevant brochures and videos. Participants will also be asked to indicate (p)
traditionally stigmatized group membership. Finally, manipulation checks will be conducted by asking
participants (q) what kind of information was available in the waiting room and (r) how much privacy was
available in the waiting room.
D.1.6. Data Analyses. Multiple analyses will be conducted with the rich dataset resulting from our study.
First, analyses will be conducted to measure reliability and to check for violations of normality and sphericity.
Analyses will also first be conducted to rule out spurious findings due to outliers (+/- 3 standard deviations from
the mean). After the data are verified, structural equation modeling (SEM) will be used to test the measurement
model. With this strategy, we can also control for differences in measurement error. Next, we will use SEM to
examine the impact of type of information, delivery context, and group membership on attention to the
brochures and video. Furthermore, mediation analyses will be conducted using SEM to examine if anticipated
stigma, shame, and fear of being stigmatized mediate the hypothetical relations between type of information
available, delivery context, and group membership with attention to the information. Type of information
available, delivery context, and group membership will be included in the model as exogenous factors and
anticipated stigma, shame, and fear of being stigmatized will be included as endogenous factors.
D.2. Study 2 Overview and Design
Although the first study is important in establishing effects on attention in a natural setting, the data on
observed and self-reported attention will comprise a very tentative measure of attention (Nisbett & Wilson,
1977). Furthermore, participants who feel stigmatized, ashamed, or scared of being stigmatized may be unable
or unwilling to report these experiences (Schlenker, 1980). An additional problem is that in Study 1, the
proposed mediators of attention will be measured retrospectively. In view of these concerns, the second study
will examine attention and emotional reactions using psychophysiological measures. In this study, participants
will view both HIV-relevant and Leukemia-relevant information while connected to an Electroencephalogram
(EEG) machine to measure Event-Related Potentials (ERPs). Attention to the message will be measured by
examining the amplitude of N100 and P300 ERPs of auditory oddballs while participants are also reading
health-relevant information (Ruiter et al., 2006). In addition, emotional evaluation will be measured later in the
ERP trajectory examining the amplitude of the Late-Positive Potential (Ito et al., 2004). Finally, half of the
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participants will be asked to complete a self-report questionnaire before obtaining the attention measures. The
questionnaire will be the same used in Study 1, which will measure attention to the messages, recognition of
information, as well as anticipated stigma, shame, and fear of being stigmatized.
The design of the study will be a 2 X 2 X 2 randomized-block design with information type (HIV versus
control) and delivery context (larger versus smaller group) as two, two-level within-group factors and group
membership (traditionally stigmatized versus non-stigmatized) as a two-level between group factor. In line with
the theoretical model, we predict an interaction between these three factors, such that both the attention ERP
components (i.e., attention to the auditory oddball) and the evaluation ERP components will be highest when
HIV-relevant information is presented in a larger group delivery context to members of a traditionally
stigmatized group than in other conditions.
D.2.1. Participants. To have adequate power (.80) to detect a small effect for the two- and three-way
interactions, f = .25, and an alpha level of .05, a total of 50 participants are needed (Faul et al., 2007).
Participants will be clients of the Champaign-Urbana Public Health District, who will have normal or correctedto-normal audition and vision. Participants will be paid U$5 for the eligibility screening and U$20 for
participation in the main study if eligible. Non-eligible participants will be paid U$5, and completers will be paid
a total of U$25.
D.2.2. Recruitment. Participants will be recruited through referral from Champaign-Urbana Public Health
District staff. In addition, to prevent contamination and reduce self-selection, instructions for referral will
describe the study as assessing “opinions about health materials” with no mention of HIV. Participants will be
screened for eligibility when they are initially recruited, and if eligible will call a telephone number provided to
them to make an appointment. Participants will have to be over 21 years of age, literate, sexually active, and
not pregnant or trying to get pregnant.
D.2.3. Information. HIV-relevant and Leukemia-relevant information will include messages taken from the
brochures used in Study 1.
D.2.4. Manipulation of Group/Individual Delivery Context. Because ERPs are recorded in a booth to
minimize noise and other distractions, it is not feasible to actually measure ERPs in a group delivery context.
Instead, to mimic the conditions of a public health district waiting room in which participants may expect that
others will be able to view their behavior, we will manipulate larger versus smaller group delivery context. In the
larger group delivery context condition, participants will be instructed to think about several aspects of the
waiting room, including who is usually there (e.g., doctors, nurses, other patients, children, etc.). To help aid
visualization, participants will also view pictures of the Champaign-Urbana Public Health District waiting room
when it is full. In the smaller group delivery context condition, participants will be instructed to think about
several aspects of the waiting room, while imagining that they are there alone (i.e., a group of one). To help aid
visualization, participants will also view pictures of the Champaign-Urbana Public Health District waiting room
when it is empty. Participants will be instructed to complete the manipulation at the beginning of each block.
Pictures corresponding to each condition will also be present parafoveally on the computer screen throughout
all trials within the block.
D.2.5. Self-Report Measures of Expectations and Reactions to the Information. We will use the same
questionnaire as in Study 1, which will measure intentions to attend to the messages, attention to the
messages, and anticipated stigma, shame and fear of being stigmatized.
D.2.6. Interview/ERP Protocol. First, participants will be attached to the EEG using a cap with 30 scalp
sites, with the electrodes referenced to the left mastoid signal (Ruiter et al., 2006). In addition, to capture
vertical eye movements and eye blinks as measures of artifacts, electrodes will be attached to both the upper
and lower orbital ridge of the left eye. Next, half of the participants will be asked to complete the expectations
questionnaire detailed above which assesses participants’ a priori expectations about the content of the
information they will see, as well as their anticipated reactions to the information. The other half of the
participants will complete this questionnaire after viewing the information.
Subsequently, participants will begin the dual-task paradigm, in which participants with both view the HIVrelevant and Leukemia-relevant information crossed with larger versus smaller group delivery context while
also performing the auditory oddball task. Both of these factors will be counter-balanced across blocks. To
minimize movement, both HIV-relevant information and Leukemia-relevant information will be presented one
word at a time to participants with an interstimulus interval of 1,000ms. Each word will appear on the screen for
250ms, followed by a black screen for 750ms (Kessels et al., 2008; Ruiter et al., 2006, 2008). During this time,
pictures corresponding to larger versus smaller group delivery context will be presented parafoveally on the
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screen. In addition to reading the HIV-relevant and Leukemia-relevant information, participants will listen to
sequences of high- (1,000 Hz) and low-frequency (500 Hz) tones. The tones will be presented simultaneously
with the messages. Specifically, the tones will be presented 150ms after a word is presented and will last for
100ms. High- and low-frequency tones will be presented in a random order with an overall probability of 17%
high-frequency tones and 83% low-frequency tones. Participants will be instructed to push a button when they
hear the infrequent high-frequency tone (target) and ignore the frequent low-frequency tones (standard).
Although required to complete both tasks, participants will be instructed that they are equally important and
that both need to be performed accurately. In addition, to minimize artifacts, participants will be instructed to
avoid eye blinks and other body movements as much as possible during presentation of the audio and visual
stimuli. Finally, participants will be asked to complete post-test measures of their reactions to the information.
D.2.7. Analytic Strategy. The EEG will be digitized at 250 Hz and amplified using a 32-channel amplifier
with a bandpass of 0.05-30 Hz. All electrode impedances will be kept below 5 kΩ. Trials including artifacts
(e.g., eye blinks, muscle movement, etc.) will be removed from the data analyses. Subsequently, ERP epochs
will be selected from the continuous EEG output. Specifically, 900ms intervals will be obtained to measure
attention, shame and fear of being stigmatized. To analyze attention, N100 and P300 ERPs will be derived
separately for the target and standard tones for both HIV-relevant and Leukemia-relevant information across
both larger versus smaller group delivery context. Next, difference waves will be calculated for each participant
across information types and delivery context by subtracting the N100 and P300 ERPs to the standard tone
from the N100 and P300 ERPs to the target tone. To analyze emotional evaluation, LPP ERPs will be derived
separately for responses to “HIV” and “Leukemia” across larger versus smaller group delivery context.
Difference waves will also be calculated for each participant by subtracting the LPP to “HIV” from the LPP to
“Leukemia” for each delivery context.
D.2.8. Data Analyses. Multiple analyses are proposed with ERP, reaction time, and self-report
measures. Analyses will be conducted using ANOVA with type of information (HIV-relevant versus Leukemiarelevant) and delivery context (larger versus smaller group) as two, two-level within-subject factors, and group
membership (traditionally stigmatized versus non-stigmatized) as a two-level between-subjects factor, and the
relevant interaction terms, predicting ERPs, reaction time, and self-report. In line with past work, we predict
that N100 and P300 amplitudes to the auditory oddball task will be attenuated when participants are attending
to the visual information (Kessels et al., 2008; Ruiter et al., 2006, 2008). Thus, as predicted by the model, we
expect that N100 and P300 amplitudes will be highest when HIV-relevant information is presented in a group
delivery context to members of traditionally stigmatized groups. Also, as a measure of emotional evaluation,
we expect LPP amplitude to be highest when HIV-relevant information is presented in a group delivery context
to members of traditionally stigmatized groups. Reaction times will be log-transformed prior to analysis. In line
with past work, we predict that reaction times to the auditory oddball task will be attenuated when participants
are attending to the visual information (Kessels et al., 2008; Ruiter et al., 2006, 2008). Thus, as predicted by
the model, we expect that reaction times will be fastest when HIV-relevant information is presented in a group
delivery context to members of traditionally stigmatized groups. Analyses with self-report measures will also be
conducted to examine the effects of self-reported attention, anticipated stigma, shame and fear of being
stigmatized. Similarly, we expect that self-reported attention will be lowest, and self-reported anticipated
stigma, shame, and fear of being stigmatized will be highest when HIV-relevant information is presented in a
larger group delivery context to members of traditionally stigmatized groups.
D.2.8.4. Mediation Analyses. Mediation analyses will be performed to see if anticipated stigma,
shame, and fear of being stigmatized affect the hypothesized relation between type of information available,
delivery context, and group membership, with attention to the information. Structural equation modeling will be
used to test mediation with both ERP and self-report measures of attention. Type of information available,
delivery context, and group membership will be included in the model as exogenous factors and anticipated
stigma, shame, and fear of being stigmatized will be included as endogenous factors.
D.3. Future Directions
One potential application of this work may be how to better recruit target audiences to preventive
programs. For instance, although past work suggest that those at highest risk do not participate in preventive
programs (Earl et al., 2008; Noguchi et al., 2007), the proposed studies may shed some light on why target
audiences are reluctant to enroll in programs. Thus, in the future, the work outlined in this application may
inspire meta-interventions that may increase attention to HIV-relevant information by decreasing anticipated
stigma, shame, and fear of being stigmatized.
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