STIGMA AND STUTTERING: A HEALTH COMMUNICATION PERSPECTIVE By Erika Mueller A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Communicative Sciences and Disorders – Master of Arts 2025 ABSTRACT Globally, negative stigma and misconceptions of stuttering profoundly impact people who stutter, limiting their participation in daily life activities, and vocational, educational, and social opportunities (Boyle, 2018; Boyle et al., 2018; Boyle & Fearon, 2018; Briley et al., 2021a; Werle et al., 2021). Previous anti-stigma interventions have demonstrated moderate attitudinal improvement among the general population toward stuttering (Abdalla & St. Louis, 2014; Boyle et al., 2016; Flynn & St. Louis, 2011; Kuhn et al., 2015; Langevin & Prasad, 2012; St. Louis et al., 2018, 2020a; St. Louis & Flynn, 2018; Weidner et al., 2018). The current study examined previous anti-stigma interventions across various stigmatized conditions, populations, and settings and sought to identify facilitators and barriers associated with stigma reduction toward stuttering. Key components from previously successful interventions were used to guide the formation of a novel evidence-based intervention: a pre-recorded presentation given by a person who stutters designed for adults who are not communicative sciences and disorders students or graduates and do not stutter, which utilized contact and education approaches. Using the Public Opinion Survey of Human Attributes – Stuttering (POSHA-S) (St. Louis, 2022), a standardized assessment, participants’ attitudes, reactions, and beliefs toward stuttering were measured using posttest only control group design and open-ended questions. ACKNOWLEDGEMENTS I want to express my most heartfelt appreciation and gratitude for each person who have supported me throughout this journey. I am deeply appreciative of my mentor and advisor, Dr. J. Scott Yaruss, for his unwavering support, endless patience, guidance, and encouragement throughout my journey. His dedication, passion, and professionalism I have had the privilege of learning from - as a researcher, clinician, professor, and mentor – continue to inspire me beyond measure. His ability to always find a solution and recognize potential where I might otherwise miss it has opened doors I never imagined existing for myself, and I am forever indebted. I would also like to acknowledge and thank my committee, Dr. Bridget Walsh, and Dr. Jim Dearing, for continuously offering valuable insight, inspiring my research pursuits, and supporting my growth as a student and researcher. It is an honor to learn from this committee. Thank you. I am grateful for every individual, stranger, friend, or family, who has contributed to this project in some way through hours of brainstorming conversations, lending a listening ear, a helping hand, or reminding me of my own capabilities (particularly the Messer family). The constant and immense love and support from each of you is not lost on me. This thesis is not only a culmination of my own work, but an homage to each of you. I sincerely thank you for being a part of this journey, and I am forever obliged. iii TABLE OF CONTENTS INTRODUCTION .......................................................................................................................... 1 LITERATURE REVIEW ............................................................................................................... 6 METHOD ..................................................................................................................................... 32 REFERENCES ............................................................................................................................. 52 APPENDIX A: THEORETICAL EVIDENCE ............................................................................ 60 APPENDIX B: OUTLINE OF PRESENTATION SCRIPT ........................................................ 67 APPENDIX C: OPEN-ENDED QUESTIONS FOLLOWING THE INTERVENTION ............ 69 APPENDIX D: HEALTH COMMUNICATION LITERATURE BACKGROUND .................. 70 APPENDIX E: POSHA-S SURVEY ............................................................................................ 75 APPENDIX F: POSHA-S SUMMARY DATA............................................................................ 93 iv INTRODUCTION Attitude and stigma, though closely related, are distinct concepts. Attitudes are evaluative responses towards specific entities or objects, such as topics, behaviors, or groups of people. Evaluative responses, whether covert or overt, include cognitive, affective, and behavioral aspects (Eagly & Chaiken, 1993). Stigma, as defined by Goffman (1963), is “… a mark or attribute that reduces an individual from a whole and usual person to a tainted, discounted one” (p.3). Stereotypes, which link conditions or traits to negative social identity (Link & Phelan, 2001), oversimplify beliefs about particular groups or conditions (Corrigan & Kleinlein, 2005; Major & O’Brien, 2005). Stereotypes often lead to negative perception and societal consequences, including avoidance, segregation, and discrimination of the stigmatized group (Boyle, 2017), and this can contribute to the stigma. While attitudes involve evaluative responses towards specific entities, stigma often results in adverse societal consequences. When a significant portion of society agrees with negative stereotypes, it results in public stigma (Jones, 1984; Rabiner et al., 1983). Prejudice occurs as individuals endorse particular beliefs (Corrigan, 2018), and this can result in discrimination, also known as enacted stigma (Boyle, 2018; Corrigan, 2018). Individuals in a stigmatized group may experience anticipation or fear that they will incur enacted stigma because of their stigmatizing condition; this is known as felt stigma (Corrigan et al., 2006; Link et al., 1989). The internalization and application of seemingly far-removed and widely held beliefs toward a stigmatized group has the potential to influence an individual’s reactions, affecting their participation in a variety of contexts. Stigmatized individuals may internalize such stereotypes, resulting in self-stigma (O’Brien, 2005; Morris, 2012; Stangl et al., 2019; Waqas et al., 2020; Weidner et al., 2018). 1 Evidenced-based interventions (EBIs) encompass effective programs, practices, policies, and guidelines (Walker et al., 2022) for stigma reduction and attitude improvement toward stigmatized conditions. Dissemination is the targeted spread of information through various message channels (Dearing et al., 2017). Diffusion is “a social process that occurs among people in response to learning about an innovation such as new evidence-based approach…” (Rogers, 2003, p. 183). The rate and extent of an innovation's adoption are influenced by numerous factors, including adopters’ perceptions of innovation and dissemination processes (Dearing & Cox, 2018). The spread of innovations does not guarantee changes in beliefs and practices, emphasizing the importance of considering adoption and diffusion within the context of EBIs (Dearing & Cox, 2018). Understanding that spreading innovations does not result in changes in belief or behavior, it is critical to consider the dissemination and adoption of EBIs to ensure an innovation’s efficacy and effectiveness in reducing stigma and negative attitudes. Further background information can be found in Appendix D. This information will be considered in future directions. Negative stigmas and public attitudes have long impacted a variety of groups, such as those with mental illness (Corrigan et al., 2012; Corrigan & Kleinlein, 2005; Stangl et al., 2019; Waqas et al., 2020), Human Immunodeficiency Virus (HIV) (Brimlow et al., 2003; C. B. Collins & Sapiano, 2016; Kohli et al., 2023), obesity (St. Louis, 2020; Westbury et al., 2023), and stuttering. Extensive literature highlights the prevalence of negative attitudes and stigma towards stuttering among the public (Abdalla & St. Louis, 2014; Amick et al., 2017; Arnold & Li, 2016; Boyle, 2017; Boyle et al., 2009; Croft & Byrd, 2021; Crutchfield & Wang, 2016; de Britto Pereira et al., 2008; Iimura & Miyamoto, 2021; Klompas & Ross, 2004; Koutsodimitropoulos et al., 2016; Ma et al., 2023; Singh & Kumar, 2021; St. Louis, 2020). Attempts to reduce and 2 mitigate the negative perceptions of numerous stigmatized groups have been made by various organizations such as researchers, advocacy groups, government organizations, and grassroots groups. Boyle et al., (2016) identified three processes that may serve as powerful interventions that may impact public stigma. These processes include (a) contact, i.e., hearing personal stories or interacting with individuals from the stigmatized group; (b) protest, i.e., “condemning negative attitudes,” and (c) education, i.e., replacing myths with facts (Boyle, 2017, p. 922). Vehicles are the modalities in which processes may be delivered which includes media-based and/or in-person delivery of the message (Boyle, 2017). It is important to carefully consider which processes and vehicles will be utilized, as each factor possesses its facilitators and barriers to reducing stigma. The implications of negative public stigma and attitudes can be profound for people who stutter, potentially catalyzing the development of self-stigma, potentially affecting various aspects of individuals’ lives. As a result, negative implications for stigmatized individuals have been seen in overall psychological well-being (Boyle, 2018; Boyle & Fearon, 2018; Gerlach et al., 2021) and self-perceived communication competency (Werle et al., 2021), opportunities in academic (Walker Robert Mayo & St Louis, 2016; Werle & Byrd, 2021) and vocational (Gerlach et al., 2018; Hurst & Cooper, 1983) domains, and hindrance of pursuing of life goals (Boyle, 2017). Research has consistently shown that stutterers experience heightened levels of self- stigma and reduced self-esteem (Boyle, 2018; Boyle et al., 2018; Boyle & Fearon, 2018; Gerlach et al., 2021; Tichenor & Yaruss, 2019). The vast impact of negative public stigma and attitudes towards stuttering encompasses psychological well-being, self-perceived communication competence, academic and vocational opportunities, and the pursuit of life goals, thereby highlighting the detrimental impact of self-stigma and reduced self-esteem among individuals 3 who stutter. This knowledge poses an urgency to address the widespread issue of stigma towards stuttering and the necessity of improving public attitudes and reducing stigma. Previous research highlights the difficulty of altering attitudes and stigma towards conditions such as mental illness across diverse populations using anti-stigma approaches (Corrigan & Shapiro, 2010; Morris, 2012; Waqas et al., 2020). While the impact of stigma on people who stutter is well-documented, there is limited evidence demonstrating long-term effectiveness in improving attitudes and reducing stigma. Negative attitudes toward stuttering have persisted despite numerous efforts to reduce stigma. Researchers have examined previous interventions to identify characteristics that may contribute to the relative success or failure of a campaign (Boyle, 2017; Byrd et al., 2020; Eagly & Chaiken, 1993; Ma et al., 2024; St. Louis et al., 2020a; Walker Robert Mayo & St Louis, 2016). Researchers have extensively explored this area typically using similar approaches which includes various psychological and attitudinal theories, but the results have not been particularly effective. Considering the complexity of human attitudes, it is unlikely that there will be a one- size-fits-all approach to stigma reduction, indicating that a novel approach may offer a unique and innovative approach. Research across various domains, which are discussed below, has effectively utilized various health communication principles to identify several attributes that may contribute to the success or failure of various anti-stigma campaigns among the public. Therefore, it is useful to examine previous stuttering anti-stigma campaigns through the lens of health communication principles such as Diffusion of Innovations, dissemination, and adoption theories, to identify key elements that determine the success of interventions. In doing so, key intervention strategies may 4 be identified to facilitate the reduction of stigma towards stuttering amongst adults in hopes of improving communication experiences for people who stutter. 5 Stuttering LITERATURE REVIEW Encompassing stuttering in a singular definition proves to be challenging due to its dynamic nature. Stuttering has often traditionally been defined using Wingate’s (1964) proposal: frequent and uncontrollable repetitions or prolongations in short speech, consisting of “stuttering-like disfluencies,” that are not typically seen in non-stuttered speech (see also Yairi & Seery, 2023, p. 10). In adults, stuttering-like disfluencies may include part-word repetitions, single-syllable word repetitions, prolongations of sounds, and blocks or stops within speech (Bloodstein et al., 2021). Non-stuttered disfluencies include phrase repetitions, multiple-syllable word repetition, word and/or phrase revision, and interjections within speech (Yairi & Seery, 2023). Non-stuttered disfluencies are unremarkable on their own, but when coupled with stuttering-like disfluencies, they may be indicative of stuttering (Yairi & Seery, 2023). Yairi & Seery (2023) proposed that stuttering consists of six dimensions including, “overt speech characteristics, physical concomitants, physiological activity, affective features, cognitive processes, and social dynamics,” highlighting that stuttering extends beyond observable characteristics (p. 14). Objective and observable measures of fluency, whether stuttered or not, cannot be the sole criteria when considering the life impact of stuttering, as they are only a fraction of the overall experience. The speaker’s experience of stuttering ranges far beyond listener perception and is most often defined as “a loss of control,” or an “… underlying sensation of being stuck,” (Tichenor & Yaruss, 2019, p. 4364). These perceptions may result in covert or overt affective, behavioral, or cognitive speaker reactions (Tichenor & Yaruss, 2019). Such reactions, visible or audible, may include physical tension, altered emotional states, or psychological responses in anticipation or 6 as a response to moments of stuttering (Bloodstein et al., 2021; Tichenor & Yaruss, 2019). Moments of feeling stuck, coupled with speaker-listener reactions, can lead to adverse life impacts (Tichenor & Yaruss, 2019). Because the stuttering experience is broad-based and highly individualized, it can be difficult to educate various populations accurately and effectively regarding the nature and experience of stuttering. Stuttering Development The development of stuttering within early childhood has been attributed to atypical development and or maturational lag within the speech-motor neural networks (Smith & Weber, 2016). The multifactorial-dynamic pathway model suggests that developmental factors, such as neurological, motoric, genetic, environmental, and social influences, may also play a role (Smith & Weber, 2017). Individual factors themselves do not account for the development of stuttering; rather, interactions between one’s genetics and environment result in the expression of the stuttering phenotype (Smith & Weber, 2016). Neurological differences have been observed in children who stutter compared to same-age children who do not stutter, including delayed maturation in speech-motor coordination and speech movement mechanisms (Smith & Weber, 2016). There is a complex interplay of numerous developmental factors that may influence the development of stuttering in early childhood. Individual factors alone do not cause stuttering, but one or more may contribute to persistence and overall life impact. Research continuously aims to understand how each factor impacts the onset, persistence, discontinuation, treatment, and life impact of stuttering. Incidence and Prevalence of Stuttering Bloodstein et al. (2021) estimate an 8-10% incidence of stuttering across the lifetime, with 75-80% of children spontaneously discontinuing stuttering without intervention. The precise 7 prevalence of stuttering is debated, with Yairi & Seery (2023) suggesting 0.70% worldwide. Determining exact prevalence is challenging due in part to the listener’s perception, difficulty accounting for covert stuttering, and the individual’s possible reluctance to disclose stuttering because of shame or anxiety. While the exact number of stutterers can be debated, there is an abundance of qualitative and quantitative data that demonstrates the adverse life impact of stuttering for those who start to stutter and, especially, for those who continue to stutter throughout their lives. Given the high prevalence and incidence of stuttering worldwide, individuals are likely to encounter someone who stutters in their lifetime. Given that a precise understanding of stuttering is yet to be wholly understood even by experts, it is no surprise that there is a large misunderstanding of the cause, experience, and impact of stuttering on stutterers among the public, perpetuating negative stigma toward individuals who stutter. This stigma persists across time, culture, and regions, affecting participation in social, vocational, or educational opportunities, and potentially inhibiting their ability to achieve life goals (Boyle, 2017). Factual education about stuttering’s nature and experience is imperative if we are to alleviate the adverse life impacts associated with stigma toward stuttering. Stigma The concept of stigma has been defined by many authors across a variety of disciplines. Goffman (1963) stated that stigma is “…an attribute that is deeply discrediting,” (p. 3). Stigma exists as a particularly negative stereotype that is developed to help individuals make sense of the complex world we live in (Stuber et al., 2008). Social identity refers to developed normative expectations for others based on experiences and anticipated encounters with individuals (Goffman, 1963). When these expected attributes or anticipated interactions are challenged by a 8 “stranger” or someone outside of the normative expectation, a person is reduced to a “…tainted, discounted one,” (Goffman, 1963, p. 3). Stigmatized attributes may be visible or invisible, controllable, or uncontrollable, and related to behavior, appearance, or membership of a group. Stigmatized traits or marks do not reside within the individual but rather are contextually and relationship-dependent on the social context in which one is engaged (Major & O’Brien, 2005). Stigma Development The concept of stigma consists of cognitive and behavioral constructs (Corrigan & Shapiro, 2010). Cognitive constructs consist of stereotypes and attitudes, and behavioral constructs are acts of discrimination (Corrigan & Shapiro, 2010). The development of stigma in any capacity is complex and is comprised of multiple influential factors. Link & Phelan (2001) suggested that the process of stigmatization arises as traits or characteristics become linked to a negative social identity, in turn creating stereotypes. Major & O’Brien (2005) discussed that humans have cognitively adapted to separate themselves from those who possess or are believed to possess negative or unfavorable traits (i.e., stigmatization) to make sense of the world’s complexities. Self-stigma is the result of internalizing and applying negative beliefs perpetuated by the public, to oneself. As a result, stigmatized individuals may experience decreased self- esteem and limited participation or pursuit of goals (Corrigan & Shapiro, 2010). Attitude From the perspective of social psychology, “attitude is a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor,” (Eagly & Chaiken, 1993, p. 1). This psychological tendency represents an internal bias, positively or negatively influencing an individual’s evaluative responses. The evaluative process forms the basis of attitude and may manifest overtly or covertly, including affective, behavioral, and 9 cognitive responses (Eagly & Chaiken, 1993). Psychological tendencies are formed as evaluations occur, potentially predisposing individuals to respond to a future attitude object with a specific evaluative response (Eagly & Chaiken, 1993). An established response tendency is the formation of attitude, which can be stored as mental representations of the attitude object. Encounters, interactions, and stimuli associated with the object can activate this stored attitude (Eagly & Chaiken, 1993). Understanding the intricacies of attitude formation is essential when seeking to alter individuals’ affective, behavioral, and cognitive response tendencies toward an attitude object, particularly if there is an established attitude and mental representation. A keen understanding of factors that influence attitude formation is necessary for interventions aimed at influencing and potentially modifying established attitudes. Theory of Normative Conduct Injunctive norms reflect an individual’s belief about how others should behave, while descriptive norms represent actual behaviors observed in a given context (Jacobson et al., 2011). Seeking social approval and striving for self-efficiency and accuracy are linked to injunctive norms (Jacobson et al., 2011). Descriptive norms serve as a guide for navigating uncertainty or ambiguity (Jacobson et al., 2011). Typically, these norms co-exist in tandem and influence one another. The Theory of Normative Conduct suggests that injunctive and descriptive norms evoke different psychological response tendencies, dependent upon which norms are made salient, as well as upon the affective, behavioral, and cognitive responses associated with each context (Jacobson et al., 2011). The theory posits that fundamental human goals include, “making accurate/efficient decisions and gaining/maintaining social approval,” (Jacobson et al., 2011, p. 433). Circumstances where individuals feel they are being judged or watched can be influential on an individual’s adherence to injunctive or descriptive norms. According to the Social 10 Desirability Bias, individuals tend to “present themselves in a favorable manner, especially on sensitive topics,” (Boyle, 2017, p. 923). Individuals may react in adherence to either injunctive or descriptive norms depending on which norms are made salient in a situation. Given this, coupled with individuals' desire for social approval, attempting to measure individuals’ internal beliefs compared to their observable reactions is challenging. This becomes problematic when considering respondents’ true attitudes and, consequently, when measuring attitudinal change in response to an anti-stigma intervention. In essence, people often align their actions with what they perceive as the prevailing behavior in society. Understanding the relationship between injunctive and descriptive norms is critical for comprehending an individual’s decision-making and behavior. It illustrates how individuals navigate societal expectations, make decisions, and seek approval. This knowledge is instrumental when designing interventions that align with prevailing norms to prevent stigma and promote positive attitudes toward stuttering. Stigmatization Across Various Domains The existence of negative attitudes and stigma towards a particular group of people is not inherent to stuttering. Stigmatization may occur in response to several characteristics, such as race, sexuality, gender, beliefs, physical attributes, and beyond, with existing evidence highlighting the detrimental impact of stigma and discrimination on stigmatized populations. Traits and groups are stigmatized because a characteristic has been deemed unfavorable by groups in power, or those not subject to stigmatization (Major & O’Brien, 2005). These beliefs are then widely shared among the group in power, and these negative evaluations become the basis for the members of the “in” group. Stigma and stereotypes typically persist when there is a group in power to perpetuate the reactions and attitudes (Major & O’Brien, 2005). These 11 responses influence the expected attitude formation for other members of the in-power group, further perpetuating stigma. Major & O’Brien (2005) suggested that while both powerful and powerless groups may harbor negative stigma toward one another, the former’s access to resources and perceived status often allows for their perspective to prevail. One example of a stigmatized group includes people with mental illness. Those with mental illness often face discrimination and prejudice across multiple domains, including healthcare, the criminal justice system, workplace opportunities, social relationships, limitations of available resources, and educational opportunities (Abasi, 2022; P. W. Corrigan & Kosyluk, 2013; P. W. Corrigan & Shapiro, 2010; Waqas et al., 2020). Consequently, individuals with mental illness may experience limited opportunities to pursue desired opportunities. Societal stigma can exacerbate self-stigma among those with mental illness, resulting in reduced self- esteem and self-efficacy (Corrigan, 2013; Corrigan et al., 2006). Another example of a stigmatized group is individuals with Human Immunodeficiency Virus (HIV). Historically, the stigma surrounding the prevention, contraction, and treatment of HIV has limited the diffusion of preventative approaches and equitable healthcare among those at-risk or those who have contracted HIV (Brimlow et al., 2003; C. B. Collins & Sapiano, 2016; Kohli et al., 2023; Stangl et al., 2019). At-risk or HIV-positive individuals may encounter negative perceptions and decreased social status, discrimination in various societal contexts, and increased self-stigma (Brimlow et al., 2003; C. B. Collins & Sapiano, 2016). Similarly, the stigmatization of obesity can negatively impact an individual’s quality of life, mental health, healthcare opportunities, and sociocultural opportunities (Westbury et al., 2023). 12 The Impact of Stigma Toward Stuttering Stigma is a pervasive phenomenon that influences society across various domains, including stuttering. Comprehending the formation, persistence, and consequences of stigma in a broader context is crucial in highlighting the necessity of stigma reduction in stuttering. Stigmatization is not an isolated occurrence; it has impacts across the lifespan of individuals from many groups. There are important social dynamics, stereotypes, and negative beliefs that warrant a deeper exploration of these issues within stuttering. With this information, targeted interventions can aim to challenge the stigma and negative attitudes that prevail towards stuttering. Drawing parallels from well-documented instances of stigma underscores the significance of replacing stigma with inclusivity, empathy, and understanding for all members of society so that they may fully engage in life’s opportunities without limitations. Those who stutter are often subject to enacted stigma, discrimination, and bullying across their lifespan. Studies indicate that, from preschool through adolescence, children who stutter are more likely to be perceived to have less communication competence and experience bullying compared to children who do not stutter (Blood & Blood, 2004; Langevin & Prasad, 2012). Adolescents who stutter demonstrate heightened apprehension towards communication participation, frequent instances of bullying and teasing, and attempts to hide their stuttering (Erickson & Block, 2013). These findings paint a persisting challenge, as existing data do not suggest an improvement in self-perceived communication competency, or a reduction in enacted, felt, or self-stigma with age. It is useful to redefine bullying beyond the context of traditional schoolyard aggression but instead within the broader framework of enacted stigma, felt stigma, discrimination, and negative stereotypes experienced by individuals who stutter. 13 Enacted and Felt Stigma Among Stutterers Stigma and the experiences of stigmatized individuals can be divided into enacted stigma and felt stigma. Enacted stigma refers to “… actual episodes of negative reactions and discrimination from the public toward individuals with stigmatized traits,” (St. Louis, 2015, p. 45). Felt stigma refers to “… the shame associated with the stigmatized trait and fear of being evaluated negatively by other people,” (St. Louis, 2015, p. 45). These forms of stigma can exist independently, and the frequency of felt stigma may be low even in the presence of enacted stigma, possibly due to individuals taking extensive measures to conceal their stigmatized identity (St. Louis, 2015). Enacted and felt stigma can be detrimental to an individual’s participation and functioning in daily activities, further necessitating the need for accurate education in society. The anticipation and knowledge that discrimination, or enacted stigma, may occur given characteristics or conditions, can result in the fear of social rejection (Boyle, 2018). Ample data demonstrates felt and enacted stigma towards people who stutter occurs in the case of vocational opportunities (Gabel et al., 2004; Gerlach et al., 2018; Hurst & Cooper, 1983), bullying (Blood & Blood, 2004; Erickson & Block, 2013), and negative perceptions and listener reactions (Amick et al., 2017; Arnold & Li, 2016; Boyle, 2017, 2018). People who stutter reported experiencing enacted stigma at least once in their lives, and most anticipate future felt stigma (Boyle, 2018). Enacted stigma within the last year positively correlated to felt stigma among adults who stutter and demonstrated significant negative relationships with global mental health (Boyle et al., 2018). Data showed that people who stutter are often met with negative reactions and stereotypes and in turn, develop self-stigma, which has negative implications for the individual (Boyle et al., 2018). This highlights the importance of re-working societal beliefs 14 about stuttering to improve attitudes and, hopefully, improve the life experiences of people who stutter. Individuals with higher levels of self-stigma were more likely to report discomfort in seeking healthcare services due to their stuttering and previous negative health outcomes (Boyle & Fearon, 2018). Higher levels of self-stigma and stigma awareness among adults who stutter also exhibited higher levels of stress and decreased physical health and healthcare satisfaction (Boyle & Fearon, 2018). Elevated self-reported speaking anxiety was observed among adults who stutter, although physiological measures of cortisol were indifferent among those who do and do not stutter (Diehl et al., 2019). Such results further support that stuttering is not only an affective, behavioral, and cognitive experience, but that it may have a detrimental impact on an individual’s overall physical well-being and participation in daily life. Listener Perceptions. Evaluative responses and response tendencies are rooted in our perception and experiences with the world. Relatedly, perceptions of stuttered speech and those who stutter are also subjective to the listener, and negative perceptions tend to remain consistent across populations. Amick et al. (2017) found that when given only audio recordings of stuttered and non-stuttered speech, unfamiliar listeners perceived speakers who stutter to be more anxious, less likable, and have lower cognitive capabilities compared to the non-stuttering speakers. These findings suggest that a listener’s cognitive impressions may be formed based on subtle but observable aspects of speech and without intention. Collins & Blood (1990) found that participants preferred to interact with a male who stuttered severely and acknowledged their stutter, rather than ones who did not acknowledge their stuttering. Likewise, individuals with mild and severe stuttering who acknowledged their stutter were rated more highly on their intelligence, personality, and appearance than those who did not acknowledge their stuttering 15 (Collins & Blood, 1990). As previously stated, evaluative responses can be reinforced, resulting in a mental schema for an attitude object. The potential for inherent bias is of course problematic, but it is of greater concern when internal stigma is overtly or covertly applied to stigmatized individuals through prejudice, discrimination, and societal inequity. Making accurate and efficient decisions, coupled with the desire for social approval, is fundamental to human decision-making (Jacobson et al., 2011). The potential for judgment from others, or the feeling of being watched, may influence individuals may act by descriptive norms (i.e., how they believe others should behave). In an attempt to control for the Social Desirability Bias in participants’ responses, Boyle (2017) indirectly and directly measured respondents’ perceptions of people who stutter. Results indicated that personal perceptions of people who stutter were favorable, suggesting that respondents personally believed that those who stutter had a high chance for success, and were intelligent and competent (Boyle, 2017). In contrast, when asked how “others” think, attitudes towards stuttering were much less positive. Boyle (2017) found that most respondents did not feel that the public feels comfortable speaking to people who stutter, nor that people who stutter should pursue public speaking and or vocational roles with high communication demands. Participants also agreed that “other” people believe stutterers experience increased negative emotional reactions and behaviors from others (Boyle, 2017). Additionally, respondents with higher levels of education and more employment experience demonstrated more negative perceptions of people who stutter Boyle (2017). Such results are indicative of respondent’s own biases. This is alarming because individuals with higher education or employment experience are likely to be in positions of power and or hiring roles within the workforce, potentially further perpetuating stigma and enforcing discrimination amongst people who stutter 16 Perceived Causality. The prevalence of widespread misconceptions about stuttering continues to contribute to a significant gap in the knowledge and understanding of stuttering. One example of this relationship can be seen in how the perceived causality of stuttering influences an individual’s perceptions of people who stutter. When rating people who stutter based on potential cause (genetic, psychological, or unknown), stuttering due to a psychological cause was perceived more negatively among respondents (Boyle et al., 2009). Of course, this is not the cause of developmental stuttering; stuttering has a neurological origin (Bloodstein et al., 2021; Smith & Weber, 2017; Yairi & Seery, 2023) Still, this finding highlights the necessity of ensuring that people have accurate information about the chronic nature of stuttering. Recent findings from Boyle (2017) suggested that while perceived causes of stuttering were more accurate, they did not correlate with improved personal attitudes toward stuttering. Familiarity with people who stutter and perceived curability of stuttering did not have significant impacts on perceptual ratings of people who stutter (Boyle et al., 2009). Contrasting evidence from Arnold & Li (2016) found that familiarity with people who stutter and accuracy of beliefs towards stuttering were positively correlated with predictive intended behavioral and affective reactions. Contrasting evidence regarding an individual’s familiarity and knowledge of stuttering necessitates further exploration of individual contributing factors toward stigma, or lack thereof, toward stuttering. Labor Market. Negative perceptions and biases towards stuttering pose challenges for people who stutter in the labor market. A study encompassing 644 employers revealed that 85% of respondents believed that stuttering decreases employability and promotion opportunities (Hurst & Cooper, 1983). Interestingly, employers did not believe that stuttering impacted job performance (Hurst & Cooper, 1983). This conflicting information suggests a nuanced 17 perspective of employers, wherein vocational opportunities might be restricted, but once granted, vocational performance is not impacted by stuttering (Hurst & Cooper, 1983). This perspective may be detrimental for people who stutter seeking employment or career advancement. It is important that future employers, including current university students, receive education about the nature of stuttering to improve attitudes towards stuttering. Data by Boyle (2017) revealed that individuals who do not stutter hold reservations about employing stutterers in roles requiring extensive public speaking or high communication demands. Moreover, a longitudinal study of 13,564 Americans (Gerlach et al., 2018)demonstrated that, even after controlling for demographics and comorbidities, the income disparity between individuals who do and do not stutter exceeded $7,000 Gerlach et al. (2018). Results suggested the existence of gender disparities as well, as women who stutter are 23% more likely to experience unemployment (Gerlach et al., 2018). These findings underscore the discriminatory outcomes faced by individuals who stutter in the workforce, reinforcing the negative impact on life participation. Vocational discrimination and prejudice towards stuttering span the globe. A survey conducted in Japan reinforced findings consistent with those in the United States, illustrating negative perceptions of employees who stutter among employers and employees (Iimura & Miyamoto, 2021). This global pattern underscores the pervasive nature of the challenges faced by individuals who stutter within the labor market. Communication Participation. People who stutter are not only perceived to have lower communication competency by listeners (Blood & Blood, 2004; Boyle, 2017) but also lower levels of self-perceived communication competency (Boyle et al., 2018; Erickson & Block, 2013; Werle et al., 2021). This perceived deficit in communication competence can significantly influence an individual’s willingness to engage in social interactions. As individuals 18 continuously anticipate or experience a loss of control or feeling stuck, they may develop affective, behavioral, or cognitive reactions to their stutter (Tichenor & Yaruss, 2019). Data suggests that uncertainty contributed to a greater variance in communication participation (Boyle & Chagachbanian, 2022). The variance and unpredictable nature of stuttering, combined with the uncontrollable environmental factors (e.g., listener’s reaction), can accumulate as negative interactions are reinforced, reducing communication participation. It may not be possible for listeners to mitigate stutterer’s loss of control, but it is possible to improve listener reactions and social support to reduce anxieties and increase communication participation among people who stutter. Psychological Impact. People who stutter experience adverse impacts in the form of heightened anxiety, suicidal ideation, and overall decreased mental health (Briley et al., 2021b; Iverach et al., 2018; O’brian et al., 2022). Gerlach et al. (2021) suggested that concealment and stigma-identity-related thoughts and behaviors were among the most predictive factors for distress, overall negative psychological health outcomes, and decreased quality of life among adults who stutter (Gerlach et al., 2021). Boyle (2018) found that both enacted and felt stigma were predictors of global mental health among adults who stutter. Such information is valuable as it highlights the difficulties of stigma and the benefit of improving the public’s reactions to stuttering. The Social Model of Disability in the Context of Stigma Reduction The medical model of disability framework suggests that it is the responsibility of individuals with disabilities to adapt and change to meet societal expectations and norms (Constantino et al., 2022). Behaviors or characteristics that are considered “normative” or accepted within a society are contingent upon multiple factors, including cultural, geographical 19 regions, and exterior influences like societal stigma. The concept of difference hinges on which traits are favored within a group, leaving those outside the favored group vulnerable to stigmatization, prejudice, and discrimination. Historically, through the context of the medical model of disability, stuttering has been viewed as a disabling experience, limiting their social (Boyle et al., 2018; Erickson & Block, 2013; Klompas & Ross, 2004), vocational (Gabel et al., 2004; Gerlach et al., 2018; Hurst & Cooper, 1983), and educational opportunities (Walker Robert Mayo & St Louis, 2016; Werle & Byrd, 2021). In contrast, the social model of disability asserts that it is the responsibility of society to accommodate, accept, and support individuals with disabilities (Constantino et al., 2022). This perspective alleviates the pressure from disabled individuals, emphasizing the responsibility of society to accommodate and accept individual differences. Here, it is not the individual who is disabled but rather the society. Society's reactions and expectations of stuttering shape the stigma and stereotypes associated with it. The preconceived notions that people who stutter are more anxious, shy, and/or less capable, limit their experiences and abilities to pursue interests and opportunities. When designing anti-stigma interventions, it is essential to consider the target population’s perspective of disability. A message lacking relative advantage or compatibility is unlikely to be adopted by recipients (Rogers, 2003). The social model of disability is an ideal framework for an anti-stigma approach targeted towards those who do not experience the stigmatized condition. This approach encourages a shift in societal attitudes and expectations, fostering a more inclusive and accepting environment for people who stutter. It can be assumed that each innovation is disseminated to improve the lives of a given group, however, many do not reach the desired levels of change. It must be considered what influences individuals to change their attitudes, beliefs, and behaviors, or not. Diffusion of 20 Innovations, dissemination of information, and adoption theories offer a unique perspective into the relative success or failure of previous stuttering stigma reduction EBIs. This knowledge can help develop best practices in stigma reduction and attitude improvement among university students. Stigma Reduction Approaches Public stigma interventions utilize various processes, including protest, education, and contact, with delivery mechanisms defined as vehicles (Corrigan & Kosyluk, 2013a). These interventions, whether delivered utilizing in vivo (in-person) or media-based vehicles, aim to address, and mitigate public stigma. Globally, researchers and organizations have made efforts to reduce stigma and negativity toward stuttering. Initiatives have encompassed diverse methods, including public service announcements, public campaigns, targeted intervention approaches delivered in-person or through media, or a combination thereof. Materials regarding ideal interaction methods, clinical and societal treatment, and destigmatizing of stuttering have been disseminated among the public and clinicians alike (National Stuttering Association, 2023; STAMMA, 2023; The Stuttering Foundation, 2023). The effectiveness of these approaches varies across different populations, emphasizing the need for tailored strategies. Despite these efforts, stigma persists for people who stutter as evidenced by studies showing adverse life impacts secondary to stuttering (Blood & Blood, 2004; Boyle & Chagachbanian, 2022; Boyle & Fearon, 2018; Briley et al., 2020; Carter et al., 2017; Gerlach et al., 2021; Klompas & Ross, 2004; Tichenor & Yaruss, 2019). It is necessary to understand the locus of the problem; where is the stuttering stigma greatest given our current understanding, and what has been done to improve attitudes within this population? It is assumed that if attitudes are improved then people 21 who stutter will have less negative communication interactions and potentially, improve quality of life. Processes are defined as, “… purposeful interventions that might impact public stigma”, including protest, education, and contact approaches (Corrigan & Kosyluk, 2013b, p. 131). Communication channels, or vehicles, are the mode of delivery for a message from one person to another. Messages aimed to reduce stigma may be delivered either in vivo, media-based, or both. The interplay of processes and vehicles is important to an intervention’s success or lack thereof and must be carefully considered during the formative stages. Vehicles In vivo approaches include members of the stigmatized group interacting with members of the target population. Effective stigma reduction requires a member of the stigmatized group to interact with the target group. Messages that are targeted to specific populations, rather than mass-curated, are more likely to be successful (Corrigan & Kosyluk, 2013a). Typically, message content includes stories of struggle due to the individual's stigmatized condition and success despite these challenges. The target audience will influence the content of the messages, for example, employers versus the general public (Corrigan & Kosyluk, 2013a). Media-based approaches consist of curated videos, audio clips, public service announcements, and messages that are disseminated through communication channels including radio, television, social media, billboards, etc. (Corrigan & Kosyluk, 2013a). Disseminating anti-stigma interventions via indirect means allows for an inexpensive and widespread approach to reaching a mass audience (Corrigan & Kosyluk, 2013b). 22 Processes Protest. The protest approach involves the rejection of negative attitudes and beliefs directed toward members of stigmatized groups and emphasis on the unjust impact of various forms of stigma (Corrigan & Kosyluk, 2013a). The tenor of protest messages is often angry and seeking justice for the wronged members of stigmatized groups while chastising those doing the stigmatizing or discrimination. It is meant to instill a sense of guilt in shame in the perpetrators for harboring and/or promoting incorrect or harmful beliefs about a stigmatized group. Using protest must be done with caution. Data has shown that attempts to ask individuals to suppress or withhold prejudiced beliefs may produce a “rebound” effect, potentially counteracting the anti- stigma initiative and leaving prejudices unchanged or worsened (Corrigan et al., 2012, p. 132; Corrigan & Shapiro, 2010, p. 910). The efficacy of protest in stuttering anti-stigma efforts has limited evidence. Boyle et al. (2016) compared the effects of a video utilizing a protest, education, or contact approach, and found that only education and protest were maintained. To combat the potential rebound effect from protest interventions, Boyle (2017) suggested that interventions refute negative perceptions, stigma, and discrimination targeted toward stuttering. Protest interventions are difficult to improve attitudes towards stuttering due to the nuances of the target populations. Contact. Interpersonal contact with members of the stigmatized group, either in vivo or via indirect means (e.g., a recorded video) is another process for anti-stigma approaches. In this approach, stigmatized individuals share their personal stories of living with a stigmatized condition, and disclosure of their stigmatized condition is required (Boyle et al., 2016). A review by Corrigan and Kosyluk (2013) examined the three processes used in stigma reduction and found that contact had positive effects on improving attitudes toward mental illness compared to 23 protest, education, and control groups. There are factors to be considered when utilizing the contact strategy, including a common goal and a willingness amongst stigmatized and non- stigmatized groups to reach the goal(s), equal status of the groups, and support of the authorities, laws, or customs (Corrigan & Kosyluk, 2013a). Various mental illness anti-stigma interventions indicated that in vivo contact was the most effective method for reducing stigma, especially when the person speaking challenges the prevailing stereotype (Corrigan et al., 2012; Corrigan & Kosyluk, 2013a). Similar positive effects on participant attitudes have been achieved using a media-based approach (Abasi, 2022; Abdalla & St. Louis, 2014; Boyle et al., 2016). Corrigan and Kosyluk (2013) suggested that local programs have a greater impact, given that group interests and decisions are influenced by local factors. The locality of contact programs is subjective depending on context but can include diversity, socioeconomic status, religion, etc. For contact to be credible, “…the contact should try to mirror local concerns of the crafted program,” (Corrigan & Kosyluk, 2013a, p. 136). This could include a speaker with a similar ethnicity, age, socioeconomic status, and other sociodemographic factors. Secondly, credible contacts should be in a role resembling the target audience (e.g., teachers speaking to teachers). Lastly, effective contact should be continuous instead of limited to single interactions (Corrigan & Kosyluk, 2013a). The effective and credible formation of messages for a target audience is a crucial component of impactful interventions. Strategies that have been successful in areas such as mental illness can serve as a guide for anti-stigma interventions for stuttering. The contact approach has demonstrated positive effects on public attitudes towards stuttering. Inter-personal contact alone, or in combination with another process, may be an effective stigma reduction approach. Abasi (2022) found moderate success utilizing an interpersonal education approach with a pre-recorded documentary shown to university students. 24 Similar results have been observed with university students in Poland and Kuwait (Abdalla & St. Louis, 2014; St. Louis et al., 2018), and adolescents, university students, and adults in the United States (Boyle et al., 2016; Flynn & St. Louis, 2011; St. Louis & Flynn, 2018; Williams et al., 2023). Each intervention included a person who stutters or a relative of someone who stutters communicating with the target population, either directly or indirectly. Messages included personal stories about lived experiences with stuttering, information to dispel misconceptions, and in one, appropriate humor (Flynn & St. Louis, 2011). Establishing credibility, either as a person who stutters or being a close relative to someone who stutters, is essential in establishing buy-in from the target audience (Corrigan & Kosyluk, 2013a). Messages that are not credible, engaging, or relevant are not likely to diffuse. Likely, the studies mentioned successfully established some degree of credibility and relevance through tailored messages for target audiences. Moderate success utilizing contact, either alone or in combination with another process, suggests that there is reason to believe it will continue to be successful when coupled with lessons learned from diffusion, dissemination, and adoption theories, and previous various interventions. This necessitates a novel combination of message design, dissemination, and anti- stigma intervention to improve attitudes toward stuttering among adults. Education. An education approach involves replacing inaccurate beliefs, knowledge, and stereotypes with factual information about the stigmatized condition (Corrigan & Kosyluk, 2013a). Researchers or individuals seek to dispel myths and harmful stereotypes of a stigmatized condition with relevant and correct information. Educational approaches may include public service announcements, pamphlets, flyers, movies, and more. Education approaches are advantageous due to the cost-effectiveness and timely ability to quickly disseminate information 25 on a large scale. Similar to protest, education must also be employed with care, as it may produce rebound effects, resulting in skepticism and psychological reactance (Corrigan & Kosyluk, 2013a). Educational approaches designed to improve attitudes and knowledge toward stuttering have been successful across populations. Two curriculum-level interventions, the Attitude Change and Tolerance (ACT) (Weidner et al., 2018) and the Teasing and Bullying: Unacceptable Behavior (TAB) (Langevin & Prasad, 2012) programs, were delivered in person by researchers and teachers to preschoolers in the United States and Canada, and results indicate notable success. Both interventions yielded improved attitudes, perceptions, and reactions toward stuttering among participants (Langevin & Prasad, 2012; Weidner et al., 2018). The combination of education and contact has also shown some positive impact on adolescent and adult attitudes towards stuttering (Abasi, 2022; Abdalla & St. Louis, 2014; Boyle et al., 2016). Limited data exists that demonstrates the longevity of these results, but it is of interest to explore additional methods for improving attitudes toward stuttering. Complex interactions between intervention vehicles and processes, the target population’s pre-established attitudes, beliefs, and stigma, willingness to change, and extraneous influences on personal attitudes pose a challenge for stigma interventions. Yet, evidence suggests that there has been success in utilizing one or more of these approaches across populations. St. Louis & Flynn (2018) demonstrated small-scale, long-term, positive effects of an anti-stigma intervention seven years prior (Flynn & St. Louis, 2011). Beyond St. Louis & Flynn (2018), there is little to no data that measures the long-term efficacy of anti-stigma interventions. Evidence demonstrating positive change, regardless of how large, suggests that future campaign efforts are worthwhile to improve attitudes toward stuttering. 26 A systematic umbrella review by Dietz et al. (2020) identified various influencing intervention factors on university students’ modifiable health behavior. Results suggest that a combination of in vivo, media-based, and internet-based approaches were successful for interventions targeting alcohol safety, improved dietary choices, and increased physical activity at various universities (Dietz et al., 2020). Similarly, Eifert et al. (2017) demonstrated success utilizing a social media and internet-based approach, combined with support from Florida State University administration, in creating positive attitudes toward healthy behaviors while normalizing health behavior among university students. A media-based, education, and protest approach employed on Michigan State University’s campus over ten years found significant success utilizing messages that targeted either injunctive or descriptive norms (Hembroff et al., 2021). The success of different intervention approaches, combined with the targeting of injunctive and descriptive norms, highlights the high success potential for a stigma reduction intervention among university students. Given that college students are generally adults, lessons from the aforementioned intervention may be applicable more broadly among adults when presented with tailored messages. When determining which anti-stigma approach to employ in an evidence-based intervention, careful consideration must be made to ensure not only effective dissemination but also diffusion. Despite the widespread reach of today’s mass media, the impact of messages is not guaranteed, necessitating tailored content for the greatest reach and maximum impact on the target audience. It is necessary to consider the target population, the vehicles and processes, and potential pre-existing attitudes towards the stigma being targeted. A one-size-fits-all anti-stigma approach for stuttering or other stigmatized conditions is yet to exist. However, successful 27 interventions in areas like mental illness, obesity, and HIV, can offer valuable insights in anti- stigma design and implementation. Recommendations for implementing anti-stigma interventions toward stuttering, drawn from previous interventions (Boyle et al., 2016; St. Louis, 2015; St. Louis et al., 2020a) and lessons from disseminated interventions in other areas such as HIV (C. B. Collins & Sapiano, 2016), mental illness (Corrigan et al., 2006, 2012; Corrigan & Kosyluk, 2013a; Corrigan & Shapiro, 2010), and general Theory of Diffusion literature (Dearing & Cox, 2018; Dearing & Lapinski, 2020; Rabin et al., 2008; Stangl et al., 2019), can inform an evidence-based approach to reduce stigma among the adults within the United States. A retrospective analysis of 29 anti- stigma stuttering interventions identified key factors associated with successful interventions, “…(a) be captivating and interesting to the target audience, (b) deal with material that has meaning to the audience, and (c) contain sufficient information about the disorder,” (St. Louis et al., 2020a, p. 29). Recognizing that efforts to improve attitudes towards stuttering must be tailored, engaging, and meaningful for recipients (Corrigan & Kosyluk, 2013a; St. Louis et al., 2020a), a precise and predictive combination of factors (vehicles, processes, and content) remains elusive. Boyle (2017) posited that a person who stutters sharing their story, emphasizing that there are no fundamental differences between the speaker and audience (people who do not stutter), may be an effective approach to improving the stigma towards stuttering. Given the evidence that suggests familiarity with stuttering is associated with less negative attitudes (Arnold & Li, 2016), interpersonal contact with a person who stutters suggests it may be an ideal approach. The intervention’s message should aim to dispel previous misinformation, offering recommendations for interacting with people who stutter in a tailored, engaging, and meaningful fashion (Boyle, 28 2017; St. Louis et al., 2020a). Interventions containing humor and less direct participation with people who stutter have shown great success in improving attitudes toward stuttering (St. Louis et al., 2020a). Within this reviewed literature, the most successful stigma reduction campaigns have utilized contact, education, or a combination of these processes. Greenhalgh & Papoutsi (2019) advocated that one approach is not the best and interventions should use a combination of vehicles and processes. Ideally, an effective campaign would utilize interpersonal contact and education, consisting of information that dispels prevailing stereotypes in a digestible manner (Godwin & Heymann, 2015). Intervention content using education and contact approaches could include personal success stories, with a balance between dispelling myths and proving facts, and appropriate humor. Education approaches require caution, as excessive education might lead to a rebound effect and an increase in negative attitudes (Corrigan & Kosyluk, 2013a). Educational messages must be delivered engagingly and succinctly to capture the audience’s attention without overwhelming them with information. Extensive research exists to document the present stigma toward stuttering and its impact on those who stutter. However, limited data examine anti-stigma evidence-based interventions that utilize health communication theories and principles to improve attitudes towards stuttering. It is of use to understand and utilize the key intervention strategies previously mentioned to facilitate targeted and effective anti-stigma interventions towards stuttering. It is hoped that attitudes will improve and stigma towards stuttering will be reduced, consequently improving communication interactions for those who stutter. Attitudes, stigmas, and stereotypes are prevalent globally across a variety of life’s domains. Understanding the formation and influences of attitudes and stigma is critical for future 29 modification attempts. Analyzing previous attempts from various fields, including stuttering, provides a comprehensive background to the various approaches including vehicles, processes, and content. While claiming a universal approach for all stigmatized conditions and target populations would be misleading, consolidating insights from different health domains and target populations may prove effective in future attempts to improve attitudes. Improving attitudes toward stuttering is paramount considering the adverse impact of stigma, prejudice, and discrimination toward people who stutter. The unjust treatment and unfavorable opinions not only limit their opportunities to fully participate in daily activities and pursue life goals but also impact their overall psychological well-being and self-image. The consequences of stuttering stigma may be vast and significantly impact the overall quality of life for a person who stutters. Previous interventions designed to improve attitudes toward people who stutter have not all proven successful, underscoring the need for a novel anti-stuttering stigma campaign, such as a health-communication perspective. The utilization of the Theory of Diffusion, dissemination, and adoption theories, in addition to lessons learned from previous anti-stigma interventions, will be useful in guiding a novel anti-stigma approach to improve attitudes toward stuttering. There have been attempts to improve public attitudes and stigma toward stuttering for years, yet negative attitudes and perceptions remain. If success may be found in stuttering stigma reduction, then it may be possible that the same principles may be applied to other stigmatized communication disorders. It is essential that those who know about stuttering and the impacts that it may have assist in advocating for increased awareness and improved reactions toward stuttering. Given the evidence from the current literature, an anti-stigma approach tailored for adults who do not stutter, involving engaging, interpersonal contact, humor, and education may 30 positively influence attitudes and reactions towards stuttering. This study will therefore add to the current literature on stigma reduction toward stuttering. 31 METHOD The purpose of this study was to examine the effects of a media-based intervention utilizing interpersonal contact and education approaches on public attitudes, reactions, and beliefs toward stuttering using the Public Opinion Survey of Human Attributes – Stuttering (POSHA-S) (St. Louis, 2022) distributed via Qualtrics (Qualtrics, 2024). The originally proposed methods for this project were unable to be completed but are detailed in the footer below1. The experimental group will be referred to as such or “intervention” group interchangeably in the following sections. The structure and format of all following tables mirror the format used in the POSHA-S. Participants Survey participants were recruited via convenience and snowball sampling. This study was determined exempt by the Michigan State University Institutional Review Board within the Office of Regulatory Affairs Human Research Protection Program under statue 45 CFR 46. 104(d) 3(i)(B) of the Federal Policy for the Protection of Human Subjects. All data and survey responses collected were anonymous. Inclusion criteria included being over eighteen years old, having not received a stuttering diagnosis, and not currently or formerly pursuing a degree or career in communicative sciences and disorders. Participants were able to complete the survey from any device able to access Qualtrics (e.g., cellphone, computer, etc.). Self-reported demographic data was collected from open-ended responses and the Demographics section of the POSHA-S, (e.g., age, sex, gender, education, vocational history, etc.) which are listed below 1 Original methods for this project included an in vivo presentation given by a person who stutters to university students at Michigan State University recruited using the SONA system at Michigan State University and convenience sampling using a pre- and posttest design. A short question and answer session was anticipated to follow the completion of the POSHA-S. Information about where to learn more about stuttering was to be provided to all participants. 32 (Table 1). All participants reported currently living in one of the following states: Illinois (n1 = 1, n2 = 0), North Carolina (n1 = 1, n2 = 1), Michigan (n1 = 8, n2 = 8), Ohio (n1 = 1, n2 = 2), or Wisconsin (n1= 1, n2 = 0). Eighty-three percent of respondents in the control group and 92% in the experimental group self-reported their race as Caucasian; 17% and 8% reported Asian American, respectively. It should be noted some demographic data total less than one-hundred percent due to no response on some demographic variables. Table 1 Participant Demographic Data Variable % or M (SD), range Age (years) Education (years) Income Score Income: Family/Friends Income: Countrymen DESCRIPTORS (%) Male Female Single Married Parent Student WORK STATUS Working Not working Retired SELF- IDENTIFICATION Multilingual Intelligent Left-handed Obese Mentally Ill Stuttering Control (n = 12) Experimental (n = 12) 41.5 (16.9), 23-71 15.64 (2.16) 31.94 (40.63) 13.63 (39.12) 39.5 (18.5), 20-70 13.64 (1.89) 16.67 (22.97) 12.5 (23.15) 33.33 (40.82) 16.67 (25.82) 0.33 0.66 0.33 0.67 0.67 0.15 0.62 0.08 0.17 0 0.67 0 0.08 0.17 0 0.5 0.42 0.42 0.58 0.58 0.42 0.42 0 0.17 0.08 0.5 0.08 0.17 0.08 0 33 Table 1 (cont’d) Participant Demographic Data Control (n = 12) Experimental (n = 12) 0.25 0.25 0.33 0.17 0.67 0.58 0.58 0.5 0.42 0.42 Variable % or M (SD), range NO PERSONS KNOWN… Intelligent Left-handed Obese Mentally Ill Stuttering Materials A broad outline of the pre-recorded seventeen-minute intervention was constructed utilizing pre-existing data and literature (see Appendix A; Appendix B). Themes of the intervention emphasized accurate information, such as the similarity between people who do and do not stutter, and the presenter’s personal challenges and successes with stuttering. The speaker provided brief recommendations for interacting with people who stutter using appropriate humor delivered in an engaging manner. The intervention video was recorded on the speaker’s personal computer and emailed to the first author. It was then posted as an unlisted video on YouTube.com and embedded into the experimental portion of the Qualtrics (Qualtrics, 2024) survey. Prior to the dissemination of this intervention, the author conducted a one-hour focus group with two adults who stutter. The purpose of this panel was to gather insight, feedback, and recommendations regarding the specific material to be presented during the study. Under the guidance of the focus-group, the content and order of materials presented during the actual experiment were minimally altered. Changes made included adding an explanation of the speaker’s most common disfluencies and personal anecdotes. An individual from the focus group 34 was asked and agreed to record the intervention given to participants in the experimental condition. Public Opinion Survey of Human Attributes – Stuttering (POSHA-S) The POSHA-S (St. Louis, 2022) was selected for this study given its accessibility, standardization, and high reliability and validity. Attitudes towards stuttering have been observed in a variety of populations utilizing the POSHA-S. The POSHA-S is a standardized, reliable, valid, and evidence-based, written questionnaire that measures the public’s attitudes and beliefs toward stuttering and people who stutter (St. Louis, 2011, 2012). This standardized assessment has been used worldwide to measure and compare attitudes toward stuttering across various cultures, geographic locations, occupations, genders, ages, and more. Such data allows researchers to quantitatively assess attitudes towards stuttering across populations, with or without intervention attempts at reducing stigma. Items of the POSHA-S are intended to reflect the frequency or strength of individuals’ attitude, beliefs, or reactions (St. Louis, 2022). Means of each subtest and component test are scored on a scale of -100 to 100, with a score of 100 representing strong beliefs and attitudes. Respective subsections of the POSHA-S generate two main component scores, (a) Beliefs and (b) Self Reactions (St. Louis, 2022). The Beliefs and Self Reaction components reflect the mean of its respective four subtests and are used in the calculation of respondent’s Overall Stuttering Score (OSS). Scores obtained from the Beliefs component reflect participant’s external attitudes (i.e., not personally involved) and the Self Reaction component is reflective of participant’s attitudes and beliefs in situations of direct involvement (St. Louis, 2022). The POSHA-S utilizes “anchor” attributes to compare respondent’s attitudes, reactions and beliefs toward stuttering to a “positive” trait (intelligent), “neutral” trait (left-handed), and 35 “negative” (obesity/mental illness) (St. Louis, 2022). The Obesity/Mental Illness component score is not factored into respondent’s OSS. Reverse coded questions are scored opposite, such that more “positive” results are more aligned with “current” research (i.e., responding no when asked if people who stutter should try to hide their stutter) (St. Louis, 2022). The reverse is true for negative scores (i.e., answering yes or unsure when asked if stutterers should hide their stuttering). Identifying areas of negative attitudes towards stuttering may be useful when considering how to approach stigma reduction in the future. Following the classifications set forth by St. Louis et al. (2020) in a retrospective analysis of 29 pre-posttest, anti-stigma stuttering interventions, an increase of 5 units across all three summary scores (Beliefs, Self-Reactions, and OSS), indicates a “very successful” intervention (p.5). An improvement in two out of the three categories suggest a “successful” intervention, and improvement in one of three summary scores is “marginally successful,” (p.5). Interventions with less than a 5-unit increase across all three summary scores are deemed “unsuccessful” (p. 5, St. Louis et al., 2020). Procedure This experiment was designed and conducted using a quasi-experimental, randomized, posttest-only control group design, with quantitative and qualitative analyses performed to examine the effects of the described intervention on adults’ attitudes and beliefs toward stuttering. An exact representation of the theoretical rationale for this study was compiled and used to guide the formation of the intervention (see Appendix A)2. The sample size for this study was calculated using the following constraints for a two- sample t-test (pooled variance): distribution = student’s t, α = 0.05, power = 0.8, effect = large, 2 Given the pivot in study design, it was not possible to carry out each element within the rationale in the described study. This rationale was used in guiding the alternative design and experiment carried out by the researcher. 36 effect type: Cohen’s d, effect size = 0.8, SD = equal  (Statistics Kingdom, 2017). To obtain a power of 0.807487, the desired sample size for each group was 26 (n1 = n2 = 26). A total of 41 individuals opened the survey link and at the minimum, consented to their participation in the given study. Of the 41 individuals who consented to participation, 17 responses were excluded from final calculations due to survey incompletion. Therefore, N = 24, n1 = n2 = 12. All respondents completed an informed consent form prior to being assigned a group condition and completed a virtual copy of the 35-question POSHA-S (St. Louis, 2022) administered via Qualtrics (Qualtrics, 2024). The survey was administered as written and multiple questions are multilayered, requiring multiple responses to individual items within a single question. Respondents who were randomly assigned to the experimental condition were shown the pre-recorded intervention prior to their completion of the POSHA-S. The administered survey and supplemental questions, and results are detailed in Appendix E and Appendix F, respectively. Data Analysis and Results Given the small sample size of both conditions and qualitative nature of the data, presented data analyses and results will be presented in tandem. Survey data was downloaded from Qualtrics (Qualtrics, 2024) and exported into a data sheet. Data were analyzed using a Microsoft Excel sheet purchased via Teachers Pay Teachers from the creator of the POSHA-S (St. Louis, 2022). Individual data were then entered into the spreadsheet and automatically scored according to the scoring procedures. POSHA-S Results Attitudes of the control and intervention groups were compared to examine the efficacy of an anti-stigma intervention using a posttest-only control group intervention delivered through 37 a media-based interaction. The OSS, component, and subtest M for both conditions are reported below (Table 2). Minimal difference in OSS scores between groups suggests that the education, contact, and or humor components of the presentation were not effective on overall attitudes, reactions, and beliefs. Quantitative data obtained from the POSHA-S did not reflect a significant difference among groups, but both groups tended to score more favorably compared to the sample means obtained from the POSHA-S database (St. Louis, 2022) (Table 5).The control group reported more positive attitudes, as seen by the Overall Stuttering Score, and subtest scores on the Beliefs, Self-Reactions, and Obesity/Mental Illness sections (Table 2). A radial graph comparing data obtained from this study to existing data in the POSHA-S database is available in Appendix F. Table 2 POSHA-S Summary Data Component/Subtest Scores M (SD) Overall Stuttering Score Beliefs Traits/Personality Help From Cause Potential Self-Reactions Accommodating/Helping Social Distance/Sympathy Knowledge/Experience Knowledge Source Experimental (n = 12) 28 (19) 43 (33) 24 (52) 42 (43) 32 (68) 73 (33) 12 (20) 53 (36) 26 (45) -23 (54) -11 (50) Control (n = 12) 32 (16) 51 (21) 50 (33) 31 (26) 56 (32) 67 (58) 14 (21) 65 (18) 34 (33) -28 (35) -17 (53) 38 Table 2 (cont’d) POSHA-S Summary Data Component/Subtest Scores M (SD) Control (n = 12) Experimental (n = 12) Obesity/Mental Illness Impression Want/Have Amount Known Note. Components are left justified and calculated using mean scores from the following subtests, represented by the indented lines. More positive OSS results were observed among the control group (M = 32.2, SD = 16.1) compared to the intervention group (M = 28, SD = 19.2). Results were not statistically significant at t(24) = 0.64, p < 0.53. -33 (26) -14 (23) -70 (52) -16 (36) -31 (19) -13 (20) -67 (31) -13 (27) There was minimal difference observed between groups on the overall Self-Reactions score. When asked their impression of someone who stutters, the control group reported more negative reactions (M = -4, SD = 14) than the experimental group (M = 14, SD = 32). When asked if respondents would be concerned if their doctor stuttered, participants in the control group answered more positively (M = 33, SD = 78) than the experimental group (M = 18, SD = 87). The control group reported knowing less about stuttering (M = -46, SD = 33) compared to the experimental group (M = -23, SD = 87), yet averaged a more positive OSS overall. Open-ended Questions Following the completion of the respective experimental condition, all participants were given the opportunity to provide any general feedback or comments they may have had and asked to respond to the following questions: “Do you know a person who stutters? (If so, please describe the nature of your relationship to the individual without naming),” and “Please rank your familiarity with stuttering” (Table 3). Of the control group, 33% reported they know a person who stutters. All individuals in the control group reported that they do not know anyone who stutters. 39 Table 3 Familiarity with stuttering Familiarity Extremely Unfamiliar 2 5 Somewhat Unfamiliar 7 2 Neutral Somewhat Familiar 0 2 Extremely Familiar 0 1 2 Control 1 Experimental Note. Participants (N = 24) self-reported familiarity with stuttering. Known person(s) who stutters as reported by the control group included: Employee at frequented location, acquaintance, employer, and former co-worker. Open-ended questions represented in Table 4 and Table 5 were asked to only the experimental group following the completion of the intervention, POSHA-S, and aforementioned questions. Participants were asked to report the two most memorable components of the intervention observed. Table 4 Open-ended Question for Experimental Group What was most memorable about the presentation? N/A/Not sure Not sure N/A (x3) Cause of Stuttering: Family history, genetic Unknown Multiple factors Not psychological Stuttering experience: Negative reactions from listener Negative self-perception and feelings of shame among people who stutter Workplace discrimination Presenter: Presenter’s negative reactions in middle school Stuttering started late (adolescence) Observed changes Enjoyed speaker’s confidence and relaxed presentation “Perceived reality of the person stuttering” 40 Table 4 (cont’d) Open-ended Question for Experimental Group Stuttering is: Normal Individual “People who stutter are the same as someone who does not” Misc. “Speech therapy” “Stuttering” Note. Commonly reported ideas and concepts within participant responses were grouped and formatted into the above table by the author. When asked how likely it is that this intervention would impact their attitudes and future interactions with people who stutter (Table 5), most respondents answered somewhat likely for both. Table 5 How likely is it that the presentation you observed today will impact your…toward people who stutter? Variable Attitude Extremely Unlikely 0 Somewhat Unlikely 1 Neutral Somewhat 2 Likely 6 Extremely Likely 2 Blank Total 1 12 1 Future Interactions Note. This table depicts the intervention’s group likelihood that the observed presentation will impact their attitudes and future interactions with people who stutter. 12 2 2 6 1 1 Discussion Quantitative data obtained from the POSHA-S did not reflect a significant difference among groups, but both groups tended to score more favorably compared to the sample means obtained from the POSHA-S database (St. Louis, 2022) (Table 5). Qualitative data obtained from this study may therefore provide a better understanding into the effects of this study’s design, intervention, and effects on respondent’s attitudes, reactions, and beliefs toward stuttering. The 41 theoretical rationale for this study is summarized in outline form in Appendix A, and its relevance to the observed results will be discussed below. The present study was designed according to recommendations specific to in-person interventions, in that they must be targeted, local, credible, and continuous in nature (Corrigan & Kosyluk, 2013a). This intervention was targeted, not tailored, toward adults who do not stutter. Tailored interventions are created for a specific population bearing in mind cultural, demographic, and personal differences among participants. Targeted interventions are curated for a wider audience that share a commonality (e.g., university students, children, etc.) about a particular topic. Because of recruitment challenges, the inclusion criterion of being a student at Michigan State University was lifted; instead, the planned study was revised to include all individuals over the age of eighteen, as well as no history of pursuing a career in CSD and no prior diagnosis of stuttering. It is possible that this targeted study was too narrow and too small to demonstrate significance of the intervention. The Theory of Normative Conduct states that humans strive to achieve two fundamental goals: “making accurate/efficient decisions and gaining/maintaining social approval” (Jacobson et al., 2011, p. 433). Messages conveyed in the intervention were framed from this perspective, in that it was assumed most participants did not have a deep understanding of stuttering at baseline. This assumption is supported by current literature reflecting that the general populace harbors misperceptions about stuttering and people who stutter (Boyle, 2017; Boyle et al., 2009; St. Louis, 2015, 2020; St. Louis et al., 2020a). This intervention sought to provide accurate information regarding multiple aspects of the lived experience of stutterers in an attempt to reduce the ambiguity potentially related to an unknown concept (i.e., stuttering). This approach is in line with the first fundamental goal proposed by the Theory of Normative Conduct. 42 Messages were also framed from the perspective of the Social Model of Disability as it relates to stuttering (Constantino et al., 2022). The speaker explained to listeners that it is society’s responsibility to support disabled individuals and those who are disabled are not at fault. The messages were curated and delivered in a manner that did not chastise viewers for possible negative reactions or treatment of people who stutter. Rather, it was created with the intention to educate listeners in an engaging manner that provided information regarding society’s responsibility to accept and accommodate differences and how to avoid contributing to the perpetuation of stigma in the future. The decision to have a speaker who is also a Michigan State University (MSU) student reflected a deliberate attempt to create local relevance for the intended audience (other MSU students). It is likely that the value and relevance of this component was lost among viewers as a result of the switched study design, especially given that participants reported currently living in five different U.S. states (All but one reported state within the Midwest Region, although this probably did not represent a sufficient tie to MSU to yield local relevance). The speaker was chosen because they are a successful, well-educated, and personable individual who was able to provide a strong representation of people who stutter and dispel common misconceptions of people who stutter. These speaker characteristics were considered during the design stage in effort to establish speaker locality and credibility among message receivers. Not all participants were university students; however, it was hoped that the communicated successes of the speaker would effectively establish credibility as a speaker attempting to educate others. Upon review of the responses to the open-ended questions (Table 4;5), it appears that some degree of speaker credibility was achieved. This is seen in responses that either directly or indirectly commented on the speaker’s professionalism, ability to effectively communicate, and be successful despite 43 previous challenges. Still, future studies should seek speakers that represent or are respected within the targeted community. Continuous contact was not achieved given the study design. Given that a majority of the existent research consists of pre-posttest study designs with one-time exposure to a created intervention (Boyle et al., 2016; St. Louis, 2015; St. Louis et al., 2020a), it is of interest to examine the dosage required of an innovation to produce attitudinal shift toward stuttering. To date, there has been only one longitudinal study of the effects of an intervention overtime on participant attitudes toward stuttering, emphasizing the necessity of larger studies over a period of years. Thus, future studies should investigate attitudinal changes among participants following repeated exposures to an intervention to explore the most effective dosage required to produce positive attitudinal shifts. The author and the panel of stutterers were purposeful in which messages were to be included and how these messages were to be communicated to the listener. It was hoped that participants would adopt the positive attitudes, reactions, and beliefs communicated in the video. In efforts to achieve said success, Rogers’s (2003) five key attributes of an innovation that contribute to the perception and adoption (relative advantage, compatibility, complexity, trialability, and observability) were carefully considered throughout this study and will be discussed below. Relative advantage is the extent to which one feels adopting an innovation will benefit their life. This intervention attempted to highlight the relative advantage and compatibility of positive or less negative attitudes toward stuttering by addressing the injunctive and descriptive norms related to individual perceptions of stuttering. It was stressed in the intervention that this component, also framed according to the Social Model of Disability, served to establish 44 compatibility and trialability of the implementation of the accurate beliefs and knowledge with the listener’s current lifestyle. The overarching message is that it is valuable for society to accept people who stutter, because: a) stutterers are not at fault and b) individuals will knowing or unknowingly encounter someone who stutters, and c) stigmatizing people for something beyond their control is damaging on a personal and societal level. The complexity of the information provided was carefully thought out and presented in a manner that the author, advisory committee, and stutterer panel thought would be accessible to participants. The design of this study did not allow for observability; however, participant’s familiarity with stuttering and self- reported behavior expectations were broadly assessed using the open-ended questions in Table 3 and Table 5. Studies of various mental illness anti-stigma interventions have shown that in-vivo contact was the most effective method for reducing stigma, especially when the person speaking challenges the prevailing stereotype (Corrigan et al., 2012; Corrigan & Kosyluk, 2013a). Interventions utilizing the contact approach must include a common goal, a willingness among stigmatized and non-stigmatized groups to reach the goal(s), equal status of the groups, and support of the authorities, laws, or customs (Corrigan & Kosyluk, 2013a). The quantitative data yielded from this study suggests that the efficacy of the contact approach was lost among experimental participants. This may be attributed to several factors, including the informal nature and quality of the pre-recorded intervention, technical difficulties in showing the video, and listener perception of the audio and visual components of the intervention. It may also be possible that listener involvement related to stuttering was low at baseline and did not increase during or following the intervention. As a result, participant engagement with the video and the 45 subsequent survey may have been diminished. This may explain the variability between groups’ POSHA-S scores and the differences reflected in the open-ended questions. Messages intended to educate listeners regarding the etiology and nature of the lived experience of stuttering were selected in an effort to dispel common myths and replace potentially inaccurate or harmful beliefs and reactions with accurate information and less negative attitude. This is consistent with recommendations in the reviewed literature. For example, Boyle et al. (2009; 2017) posited that psychological causes of stuttering were perceived to be most negative, and more accurate perceived causes of stuttering were not correlated with more positive attitudes. This study provides some evidence, albeit statistically non-significant, to refute this proposal. This is reflected in the groups scores on the Cause subcomponent of the Beliefs component of the POSHA-A. Results suggested that the control group had more accurate knowledge about the etiology of the stuttering (n1 = M = 56, SD = 32, n2 = M = 32, SD = 68). The POSHA-S quantitative data obtained may not reflect an entirely accurate depiction of the intervention groups’ knowledge. Analysis of the open-ended questions demonstrated that some component of the education messages stuck with recipients. Specifically, participants reported understanding that stuttering is multifactorial, genetic in nature, and an individualized experience (Table 4). Interestingly, the control group reported less favorable attitudes on each subtest of the Knowledge/Experience component, suggesting that the participants in the intervention group had more accurate knowledge of stuttering. Vocational capabilities were intentionally discussed in attempt to combat the long- standing stigma stutterers face in the work force. Boyle (2017) suggested that an effective approach for reducing stigma towards stuttering could involve a person who stutters sharing their life story and emphasizing that there are no fundamental differences between the speaker and the 46 audience of people who do not stutter. The combination of education and contact has also been shown to yield some positive impact on adolescent and adult attitudes towards stuttering (Abasi, 2022; Abdalla & St. Louis, 2014; Boyle et al., 2016). Analysis of individual questions regarding vocational capabilities of stuttering indicated that the experimental group would be more concerned if their doctor stuttered (M = 18, SD = 87), compared to the control group (M = 33, SD = 78). When reviewing individual survey items, the control group reported more negative reactions (M = -4, SD = 14) than the experimental group (M = 14, SD = 32) when asked their impression of someone who stutters. The control group (M = -46, SD = 33) reported knowing less about stuttering compared to the experimental group (M = -23, SD = 87). Still, this group averaged a more positive OSS, overall. This may suggest that some component of the intervention was not effective for the experimental group, respondents felt it was necessary to report scores that were not reflective of their true knowledge and beliefs, or a combination of factors beyond the researcher’s control. Feedback was sought from all participants who completed the survey. The most common feedback received was related to challenges navigating the Qualtrics software, difficulties navigating the survey itself due to the design and length of the POSHA-S, and recommendations for a shorter intervention video. Technological awareness and understanding are variable and presents a challenge when attempting to assess components of individual being, such as attitude, across a wide population. Finally, it is worth noting that although the POSHA-S is widely used, it does present a number of issues given its length and complexity. Limitations and Future Directions St. Louis et al. (2020) suggested that a meaningful level of change on the POSHA-S would be at least 5 points in at least one subcomponent or component on the overall POSHA-S 47 Summary Scores. Based on this guideline, results from this study would qualify as “unsuccessful” (Table 2) if one were to compare the two participant groups directly. Application of this scoring system on a posttest-only control design, as in this study, have not been discussed in the current literature. It may be premature to apply this efficacy convention to the given study design, given that there was no pre-test collection of participant’s attitudes. Little data exists regarding unit changes in the opposite direction (i.e., control group yields more positive results compared to the intervention group). In future studies, it will be valuable to determine precise and meaningful changes among participants’ POSHA-S results across varying study designs. It is also possible that the POSHA-S is not the most effective measurement for capturing changes in participant attitudes, reactions, and beliefs, as these reactions are dynamic in nature. It would be erroneous to assume that behavior expectation will correlate to a change in behavior; however, it was of interest observe the effects of this intervention on participants’ attitudes directly following the video. It is also instructive to consider participants’ interpretation of how their involvement in the study may impact their future behavior, or “likelihood of adoption (Rogers, 2003). These results suggest that perhaps at least some aspect of the intervention was successful, as evidenced by the accurate and reported answers to the cause of stuttering, the experience of stuttering, and respondent definitions of stuttering (Table 4). These results are at odds with the scores obtained on the POSHA-S and suggest that there may have been some challenges with respondent attention during completion of the lengthy POSHA-S scale. In future studies, it will be meaningful for the intervention to be continuous and observable, as suggested by Rogers (2003). Measurement of attitudinal and behavioral change because of an innovation continues to present challenges possible due to participant response 48 bias and logistical challenges associated with longitudinal studies. It will be important to explore a validated metric in place to assess adoption or lack thereof. Participant recruitment, attrition, and acquiescence posed challenges through the research process. Individual responses within each group suggest that careful attention was not paid to reverse coded questions, as evidenced by their “straight-line” responses across items. One individual in the control group and three individuals in the experimental group did not engage with the questions. This was apparent in their conflicting responses across reverse-coded items and their direct counterparts. For example, these respondents answered that people should try to hide their stutter, that they would act like the person talking “normally,” and that they would make a joke about stuttering. The chosen experimental design did not allow for analysis of the intervention’s individual variables (contact, education, or a media-based interaction) on participants’ attitudes. This experiment was intended to provide a holistic examination of the efficacy of the intervention, which was statistically non-significant. Yet, the qualitative data obtained from this preliminary study offered a foundation of understanding regarding the effect of the intervention’s combined characteristics on participants’ attitudes, reactions, and beliefs. Another factor affecting the findings is the fact that the experimental group appeared to have more positive attitudes toward stuttering at baseline compared to the control group, as demonstrated by their more positive OSS, Knowledge/Beliefs, and Reaction scores (Table 2). Additional contributing factors such as survey order and length or participant engagement may explain the difference in group means. Finally, the intervention’s modality was converted from the original in-person format to a digital format to increase participant recruitment and provide respondents with the option to complete the survey on their own time. Despite the accessibility of an online intervention, the 49 desired N = 52 required to achieve the desired statistical power was not achieved. The small N of this experiment limits the generalization of these results beyond this study. Future studies should expand this intervention utilizing an in vivo message and a larger, more diverse population. Given the current evidence and the complexity of human emotions, changing, or preventing the formation or exacerbation of negative attitudes can be challenging. For there to be change, there must be a willingness to change, and this willingness may be difficult to determine in advance of administering an intervention such as the one used in this study. The contexts, personal characteristics, and sociodemographic variables of the target population may largely influence the success or failure of an intervention. Data collected from this study provide a preliminary and holistic overview of the successes and challenges of a media-based intervention utilizing interpersonal contact and education approaches on stigma reduction toward stuttering among adults. These findings provide a valuable springboard for future research that further examines ways of improving attitudes toward stuttering. Conclusion This research provides valuable preliminary insights into the potential of combining education, media, and interpersonal contact to reduce stigma and improve attitudes toward stuttering. Data presented above lays an important foundation for refining intervention strategies and expanding upon current methods used to address stigma in this context. Findings from this study highlight the complexities and challenges associated with assessing attitudinal changes toward stuttering through a media-based interaction. Quantitative data from the POSHA-S indicated minimal statistical differences between groups’ overall attitudes. However, qualitative data obtained from this study suggests that some aspects of the intervention may have had a positive impact on participants’ understanding and beliefs toward 50 stuttering. Key components of this intervention inspired by previous research across various disciplines and their efficacy was assessed using open-ended response questions provided information related to respondents’ experiences with a media-based, anti-stigma intervention and a virtual assessment of attitudes, reactions, and beliefs toward stuttering using the POSHA-S. Limitations of this study, including small sample size, difficulties related to participant recruitment and engagement, and the constraints associated with a media-based intervention, emphasize the need for further research to better understand the complexities of humans’ attitudes, reactions, and beliefs, specifically toward stuttering. Future studies should aim to incorporate larger sample sizes, various validated metrics for measuring meaningful changes in attitudes toward stuttering, and explore dissemination, adoption, dosage, and additional health communication principals as a guiding theoretical rational to potentially increase intervention efficacy. 51 REFERENCES Abasi, C. (2022). The science behind stuttering: Reducing stigma and public misconceptions. Doctoral Dissertation, 3. Abdalla, F., & St. Louis, K. O. (2014). Modifying attitudes of Arab school teachers toward stuttering. Language, Speech, and Hearing Services in Schools, 45(1), 14–25. https://doi.org/10.1044/2013_LSHSS-13-0012 Amick, L. J., Chang, S. E., Wade, J., & McAuley, J. D. (2017). Social and cognitive impressions of adults who do and do not stutter based on listeners’ perceptions of read-speech samples. Frontiers in Psychology, 8(JUL), 1–8. https://doi.org/10.3389/fpsyg.2017.01148 Arnold, H. S., & Li, J. (2016). Associations between beliefs about and reactions toward people who stutter. Journal of Fluency Disorders, 47, 27–37. https://doi.org/10.1016/j.jfludis.2015.12.004 Blood, G. W., & Blood, I. M. (2004). Bullying in Adolescents Who Stutter: Communicative Competence and Self-Esteem. Contemporary Issues in Communication Science and Disorders, 31(Spring), 69–79. https://doi.org/10.1044/cicsd_31_s_69 Bloodstein, O., Ratner, N. B., & Brundage, S. B. (2021). A Handbook on Stuttering, Seventh Edition: Vol. Seventh ed. Plural Publishing, Inc. Boyle, M. P. (2017). Personal perceptions and perceived public opinion about stuttering in the United States: Implications for anti-stigma campaigns. American Journal of Speech- Language Pathology, 26(3), 921–938. https://doi.org/10.1044/2017_AJSLP-16-0191 Boyle, M. P. (2018). Enacted stigma and felt stigma experienced by adults who stutter. Journal of Communication Disorders, 73(March), 50–61. https://doi.org/10.1016/j.jcomdis.2018.03.004 Boyle, M. P., Beita-Ell, C., Milewski, K. M., & Fearon, A. N. (2018). Self-esteem, self-efficacy, and social support as predictors of communicative participation in adults who stutter. Journal of Speech, Language, and Hearing Research, 61(8), 1893–1906. https://doi.org/10.1044/2018_JSLHR-S-17-0443 Boyle, M. P., Blood, G. W., & Blood, I. M. (2009). Effects of perceived causality on perceptions of persons who stutter. Journal of Fluency Disorders, 34(3), 201–218. https://doi.org/10.1016/j.jfludis.2009.09.003 Boyle, M. P., & Chagachbanian, N. J. (2022). Uncertainty and Perceived Control as Predictors of Communicative Participation and Mental Health in Adults Who Stutter. American Journal of Speech-Language Pathology, 31(2), 757–769. https://doi.org/10.1044/2021_AJSLP-21-00230 Boyle, M. P., Dioguardi, L., & Pate, J. E. (2016). A comparison of three strategies for reducing the public stigma associated with stuttering. Journal of Fluency Disorders, 50, 44–58. 52 https://doi.org/10.1016/j.jfludis.2016.09.004 Boyle, M. P., & Fearon, A. N. (2018). Self-stigma and its associations with stress, physical health, and health care satisfaction in adults who stutter. Journal of Fluency Disorders, 56(September), 112–121. https://doi.org/10.1016/j.jfludis.2017.10.002 Briley, P. M., Gerlach, H., & Jacobs, M. M. (2021a). Relationships between stuttering, depression, and suicidal ideation in young adults: Accounting for gender differences. Journal of Fluency Disorders, 67(November). https://doi.org/10.1016/j.jfludis.2020.105820 Briley, P. M., Gerlach, H., & Jacobs, M. M. (2021b). Relationships between stuttering, depression, and suicidal ideation in young adults: Accounting for gender differences. Journal of Fluency Disorders, 67(November). https://doi.org/10.1016/j.jfludis.2020.105820 Briley, P. M., Wright, H. H., O’Brien, K., & Ellis, C. (2020). Relative contributions to overall impact of stuttering in adults using the overall assessment of the Speaker’s Experience of Stuttering (OASES). Journal of Fluency Disorders, 65. https://doi.org/10.1016/j.jfludis.2020.105775 Brimlow, D. L., Cook, J. S., & Seaton, R. (2003). Stigma and HIV/AIDS : a review of the literature. (Draft.). U.S. Dept. of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. https://purl.fdlp.gov/GPO/LPS81743 Byrd, C. T., Werle, D., & St. Louis, K. O. (2020). Speech-language pathologists’ comfort level with use of term “stuttering” during evaluations. American Journal of Speech-Language Pathology, 29(2), 841–850. https://doi.org/10.1044/2020_AJSLP-19-00081 Carter, A., Breen, L., Yaruss, J. S., & Beilby, J. (2017). Self-efficacy and quality of life in adults who stutter. Journal of Fluency Disorders, 54(September), 14–23. https://doi.org/10.1016/j.jfludis.2017.09.004 Collins, C. B., & Sapiano, T. N. (2016). Lessons Learned From Dissemination of Evidence- Based Interventions for HIV Prevention. American Journal of Preventive Medicine, 51(4), S140–S147. https://doi.org/10.1016/j.amepre.2016.05.017 Collins, C. R., & Blood, G. W. (1990). Acknowledgment and severity of stuttering as factors influencing nonstutterers’ perceptions of stutterers. Journal of Speech and Hearing Disorders, 55(1), 75–81. https://doi.org/10.1044/jshd.5501.75 Constantino, C., Campbell, P., & Simpson, S. (2022). Stuttering and the social model. Journal of Communication Disorders, 96(April 2021). https://doi.org/10.1016/j.jcomdis.2022.106200 Corrigan, P. (2013). On the Self-Stigma of Mental Illness: Stages, Disclosure, and Strategies for change. Multicultural Educ - Arora, 57(8), 9–24. https://doi.org/10.4324/9781315831817 53 Corrigan, P., & Kleinlein, P. (2005). The Impact of Mental Illness Stigma. In On the stigma of mental illness: Practical strategies for research and social change. (pp. 11–44). American Psychological Association. https://doi.org/10.1037/10887-001 Corrigan, P., & Kosyluk, K. A. (2013a). Erasing the Stigma: Where Science Meets Advocacy. Basic and Applied Social Psychology, 35(1), 131–140. https://doi.org/10.1080/01973533.2012.746598 Corrigan, P., Morris, S. B., Michaels, P. J., Rafacz, J. D., & Rusch, N. (2012). Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatric Services, 63(10). https://doi.org/10.1176/appi.ps.005292011 Corrigan, P., & Shapiro, J. R. (2010). Measuring the impact of programs that challenge the public stigma of mental illness. Clinical Psychology Review, 30(8), 907–922. https://doi.org/10.1016/j.cpr.2010.06.004 Corrigan, P., Watson, A. M. Y. C., & Barr, L. (2006). The Self-Stigma of Mental Illness: Implications for Self-Esteem and Self-Efficacy. 25(9), 875–884. Dearing, J. W., Beacom, A. M., Chamberlain, S. A., Meng, J., Berta, W. B., Keefe, J. M., Squires, J. E., Doupe, M. B., Taylor, D., Reid, R. C., Cook, H., Cummings, G. G., Baumbusch, J. L., Knopp-Sihota, J., Norton, P. G., & Estabrooks, C. A. (2017). Pathways for best practice diffusion: The structure of informal relationships in Canada’s long-term care sector. Implementation Science, 12(1), 1–13. https://doi.org/10.1186/s13012-017- 0542-7 Dearing, J. W., & Cox, J. G. (2018). Diffusion of innovations theory, principles, and practice. Health Affairs, 37(2), 183–190. https://doi.org/10.1377/hlthaff.2017.1104 Dearing, J. W., & Lapinski, M. (2020). Multisolving innovations for climate and health: Message framing to achieve broad public support. Health Affairs, 39(12), 2175–2181. https://doi.org/10.1377/hlthaff.2020.01170 Diehl, J., Robb, M. P., Lewis, J. G., & Ormond, T. (2019). Situational speaking anxiety in adults who stutter. Speech, Language and Hearing, 22(2), 100–110. https://doi.org/10.1080/2050571X.2018.1441782 Dietz, P., Reichel, J. L., Edelmann, D., Werner, A. M., Tibubos, A. N., Schäfer, M., Simon, P., Letzel, S., & Pfirrmann, D. (2020). A systematic umbrella review on the epidemiology of modifiable health influencing factors and on health promoting interventions among university students. Frontiers in Public Health, 8(April). https://doi.org/10.3389/fpubh.2020.00137 Eagly, A. H., & Chaiken, S. (1993). The psychology of attitudes (S. Chaiken (ed.)). Harcourt Brace Jovanovich College Publishers. Erickson, S., & Block, S. (2013). The social and communication impact of stuttering on adolescents and their families. Journal of Fluency Disorders, 38(4), 311–324. 54 https://doi.org/10.1016/j.jfludis.2013.09.003 Flynn, T. W., & St. Louis, K. O. (2011). Changing adolescent attitudes toward stuttering. Journal of Fluency Disorders, 36(2), 110–121. https://doi.org/10.1016/j.jfludis.2011.04.002 Gabel, R. M., Blood, G. W., Tellis, G. M., & Althouse, M. T. (2004). Measuring role entrapment of people who stutter. Journal of Fluency Disorders, 29(1), 27–49. https://doi.org/10.1016/j.jfludis.2003.09.002 Gerlach, H., Chaudoir, S. R., & Zebrowski, P. M. (2021). Relationships between stigma-identity constructs and psychological health outcomes among adults who stutter. Journal of Fluency Disorders, 70(March), 2-16. https://doi.org/10.1016/j.jfludis.2021.105842 Gerlach, H., Totty, E., Subramanian, A., & Zebrowski, P. (2018). Stuttering and labor market outcomes in the United States. Journal of Speech, Language, and Hearing Research, 61(7), 1649–1663. https://doi.org/10.1044/2018_JSLHR-S-17-0353 Godwin, H., & Heymann, S. J. (2015). A call to action: Training public health students to be effective agents for social change. American Journal of Public Health, 105, S34–S37. https://doi.org/10.2105/AJPH.2014.302356 Goffman, E. (1963). Stigma: Notes on the Management of Spoiled Identity. Prentice-Hall, Inc. Greenhalgh, T., & Papoutsi, C. (2019). Spreading and scaling up innovation and improvement. BMJ (Online), 365(May), 1–8. https://doi.org/10.1136/bmj.l2068 Hembroff, L. A., Martell, D., Allen, R., Poole, A., Clark, K., & Smith, S. W. (2021). The long- term effectiveness of a social norming campaign to reduce high-risk drinking: The Michigan State University experience, 2000–2014. Journal of American College Health, 69(3), 315–325. https://doi.org/10.1080/07448481.2019.1674856 Hurst, M. I., & Cooper, E. B. (1983). Employer attitudes toward stuttering. Journal of Fluency Disorders, 8(1), 1–12. https://doi.org/10.1016/0094-730X(83)90017-7 Iimura, D., & Miyamoto, S. (2021). Public attitudes toward people who stutter in the workplace: A questionnaire survey of Japanese employees. Journal of Communication Disorders, 89. https://doi.org/10.1016/j.jcomdis.2020.106072 Iverach, L., Jones, M., Lowe, R., O’Brian, S., Menzies, R. G., Packman, A., & Onslow, M. (2018). Comparison of adults who stutter with and without social anxiety disorder. Journal of Fluency Disorders, 56, 55–68. https://doi.org/10.1016/j.jfludis.2018.03.001 Jacobson, R. P., Mortensen, C. R., & Cialdini, R. B. (2011). Bodies Obliged and Unbound: Differentiated Response Tendencies for Injunctive and Descriptive Social Norms. Journal of Personality and Social Psychology, 100(3), 433–448. https://doi.org/10.1037/a0021470 55 Klompas, M., & Ross, E. (2004). Life experiences of people who stutter, and the perceived impact of stuttering on quality of life: Personal accounts of South African individuals. Journal of Fluency Disorders, 29(4), 275–305. https://doi.org/10.1016/j.jfludis.2004.10.001 Kohli, N., Kumar, V., & Yadav, S. (2023). People with HIV / AIDS : Stigma , Self-Esteem and Psychological Health. Psychological Studies. https://doi.org/10.1007/s12646-023-00758- y Kuhn, C. D., Louis, K. O. S., Association, L., Denver, A., Kuhn, C. D., & St, K. O. (2015). Attitudes Toward Stuttering of Middle School Students Before & After a Stuttering. Poster presented at the 2015 Annual Convention of the American Speech-Language-Hearing Association. Denver, CO. Langevin, M., & Prasad, N. G. N. (2012). A Stuttering Education and Bullying Awareness and Prevention Resource: A Feasibility Study. Language, Speech, and Hearing Services in Schools, 43(3), 344–358. https://doi.org/10.1044/0161-1461(2012/11-0031) Link, B. G., & Phelan, J. C. (2001). Conceptualizing Stigma. Annual Review of Sociology, 27, 363–385. Ma, Y., Mason, E. M., McGinn, E. M., Parker, J., Oxley, J. D., & St. Louis, K. O. (2024). Attitudes toward stuttering of college students in the USA and China: A cross-cultural comparison using the POSHA-S. Journal of Fluency Disorders, 79. https://doi.org/10.1016/j.jfludis.2024.106037 Major, B., & O’Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393–421. https://doi.org/10.1146/annurev.psych.56.091103.070137 National Stuttering Association. (2023). Stuttering Resources (Printable). https://www.westutter.org/post/free-printables-brochures O’brian, S., Jones, M., Packman, A., Onslow, M., Menzies, R., Lowe, R., Cream, A., Hearne, A., Hewat, S., Harrison, E., Block, S., & Briem, A. (2022). The Complexity of Stuttering Behavior in Adults and Adolescents: Relationship to Age, Severity, Mental Health, Impact of Stuttering, and Behavioral Treatment Outcome. Journal of Speech, Language, and Hearing Research, 65(7), 2446–2458. https://doi.org/10.1044/2022_JSLHR-21- 00452 Qualtrics. (April 2024). Qualtrics (February-April 2024). https://www.qualtrics.com Rabin, B. A., Brownson, R. C., Haire-Joshu, D., Kreuter, M. W., & Weaver, N. L. (2008). A glossary for dissemination and implementation research in health. Journal of Public Health Management and Practice, 14(2). https://doi.org/10.1097/01.PHH.0000311888.06252.bb Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press. 56 Smith, A., & Weber, C. (2016). Childhood Stuttering: Where Are We and Where Are We Going? Seminars in Speech and Language, 37(4), 291–297. https://doi.org/10.1055/s- 0036-1587703 Smith, A., & Weber, C. (2017). How stuttering develops: The multifactorial dynamic pathways theory. Journal of Speech, Language, and Hearing Research, 60(9). https://doi.org/10.1044/2017_JSLHR-S-16-0343 St. Louis, K. O. (2011). The Public Opinion Survey of Human Attributes-Stuttering (POSHA-S): Summary framework and empirical comparisons. Journal of Fluency Disorders, 36(4), 256–261. https://doi.org/10.1016/j.jfludis.2011.02.003 St. Louis, K. O. (2012). Research and development on a public attitude instrument for stuttering. Journal of Communication Disorders, 45(2), 129–146. https://doi.org/10.1016/j.jcomdis.2011.12.001 St. Louis, K. O. (2015). Stuttering Meets Sterotype, Stigma, and Discrimination : An Overview of Attitude Research: Vol. First edit. West Virginia University. St. Louis, K. O. (2020). Comparing and predicting public attitudes toward stuttering, obesity, and mental illness. American Journal of Speech-Language Pathology, 29(4), 2023–2038. https://doi.org/10.1044/2020_AJSLP-20-00038 St. Louis, K. O. (2022). Public Opinion Survey of Human Attributes-Stuttering (POSHA-S). Populore. St. Louis, K. O., & Flynn, T. W. (2018). Maintenance of improved attitudes toward stuttering. American Journal of Speech-Language Pathology, 27(2), 721–736. https://doi.org/10.1044/2017_AJSLP-17-0146 St. Louis, K. O., Węsierska, K., & Polewczyk, I. (2018). Improving Polish stuttering attitudes: An experimental study of teachers and university students. American Journal of Speech- Language Pathology, 27(3S), 1195–1210. https://doi.org/10.1044/2018_AJSLP-ODC11- 17-0179 St. Louis, K. O., Węsierska, K., Przepiórka, A., Błachnio, A., Beucher, C., Abdalla, F., Flynn, T., Reichel, I., Beste-Guldborg, A., Junuzović-Žunić, L., Gottwald, S., Hartley, J., Eisert, S., Johnson, K. N., Bolton, B., Sangani, M. T., Rezai, H., Abdi, S., Pushpavathi, M., … Aliveto, E. (2020a). Success in changing stuttering attitudes: A retrospective analysis of 29 intervention studies. Journal of Communication Disorders, 84(February 2019), 105972. https://doi.org/10.1016/j.jcomdis.2019.105972 St. Louis, K. O., Węsierska, K., Przepiórka, A., Błachnio, A., Beucher, C., Abdalla, F., Flynn, T., Reichel, I., Beste-Guldborg, A., Junuzović-Žunić, L., Gottwald, S., Hartley, J., Eisert, S., Johnson, K. N., Bolton, B., Sangani, M. T., Rezai, H., Abdi, S., Pushpavathi, M., … Aliveto, E. (2020b). Success in changing stuttering attitudes: A retrospective analysis of 29 intervention studies. Journal of Communication Disorders, 84(February 2019), 105972. https://doi.org/10.1016/j.jcomdis.2019.105972 57 STAMMA. (2023). Campaigns. British Stammering Association. https://stamma.org/about- us/campaigns Stangl, A. L., Earnshaw, V. A., Logie, C. H., Van Brakel, W., Simbayi, L. C., Barré, I., & Dovidio, J. F. (2019). The Health Stigma and Discrimination Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Medicine, 17(1), 18–23. https://doi.org/10.1186/s12916- 019-1271-3 Statistics Kingdom. (2017). Z-test and T-test sample size calculator. https://www.statskingdom.com/410multi_linear_regression.html The Stuttering Foundation. (2023). Public Service Ads. https://www.stutteringhelp.org/public- service-ads Tichenor, S. E., & Yaruss, J. S. (2019). Stuttering as defined by adults who stutter. Journal of Speech, Language, and Hearing Research, 62(12), 4356–4369. https://doi.org/10.1044/2019_JSLHR-19-00137 Mayo, R.W., & St Louis, K. O. (2016). Attitudes of College Career Counselors Towards Stuttering and People Who Stutter. https://pubs.asha.org Waqas, A., Malik, S., Fida, A., Abbas, N., Mian, N., Miryala, S., Amray, A. N., Shah, Z., & Naveed, S. (2020). Interventions to Reduce Stigma Related to Mental Illnesses in Educational Institutes: a Systematic Review. Psychiatric Quarterly, 91(3), 887–903. https://doi.org/10.1007/s11126-020-09751-4 Weidner, M. E., St. Louis, K. O., & Glover, H. L. (2018). Changing nonstuttering preschool children’s stuttering attitudes. American Journal of Speech-Language Pathology, 27(4), 1445–1457. https://doi.org/10.1044/2018_AJSLP-18-0019 Werle, D., & Byrd, C. T. (2021). College professors’ perceptions of students who stutter and the impact on comfort approaching professors. Journal of Fluency Disorders, 67(December 2020), 105826. https://doi.org/10.1016/j.jfludis.2020.105826 Werle, D., Winters, K. L., & Byrd, C. T. (2021). Preliminary study of self-perceived communication competence amongst adults who do and do not stutter. Journal of Fluency Disorders, 70. https://doi.org/10.1016/j.jfludis.2021.105848 Westbury, S., Oyebode, O., van Rens, T., & Barber, T. M. (2023). Obesity Stigma: Causes, Consequences, and Potential Solutions. Current Obesity Reports, 12(1), 10–23. https://doi.org/10.1007/s13679-023-00495-3 Williams, A. Z., Tetnowski, J., & St. Louis, K. O. (2023). Addressing Attitudes About Stuttering in Preservice Teachers. Perspectives of the ASHA Special Interest Groups, 1–8. https://doi.org/10.1044/2023_persp-22-00187 Yairi, E., & Seery, C. H. (2023). Stuttering: Foundations and Clinical Applications, Third 58 Edition: Vol. Third edit. Plural Publishing, Inc. 59 APPENDIX A: THEORETICAL EVIDENCE Health Communication Theoretical Basis 1. Theory of Normative Conduct (Jacobson et al., 2011) a. Goal: “making accurate/efficient decisions and gaining/maintaining social approval,” (Jacobson et al., 2011, p. 433). i. Aiming to hone in on the accuracy aspect during this intervention. ii. Ideally, we would normalize acceptance of stuttering so that acceptance would lead to gaining/maintaining social acceptance, but there is no time for that in this study. 1. Injunctive norms (Jacobson et al., 2011) a. Individual beliefs about how other people should behave. b. Individuals seek social approval and strive for self- efficiency and accuracy. i. People act in accordance with how they think others would want them to act, not how they want to act. 2. Descriptive norms (Jacobson et al., 2011) a. Actual behavior. b. Used as a guide for navigating ambiguity. i. People likely do not know much about stuttering therefore, they react negatively to unknown situations. b. How this applies to my intervention i. Messages will… 1. Because stuttering is likely ambiguous to many people (descriptive norm) this presentation will emphasize accurate beliefs about stuttering (injunctive norm) while drawing support from the Social Model of Disability (e.g., it is society’s responsibility to support people with differences and it’s not their fault). 2. Social desirability bias (Boyle, 2017) a. People behave differently when they feel they are being watched. b. Boyle (2017), people are inconsistent when it comes to their personal beliefs (descriptive) and how they think others behave (injunctive). c. How this applies to my intervention i. It may skew the pre-intervention and post-intervention POSHA-S data. The Social Desirability Bias is not necessarily guiding the formation of the intervention, but it is something to be considered during data analyses and discussion. 3. Diffusion of Innovations Theory a. “(1) an innovation (2) is communicated through channels (3) over time (4) to members within a social system,” (Rogers, 2003, p. 21). b. Purposive diffusion (Dearing & Cox, 2018) i. Targeted and direct dissemination curated to increase the likelihood that it will reach, be perceived positively, adapted, and implemented into practice by potential adopters. c. How this applies to my intervention 60 i. Diffusion… 1. Innovation a. Anti-stigma intervention about stuttering presented by a person who stutters. 2. Communicated through channels a. In vivo presentation. 3. Over time a. N/A. This is a one-time presentation. 4. To members within a social system a. Undergraduate students at Michigan State University. ii. Purposive Diffusion 1. This message will be a. Targeted i. Created with university students in mind by a person of a similar age within their community (MSU student who stutters). b. Direct i. In-person with digestible, engaging materials outlined below. 4. Adoption a. Adoption is the decision to commit and initiate an innovation in a community or organization (Rabin et al., 2008). b. 5 key attributes that contribute to the perception of innovation and adoption (Rogers, 2003) i. Relative advantage ii. Compatible with their lifestyle iii. Complexity iv. Trialability v. Observability c. How this applies to my intervention i. 5 key attributes 1. Relative advantage a. Make it appeal to them using appropriate humor, and engaging presentation of facts vs. myths. b. Injunctive and descriptive norms i. It serves them better to accept people who stutter because a) it is not their fault, b) you never know who you are talking to, and c) stigmatizing people for something beyond their control is damaging. 2. Compatible with their lifestyle a. It is easy to be a nice person! It takes no extra effort and stuttering does not impact who they are or what they’re capable of 3. Complexity a. Easy to understand 61 i. Not presenting the most scientific research about stuttering. ii. The presentation will be more conversation-based and information will be presented in lay terms. 4. Trialability a. Acceptance and understanding are not difficult to implement into everyday life, particularly when individuals are provided with an understanding of something they may not otherwise be familiar with. 5. Observability a. Not able to measure in this study due to time. ii. Measuring the potential for adoption or lack thereof 1. Using open-ended questions and asking something to the effect of: a. Did this presentation impact how you might interact with people who stutter in the future? i. We may see attitudinal changes through POSHA-S scores 1. Be wary of social desirability bias and injunctive/descriptive norms – people behave differently when they feel they are being watched (such as in the case of Boyle (2017)). 5. Innovation-Decision Process (Rogers, 2003). a. “… series of choices and actions over time through which an individual or a system evaluates a new idea and decides whether or not to incorporate the innovation into ongoing process,” (Rogers, 2003, p. 107). b. 5 stages (Rogers, 2003). i. Learning of an innovation ii. Developing an attitude toward the innovation iii. Deciding to adopt or reject the innovation iv. Implementing the innovation v. Confirmation of their decision c. How this applies to my intervention i. Innovation-Decision Process 1. Learning of an innovation a. Participants signing up for the study. 2. Develop an attitude a. Following the innovation, respondents are likely to have developed an attitude toward stuttering and people who stutter. 3. Deciding to adopt or reject the innovation a. Measured with POSHA-S and open-ended questions. 4. Implementation decision a. Ask participants if this intervention will impact their future interactions with people who stutter to measure their 62 potential to implement the new practices into their everyday lives. 5. Confirmation a. Not able to measure given time constraints. 6. Social model of disability in the context of stigmatized health conditions (Constantino et al., 2022). a. It is society’s responsibility to accept people who stutter, and we need to normalize this. It is not the responsibility of people who stutter to accommodate society’s potential discomfort with stuttering. b. How this applies to my intervention i. Emphasize society’s responsibility to accept and accommodate differences. ii. But this must be framed in a manner that does not blame the students for the treatment of people who stutter (i.e., avoiding the protest approach). Rather, we want to inform them in an engaging manner that provides information about how they may (and really, should) avoid contributing to this issue in the future! 1. The goal is not to chastise them for pre-existing attitudes that may exist. The goal is to provide them with the information to create accurate mental representations regarding the nature of stuttering and people who stutter. We do not want them to feel forced to have a certain opinion, but we do want to encourage fair treatment and acceptance of stuttering. Evidence from previous interventions that will be used to form the content of the speech Vehicle (in vivo) 1. In the context of mental illness, in vivo messages must be (Corrigan & Kosyluk, 2013a) a. Targeted b. Local c. Credible d. Continuous contact 2. How this relates to my intervention a. Message will be delivered in person (in vivo) i. Targeted 1. Message curated to be presented to undergraduate students not pursuing this field. ii. Local 1. MSU student presenting to other MSU students. iii. Credible 1. Member of the stigmatized group presenting to other college students about their challenges but also their successes. 2. People who stutter are not limited by their stutter, as evidenced by the MA or Ph.D. student speaking to them. iv. Continuous contact 1. Unable to achieve given the time constraints. 63 Processes 1. Education a. Dispel myths and harmful stereotypes of a stigmatized condition with relevant and correct information while replacing inaccurate beliefs, knowledge, and stereotypes with factual information about the stigmatized condition (Corrigan & Kosyluk, 2013a) b. Intervention content using education and contact approaches could include personal success stories, with a balance between dispelling myths and proving facts, and appropriate humor. Education approaches require caution, as excessive education might lead to a rebound effect and an increase in negative attitudes (Corrigan & Kosyluk, 2013a). Educational messages must be delivered engagingly and succinctly to capture the audience’s attention without overwhelming them with information. c. “…(a) be captivating and interesting to the target audience, (b) deal with material that has meaning to the audience, and (c) contain sufficient information about the disorder,” (St. Louis et al., 2020a, p. 29). d. Efforts to improve attitudes toward stuttering must be tailored, engaging, and meaningful for recipients (Corrigan & Kosyluk, 2013a; St. Louis et al., 2020a). a. What to educate about in my intervention? i. Cause of stuttering 1. The psychological cause of stuttering was perceived most negatively (Boyle et al. 2009) 2. Even when the perceived cause was more accurate, it did not correlate with improved attitudes (Boyle et al. 2017). a. Tell participants: i. Stuttering is due to 1. Neurological origin ((Bloodstein et al., 2021; Smith & Weber, 2017; Yairi & Seery, 2023) 2. Genetic and environmental ii. Stuttering is not due to 1. People being nervous, psychological reasons, etc. ii. Myths about stuttering (Amick et al., 2017; Gabel et al., 2004; Gerlach et al., 2018; Hurst & Cooper, 1983) 1. People who stutter are not: a. Unemployable b. Unable to succeed in vocational, educational, and social roles c. Unable to succeed in situations that require high speaking demands d. More shy, anxious, nervous, less likable, or have lower cognitive abilities compared to people who do not stutter. 2. People who stutter are: 64 a. Able to be successful in any vocational, academic, or social setting that requires high speaking demands, interpersonal communication, and verbal communication b. Typically, message content includes stories of struggle due to the individual's stigmatized condition and success despite these challenges (Corrigan & Kosyluk (2013) i. Example: whoever is giving the presentation may speak about their challenges but ALSO their successes in academia, the workplace, and socially 1. Based on Boyle (2017) - a person who stutters sharing their story, emphasizing that there are no fundamental differences between the speaker and audience (people who do not stutter), may be an effective approach to improving the stigma towards stuttering. c. Not necessarily more shy, anxious, or have lower cognitive capabilities compared to people who do not stutter. This is an incorrect assumption! b. Evidence that supports this approach iii. Various stigmatized conditions 1. A media-based, education, and protest approach employed on Michigan State University’s campus over ten years found significant success utilizing messages that targeted either injunctive or descriptive norms (Hembroff et al., 2021). iv. Stuttering 1. The combination of education and contact has also shown some positive impact on adolescent and adult attitudes towards stuttering (Abasi, 2022; Abdalla & St. Louis, 2014; Boyle et al., 2016). 2. Contact a. Stigmatized individuals share their personal stories of living with a stigmatized condition, and disclosure of their stigmatized condition is required (Boyle et al., 2016). b. Contact must include (Corrigan & Kosyluk, 2013a) i. A common goal and a willingness amongst stigmatized and non- stigmatized groups to reach the goal(s), equal status of the groups, and support of the authorities, laws, or customs c. How this relates to my intervention? i. Most success is seen with interpersonal contact approaches across stigmatized conditions ii. The person presenting will share personal stories about their experiences, both good and bad, therefore disclosing. d. Evidence that supports this approach i. Various stigmatized conditions 65 1. Corrigan and Kosyluk (2013) examined the three processes used in stigma reduction and found that contact had positive effects on improving attitudes toward mental illness compared to protest, education, and control groups 2. Various mental illness anti-stigma interventions indicated that in vivo contact was the most effective method for reducing stigma, especially when the person speaking challenges the prevailing stereotype (Corrigan et al., 2012; Corrigan & Kosyluk, 2013a). ii. Stuttering 1. Abasi (2022) found moderate success utilizing an interpersonal education approach with a pre-recorded documentary shown to university students. Similar results have been observed with university students in Poland and Kuwait (Abdalla & St. Louis, 2014; St. Louis et al., 2018), and adolescents, university students, and adults in the United States (Boyle et al., 2016; Flynn & St. Louis, 2011; St. Louis & Flynn, 2018; Williams et al., 2023) 2. Messages included personal stories about lived experiences with stuttering, information to dispel misconceptions, and in one, appropriate humor (Flynn & St. Louis, 2011). Establishing credibility, either as a person who stutters or being a close relative to someone who stutters, is essential in establishing buy-in from the target audience (Corrigan & Kosyluk, 2013a). 3. Protest a. Not used due to potential for rebound effects. 66 APPENDIX B: OUTLINE OF PRESENTATION SCRIPT Below is an outline of the information you are being asked to present. After reading the outline below, the addition of your personal anecdotes, appropriate humor, and any other information about stuttering you wish to include is encouraged. However, please inform the author (Erika Mueller), before doing so. 1. Introduction a. Name b. Age c. Where you are from d. Year in school/program at MSU e. Please include that you are a person who stutters 2. Stuttering and your experiences a. Briefly describe what stuttering is i. Stuttering is not just "tripping over your words" ii. It is… 1. Briefly, stuttering-like disfluencies and secondary behaviors a. If comfortable, please prime listeners for what they may see during your presentation (e.g., "You may see me tense my neck, etc.") b. How long have you known that you are a person who stutters? c. What are your earliest memories of stuttering? d. How has stuttering impacted your life? i. Have you felt that you had to hide your stutter to “fit in”? 1. How could society better support people who stutter? (Emphasizing the fact that it is no one’s fault they stutter but potentially, society has made it more difficult for you to pursue opportunities because of your stutter) e. What do you wish people knew about stuttering? 3. Myths vs. facts a. Stuttering is not i. Due to psychological distress (nervousness, stress, etc.) ii. Because something is “wrong” iii. A limiting factor for social, vocational, or academic success 1. People who stutter are limited by society a. Therefore, it is important that we know what stuttering is, b. Stuttering is and is not. i. Due to a combination of genetic and environmental factors, neurological origin 1. Maybe use the light switch analogy here a. Gene: light switch. b. Environment: flips the light switch “on.” c. People who stutter are not i. Unemployable 67 ii. Unable to succeed in vocational, educational, and social roles, or in situations that require high speaking demands 1. Please share at least one situation where you have successfully gained employment or succeeded in a role that required high speaking demands iii. More anxious, shy, nervous, less social, etc. d. People who stutter i. Fundamentally, there are zero differences between people who stutter and people who do not stutter. 1. To the extent that you are comfortable, please include at least one story of a challenge you have faced in addition to your successes, regardless of your stutter 4. Closing a. Emphasize once more i. There are fundamentally no differences between people who do and do not stutter. ii. People who stutter are just as capable as anyone in any social, vocational, or academic role. iii. We (society in general) must be supportive of people who stutter! 68 APPENDIX C: OPEN-ENDED QUESTIONS FOLLOWING THE INTERVENTION 1. Do you personally know someone who stutters? If so, who? a. No b. Yes (please specify whom and your relationship with the individual(s) without naming, i.e., sibling, acquaintance, etc.) 2. Please rank your familiarity with stuttering. a. Not at all familiar b. Slightly familiar c. Somewhat familiar d. Moderately familiar e. Extremely familiar 3. What was most memorable about what you heard during the presentation? (2 open- ended items) 4. How likely is it that the presentation you observed today will impact your attitude toward people who stutter? 5. How likely is it that the presentation you observed today will impact your future interactions toward people who stutter? a. Questions 3-5 were given only to the experimental group. 69 APPENDIX D: HEALTH COMMUNICATION LITERATURE BACKGROUND Health Communication Simply putting information into the world and expecting people to change their attitudes, beliefs, and behaviors is not sufficient for tangible change. Factors that may influence individuals to change their attitudes, beliefs, and behaviors must be considered. For this, the Diffusion of Innovations, dissemination of information, and adoption theory offer a unique perspective into the relative success or failure of previous stuttering anti-stigma EBIs. This knowledge may be leveraged to develop best practices in the areas of stigma reduction and attitude improvement among university students. Dissemination and Diffusion of Innovations Dissemination is the planned and targeted administration of an innovation to a target population through pre-determined messages and communication channels (Rabin et al., 2008; Rogers, 2003). Dissemination typically occurs through a variety of message channels including but not limited to in-person, mass media, or targeted intervention channels, however, “simply making information available is probably more common,” (Dearing & Cox, 2018, p. 186). Diffusion is a social process that occurs over time as a result of the untargeted and passive spread of information, or innovations, which is communicated to members of a social system via various communication channels (Rabin et al., 2008; Rogers, 2003). There are four necessary components for the diffusion of an innovation: “(1) an innovation (2) is communicated through channels (3) over time (4) to members within a social system,” (Rogers, 2003, p. 21). Diffusion can occur among individuals, or larger systems such as corporate organizations, government bodies, states, and so forth. Relationships among potential adopters, and their perceptions of the novel innovation and environment within a social system, influence the decision to adopt an 70 innovation (Dearing et al., 2017; Rogers, 2003). Purposive diffusion is the result of targeted and direct dissemination curated to increase the likelihood that it will reach, be perceived positively, adapted, and implemented into practice by potential adopters (Dearing & Cox, 2018). The dissemination and diffusion of anti-stigma materials is of great interest. Such information will help illustrate a better understanding of what works and for whom, which will guide future stuttering stigma reduction campaigns. The Innovation-Decision Process The Innovation-Decision process is “… series of choices and actions over time through which an individual or a system evaluates a new idea and decides whether or not to incorporate the innovation into ongoing process,” (Rogers, 2003, p. 107). It is the process of individuals or a system progressing through five sequential stages; learning of an innovation, developing an attitude toward the innovation, deciding to adopt or reject the innovation, implementing the innovation, and the confirmation of their decision (Rogers, 2003). The perceived novelty and the accompanying uncertainty associated with the innovations are distinctive components of the innovation decision-making process. The exposure to and understanding of an innovation’s functioning comprises the first stage of the innovation-decision-making process. Following the knowledge stage, negative or positive attitudes are formed toward an innovation during the persuasion stage (Rogers, 2003). Following attitude formation, individuals or decision-making units decide to engage in activities that lead to the adoption or rejection of an innovation (Rogers, 2003). Should adoption occur, the subsequent stage is the implementation or utilization of an innovation. Lastly, following implementation, confirmation, and reinforcement regarding the implementation of the innovation are sought out by the individual or decision-making unit (Rogers, 2003). The decision to adopt 71 and implement may be reversed if conflicting or negative messages are received about the innovation (Rogers, 2003). A comprehensive understanding of the nuances and factors that contribute to an individual’s decision to adopt an innovation, or not, can provide foundational information during intervention formation. Adoption Adoption is the decision to commit and initiate an innovation in a community or organization (Rabin et al., 2008). The rate of adoption among a community or organization is referred to as the rate of adoption (Rogers, 2003). As innovations and evidence-based interventions are disseminated, individuals within a collective group can embrace the novel innovation, or not. An individual or collective group’s willingness to change is known as their innovativeness (Dearing & Cox, 2018). Adopters can be categorized into groups depending on when one chooses to adopt an innovation. Numerous factors influence the adoptability of an innovation. Rogers (2003) proposed five key attributes that contribute to the perception of an innovation: relative advantage, compatibility, complexity, trialability, and observability. How each of these characteristics are perceived, and to what degree, may help to explain the likelihood and rate of adoption for an innovation. The Social Model of Disability in the Context of Stigma Reduction The medical model of disability framework suggests that it is the responsibility of individuals with disabilities to adapt and change to meet societal expectations and norms (Constantino et al., 2022). Behaviors or characteristics that are considered “normative” or accepted within a society are contingent upon multiple factors, including cultural, geographical regions, and exterior influences like societal stigma. The concept of difference hinges on which traits are favored within a group, leaving those outside the favored group vulnerable to 72 stigmatization, prejudice, and discrimination. Historically, through the context of the medical model of disability, stuttering has been viewed as a disabling experience, limiting their social (Boyle et al., 2018; Erickson & Block, 2013; Klompas & Ross, 2004), vocational (Gabel et al., 2004; Gerlach et al., 2018; Hurst & Cooper, 1983), and educational opportunities (Mayo & St Louis, 2016; Werle & Byrd, 2021). In contrast, the social model of disability asserts that it is the responsibility of society to accommodate, accept, and support individuals with disabilities (Constantino et al., 2022). This perspective alleviates the pressure from disabled individuals, emphasizing the responsibility of society to accommodate and accept individual differences. Here, it is not the individual who is disabled but rather the society. Society's reactions and expectations of stuttering shape the stigma and stereotypes associated with it. The preconceived notions that people who stutter are more anxious, shy, and/or less capable, limit their experiences and abilities to pursue interests and opportunities. When designing anti-stigma interventions, it is essential to consider the target population’s perspective of disability. A message lacking relative advantage or compatibility is unlikely to be adopted by recipients (Rogers, 2003). The social model of disability is an ideal framework for an anti-stigma approach targeted towards those who do not experience the stigmatized condition. This approach encourages a shift in societal attitudes and expectations, fostering a more inclusive and accepting environment for people who stutter. It can be assumed that each innovation is disseminated to improve the lives of a given group, however, many do not reach the desired levels of change. It must be considered what influences individuals to change their attitudes, beliefs, and behaviors, or not. Diffusion of Innovations, dissemination of information, and adoption theories offer a unique perspective into the relative success or failure of previous stuttering stigma reduction EBIs. This knowledge can 73 help develop best practices in stigma reduction and attitude improvement among university students. 74 APPENDIX E: POSHA-S SURVEY Survey Flow Standard: Consent (2 Questions) BlockRandomizer: 1 - Evenly Present Elements Block: Control (37 Questions) Block: Experimental (42 Questions) Page Break Start of Block: Consent DOCUMENTATION OF INFORMED CONSENT Please select your choice below. You may print a copy of this consent form for your records. Clicking "Agree" indicates that: - You have read the information above - You voluntarily agree to participate - You are 18 years of age or older o Agree (4) o Disagree (5) Q117 The experimental group will be asked to view a 17-minute pre-recorded video. Both groups will be asked to complete the same virtual questionnaire. I understand that I will be randomly assigned to either the control or experimental group. o Agree (1) o Disagree (2) Skip To: End of Survey If The experimental group will be asked to view a 17-minute pre- recorded video. Both groups will be... = Disagree End of Block: Consent Start of Block: Control 75 Q120 St. Louis, K. O. (2011). The Public Opinion Survey of Human Attributes-Stuttering (POSHA-S): Summary framework and empirical comparisons. Journal of Fluency Disorders. https://doi.org/10.1016/j.jfludis.2011.02.003 Q1 Today's date is: o Month (e.g., October) (1) __________________________________________________ o Day (e.g., 23) (2) __________________________________________________ o Year (e.g., 2015) (3) __________________________________________________ Q2 The date I was born was: o Month (e.g., September) (1) __________________________________________________ o Day (e.g., 10) (2) __________________________________________________ o Year (e.g., 1992) (3) __________________________________________________ Q3 I now live in: o Country (1) __________________________________________________ o State/Province (2) __________________________________________________ o City/Town/Village/Region (3) __________________________________________________ 76 Q4 I was born in (Country, State (or Province), City (or Town, Village, Region): o Country (1) __________________________________________________ o State/Province (2) __________________________________________________ o City/Town/Village/Region (3) __________________________________________________ Q52 I grew up in (Country, State (or Province), City (or Town, Village, Region): o Country (1) __________________________________________________ o State/Province (2) __________________________________________________ o City/Town/Village/Region (3) __________________________________________________ Q41 My gender identity is: (type N/A if you do not wish to respond) ________________________________________________________________ Q7 I am/have been married: ▢ ▢ Yes No 77 Q8 I am/was a parent: ▢ ▢ Yes No Q9 I have completed the following school levels: ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Primary (elementary) school (5-6 years total) Middle (junior high) school (7-9 years total) High school (11-13 years total) Trade/military/technical/other school 2-year university degree (about 14 years total) 4-year university degree (about 16 years total) Masters or similar degree (about 18 years total) Doctoral/professional degree (>18 years total) Q10 My job or work situation now is... ▢ ▢ ▢ ▢ Student in school or university Working Unemployed or not working Retired 78 Q11 The job that I am best trained to do, or the job I worked at the longest, is (was): ________________________________________________________________ Q12 My native language is: ________________________________________________________________ Q13 I can also easily understand and speak the following languages: o 1. __________________________________________________ o 2. __________________________________________________ o 3. __________________________________________________ Q14 My family's income is [...] compared to the yearly incomes of... Among the lowest About average Among the highest Not sure 1 2 3 3 4 5 My family's, friends, and relatives () All people in my county () Q15 My race is: (type N/A if you do not wish to respond) ________________________________________________________________ 79 Q42 Have you ever received speech therapy services? o Yes o No Display This Question: If have you ever received speech therapy services? = Yes Q44 If you have received speech therapy services, what was the reason? ________________________________________________________________ 80 Q17 I would rate the following four aspects of my life now as… Very poor (1) Poor (2) Average (3) Good (4) Excellent (5) Not sure (6) my physical health my mental health my ability to learn new things my speaking ability o o o o o o o o o o o o o o o o o o o o o o o o Q67 For me, the importance (or priority) of each of these 12 aspects in my life is … Never important Usually not important Equally important or not important Usually important Always important Not sure being safe and secure (1/12) being free to do what I want (2/12) spending quiet time alone (3/12) attending parties or social events (4/12) o o o o o o o o o o o o 81 o o o o o o o o o o o o imagining new things (5/12) helping the less fortunate (6/12) having exciting but potentially "dangerous" experiences (7/12) practicing my religion (8/12) earning money (9/12) doing my jobs or my duty (10/12) getting things finished (11/12) figuring out how to solve important problems (12/12) o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Q19 Now, please give us your opinions about people with all the characteristics listed. Page Break 82 Q20 My overall impression of a person who... Very negative (- 2) Somewhat negative (- 1) Neutral (0) Somewhat positive (1) Very positive (2) Not sure is obese (much overweight) (1) is left handed (2) has a stuttering disorder (3) is mentally ill (4) is intelligent (5) o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 83 Q21 I would want to be a person who… Somewhat disagree ( - 1) Strongly disagree (- 2) Neutral (0) Somewhat agree (1) Strongly agree (2) Not sure is obese (much overweight) (1) is left handed (2) has a stuttering disorder (3) is mentally ill (4) is intelligent (5) o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Q22 The amount I know about people who… None (1) A little (2) Some (3) A lot (4) A great deal (5) Not sure are obese (much overweight) (1) are left handed (2) have a stuttering disorder (3) are mentally ill (4) are intelligent (5) o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 84 Q23 Following are people I have known who… (Choose all that apply) Are obese (much overweight) Are left handed Has a stuttering disorder Is mentally ill Is intelligent o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Nobody (i.e., you do not know a person who is...) Acquaintance Close Friend Relative Me Other Page Break Q29 Now, please give us more detailed opinions about the disorder of stuttering. 85 Q30 People who stutter... Yes No Not sure should try to hide their stuttering should have jobs where they have to correctly understand and decide important things are nervous or excitable are shy or fearful have themselves to blame for their stuttering can make friends can lead normal lives can do any job they want o o o o o o o o o o o o o o o o o o o o o o o o 86 Q31 If the following people stuttered, I would be concerned or worried… Yes No Not sure my doctor my neighbor my brother or sister me o o o o o o o o o o o o 87 Q32 If I were talking with a person who stutters, I would… Yes No Not sure try to act like the person was talking normally (1) make a joke about stuttering (2) fill in the person's words (3) feel impatient (not want to wait while the person stutters) (4) feel comfortable or relaxed (5) feel pity for the person (6) tell the person to "slow down" or "relax" (7) o o o o o o o o o o o o o o o o o o o o o Q33 I believe stuttering is caused by… Yes No Not sure genetic inheritance ghosts, demons, or spirits a very frightening event an act of God learning or habits a virus or disease o o o o o o o o o o o o 88 o o o o o o Q34 I believe stuttering should be helped by… Yes No Not sure other people who stutter a speech and language therapist people like me a medical doctor o o o o o o o o o o o o Q35 My knowledge about stuttering comes from… Yes No Not sure personal experience (me, my family, friends) television, radio, or films magazines, newspapers, or books the Internet school doctors, nurses, or other specialist Page Break o o o o o o o o o o o o o o o o o o Q58 You will now be asked to complete the following short answer questions. 89 Q59 Do you know a person who stutters? If so, who? o No o Yes (please specify whom and your relationship with the individual(s) without naming, i.e., sibling, acquaintance, etc.) ________________________________________________ Q60 Please rank your familiarity with stuttering. o Not at all familiar o Slightly familiar o Somewhat familiar o Moderately familiar o Extremely familiar Page Break Q177 Please provide any feedback you may have regarding your experience with the survey format, content, length, etc., or anything else you would like to add. _______________________________________________________________ End of Block: Control and Experimental POSHA-S Start of Block: Experimental Supplemental Questions Q56 St. Louis, K. O. (2011). The Public Opinion Survey of Human Attributes-Stuttering (POSHA-S): Summary framework and empirical comparisons. Journal of Fluency Disorders. https://doi.org/10.1016/j.jfludis.2011.02.003 Q173 Please view the following video. You will be asked to complete a questionnaire afterwards. 90 Q61 Please answer the following questions about the presentation you observed today. ________________________________________________________________ Q62 What was most memorable about what you heard during the presentation? o #1 __________________________________________________ o #2 __________________________________________________ Q68 How likely is it that the presentation you observed today will impact your attitude toward people who stutter? o Extremely unlikely o Somewhat unlikely o Neutral o Somewhat likely o Extremely likely Q63 How likely is it that the presentation you observed today will impact your future interactions toward people who stutter? o Extremely unlikely o Somewhat unlikely o Neutral o Somewhat likely o Extremely likely 91 Q178 Please provide any feedback you may have regarding your experience with the survey format, content, length, etc., or anything else you would like to add. ________________________________________________________________ End of Block: Experimental 92 APPENDIX F: POSHA-S SUMMARY DATA Figure 1. Component, Subtest, and Overall Stuttering Score Note. Radial graph representing mean component, subtest, and OSS of both conditions (control and experimental) compared to the lowest, highest, and median scores obtained from the POSHA-S database (St. Louis, 2022). More negative attitudes are represented in the center and become more positive the further from the center. 93 -100-75-50-250255075100BELIEFS: ABOUT PEOPLEWHO STUTTERTraits/PersonalityHelp FromCausePotentialOBESITY/MENTAL ILLNESSImpressionWant/HaveAmount KnownSELF REACTIONS: TOPEOPLE WHO STUTTERAccommodating/HelpingSocial Distance/SympathyKnowledge/ExperienceKnowledge SourceControlExperimentalLowestHighestMedian Figure 2. POSHA-S Self-Reaction Subtest Scores Note. Line graph representing mean ratings from both group conditions used to calculate the Self-reactions component score are compared to the lowest, highest, and median scores obtained from the POSHA-S database. 94 -100-75-50-250255075100ACCOMMODATING/HELPINGIgnore StutteringI Should HelpFill Words*Say "Slow down/Relax"*Make Joke*Should Hide*DISTANCE/SYMPATHYComfortablePity*Impatient*Doctor*Neighbor*Sibling*Myself*ImpressionWant to StutterKNOWLEDGE/EXPERIENCEAmountPersons KnownSource: PersonalKNOWLEDGE SOURCETV/RadioPrintInternetSchoolSpecialistsNegative/Inaccurate toPositive/AccurateControlExperimentalLowestHighestMedian Figure 3. POSHA-S Beliefs Subtest scores Note. Line graph representing mean ratings from both group conditions used to calculate the Beliefs component score are compared to the lowest, highest, and median scores obtained from the POSHA-S database. 95 -100-75-50-250255075100TRAITS/PERSONALITY To Blame*Nervous/Excitable*Shy/Fearful*HELP FROMSLPStutterersDoctor*CAUSEGeneticLearning*Emotional Trauma*Act of God*Virus/Disease*Ghost/Demon/Spirit*POTENTIALMake FriendsHave Normal LifeHold any JobJudgment JobNegative/Inaccurate toPositive/AccurateControlExperimentalLowestHighestMedian Figure 4. POSHA-S Human Attribute Scores Note. Line graph representing both experimental conditions responses questions related to six human attributes. Values are compared to the lowest, highest, and median scores obtained from the POSHA-S database. 96 -100-75-50-250255075100IMPRESSIONIntelligentLeft HandedObeseMentally IllStutteringWANT/HAVEIntelligentLeft HandedObeseMentally IllStutteringAMOUNT KNOWNIntelligentLeft HandedObeseMentally IllStutteringNegative/Inaccurate toPositive/AccurateControlExperimentalLowestHighestMedian