A comparison of three strategies for reducing the public stigma associated with stuttering
Introduction
Stuttering is a disorder that is often misunderstood and stigmatized by society (St. Louis, 2015). People who stutter (PWS) are often stereotyped as possessing undesirable personality traits (St. Louis, 2012), reacted to with discomfort (Guntupalli, Kalinowski, Nanjudeswaran, Saltuklaroglu, & Everhart, 2006), and discriminated against for jobs that require speaking (Gabel, Blood, Tellis, & Althouse, 2004). PWS are highly aware of these stigmatizing views of the public, and sometimes endorse these negative views and internalize them (Boyle and Blood, 2015, Boyle, 2013). Mere awareness of stigmatizing public attitudes is related to significantly higher levels of anxiety and depression among adults who stutter (Boyle, 2015). The anticipation of negative societal reactions is a well-known aspect of the stuttering disorder and is hypothesized to be related to the substantially elevated levels of trait and social anxiety found in many PWS (Craig and Tran, 2014, Iverach and Rapee, 2014). Anticipation of negative reactions due to stuttering can result in avoidance of speaking in certain situations, and therefore negatively affect quality of life and the ability to achieve life goals (Butler, 2013; Plexico, Manning, & Levitt, 2009a). Therefore, stigmatizing attitudes and reactions from the public represent environmental barriers to the communicative participation of PWS (American Speech-Language-Hearing Association, 2016, World Health Organization, 2014).
Many professional and self-help organizations across the world include in their mission statement objectives of influencing the environmental barriers faced by PWS through education, outreach, and advocacy efforts at various levels from local to international (American Speech-Language-Hearing Association, 2016, British Stammering Association, 2014, International Fluency Association, 2016, International Stuttering Association, 2016). Organizations often focus on improving public awareness, dispelling common myths, and protesting against unfair treatment of PWS in society through press releases and public service advertisements (e.g., National Stuttering Association, 2016; Stuttering Foundation, 2016).
Although professional and self-help organizations worldwide implement education and stigma reduction efforts to improve attitudes toward PWS, very little empirical evidence exists regarding the effectiveness of these efforts. If organizations are spending time and resources on education and advocacy programs, it will be optimal to focus those efforts on anti-stigma strategies that are empirically validated. This study attempted to document evidence for some of the most common anti-stigma strategies currently used. The following sections will briefly review evidence of benefits of certain anti-stigma strategies from the field of psychology, stigma reduction studies that have been conducted in the area of stuttering, and the purpose of the current study.
The psychology literature provides a thorough discussion and classification system for various stigma reduction strategies. One of the most extensively researched areas related to stigma is mental illness (Corrigan & Kosyluk, 2013). Although mental illness is certainly different from stuttering, individuals with mental illness and PWS have been documented as experiencing public stigma that can be internalized and applied to the self (Boyle, 2013; Corrigan, Rafacz, & Rüsch, 2011). The public also often misunderstands the causes of both of these conditions, particularly through underestimating the extent to which biological factors play an important role in onset (Kvaale, Gottdiener, & Haslam, 2013; Van Borsel, Verniers, & Bouvry, 1999). In addition, the public stigma that both groups face includes similar features (e.g., assumptions of negative personality attributes, prejudiced emotional reactions, discriminatory intentions) (Link & Phelan, 2006). Therefore, even though the disorders are distinct, it is useful to review the literature in mental illness to provide a framework for classifying and operationalizing anti-stigma strategies in the area of stuttering.
A review by Corrigan and Kosyluk (2013) outlined three major anti-stigma strategies that have been used for individuals with mental illness. One method is interpersonal contact with a person with a stigmatized condition. In this approach, the individual tells a personal story about the lived experience of having that condition to members of the public. This strategy relies on a person disclosing the condition to others. The contact approach relies on grassroots efforts from people with disabilities to enact public attitude change. An example might be a PWS from a local self-help support group coming to speak to members of the public at an event or class in that individual’s town. The education approach focuses on separating myths from facts. In this strategy, inaccuracies or myths about a certain condition are presented and then contrasted with facts from current research. Some examples of the education approach are groups like the Stuttering Foundation producing and distributing brochures to the public (or specific groups such as pediatricians) that contrast myths with facts (e.g., “There is a common misconception that people who stutter are nervous. Nervousness does not cause stuttering, and people who stutter have the same full range of personality traits as everyone else”) (Stuttering Foundation, 2015). The protest approach responds to injustices and unfair treatment of individuals by society. There is a tone of righteous anger and moral indignation toward the offenders, who are chastised for their words or actions. An example of protest would be the Stuttering Foundation issuing a press release condemning the U.S. comedy show Saturday Night Live after a sketch aired that made light of stuttering, stating that “…they chose to overlook the pain felt by many who stutter and their families for just a cheap laugh... Not funny SNL. Not funny at all.” (Stuttering Foundation, 2012). The vehicles used to transmit these strategies to the public can be media-based (e.g., videos), or in vivo (Corrigan & Kosyluk, 2013).
Corrigan, Morris, Michaels, Rafacz, and Rüsch (2012) conducted a meta-analysis of 72 articles focusing on the effects of the anti-stigma approaches described above on public stigma related to mental illness. Outcomes of interest were categorized into areas of attitudes (e.g., stereotypes), affect (e.g., emotional reactions), and behavioral intentions (e.g., avoidance), representing the most common types of outcomes measures for anti-stigma research. The data reported came from over 38,000 research participants across 14 countries. The results of the meta-analysis revealed that, on average, education and contact both improved attitudes, affect, and behavioral intentions toward individual with mental illness (mean effect size for each strategy was significantly different from zero), and these effect sizes ranged from small to medium across different outcomes. Contact seemed to be more effective with adults, whereas education was more effective with adolescents. The results also suggested that contact led to greater effects for attitudes, whereas education led to greater effects for affect and behavioral intentions. However, when only randomized controlled trials were analyzed, contact yielded the largest effects for each outcome measure. The average effect size for protest was not significantly different from zero, and so there appears to be less support for that strategy.
Considering the recognized importance of modifying public perceptions of stuttering (National Stuttering Association, 2002), it is notable that there has been relatively little published research in this area. To date, only six peer-reviewed journal articles have focused on altering negative attitudes toward stuttering. Flynn and St. Louis (2011) compared 83 high-school student attitudes toward PWS before and after either watching a video of three PWS, or listening to an oral live presentation given by a PWS. Attitudes were measured using the Public Opinion Survey of Human Attributes–Stuttering (POSHA-S). Positive attitudes toward PWS increased following both conditions, but more so in the oral live condition. Furthermore, adding an oral live presentation to the video-only condition significantly improved perceptions of PWS. This indicates that contact with a PWS telling his or her own story can be a potentially effective way to reduce the stigma associated with stuttering. Positive attitude changes were also found by Abdalla and St. Louis (2014) after showing pre-service trainees in Kuwait an educational video discussing factual and emotional aspects of stuttering. These videos also included personal stories from two adolescents who stutter in which they described their experiences as PWS. Significant differences in attitudes were not found for a group of in-service public school teachers in that same study however. Langevin and Prasad (2012) utilized a pretest-posttest design to study changes in 608 school-age children’s attitudes about stuttering following implementation of an educational curriculum and bullying prevention program. The program resulted in significantly improved attitudes towards PWS and bullying. Others studies not published in peer-reviewed journals have found that fluency coursework for speech-language pathology students (Junuzović-Žunić et al., 2015), and interdisciplinary training and education programs for speech-language pathology and counseling students (Hughes, Gabel, Roseman, & Daniels, 2015) can improve attitudes and increase knowledge about stuttering.
Other studies have not been as effective in producing attitude change. Snyder (2001) documented little meaningful changes in the attitudes of 55 graduate students after showing them videos highlighting emotional issues related to stuttering, or information about auditory feedback. Similarly, Leahy (1994) found no significant changes in negative stereotypes, and some increased negative stereotypes, about PWS following a year-long program for 13 graduate student clinicians including contact, empathy building exercises, and simulated stuttering. Similarly, McGee, Kalinowski, and Stuart (1996) actually found more negative stereotypical attitudes about PWS after showing 36 high-school students a documentary about stuttering. In a recent literature review, Abdalla (2015) cited and summarized several other studies focusing on attitude change for stuttering that were conference papers not published in peer-reviewed journals. From this review, Abdalla concluded that results across studies varied and were overall inconclusive, and recommended more rigorous methods of data collection in future research.
The discrepancies in findings across previously published peer-reviewed studies can probably be accounted for by the use of different stimuli (i.e., content of the videos presented) and outcome measures employed by the researchers. Limitations of some of the previous studies include the fact that many of the scales employed (with exceptions such as the POSHA-S) were limited to perceptions of personality stereotypes that did not include socially valid measures of emotional reactions, discriminatory intentions, and affirming attitudes. Furthermore, the stimuli delivered to participants in many of the previous studies have included pre-existing videos (with the exception of Abdalla & St. Louis, 2014) containing very diverse content that is not clearly described in the research reports. For example, the psychology literature highlights the strategies of contact, education, and protest and outlines key ingredients necessary to include in those strategies for maximizing attitude change (Corrigan & Kosyluk, 2013), however this degree of specificity is lacking in the area of stuttering. Finally, most studies have lacked follow-up analysis to determine if attitude changes persist over time.
Given the limitations of previous research, the current study was the first to compare three popular approaches for attitude change that are empirically validated in the psychology literature (contact, education, and protest) and apply them to PWS, immediately after the intervention, and one week later. In the literature review above it was shown that not all anti-stigma strategies are effective, and some might even intensify negative attitudes. If advocates spend valuable time and resources fighting the public stigma of stuttering, they should take into account what types of programs are effective, and for what specific outcomes. Therefore, this study was intended to be a rigorous assessment of anti-stigma approaches for stuttering that could help guide advocates in their campaigns to reduce environmental barriers for PWS. The anti-stigma approaches used in this study were all media-based (web videos) because they can reach broad audiences, be shared online, and views can increase exponentially nationally and internationally, making their potential impact quite large (Corrigan & Kosyluk, 2013).
The specific research questions for this study focused on whether the strategies of contact, education, and protest, when compared to a control condition, resulted in improvements in negative stereotypes, negative emotional reactions, social distance, discriminatory intentions, and empowerment toward PWS from pretest to posttest (before and immediately after watching an anti-stigma video), and one week later. Furthermore, it was of interest to examine which particular anti-stigma approaches would yield the largest benefits for attitudes, emotions, and behavioral intentions. Based on previous research on stigma reduction approaches, it was hypothesized that all three anti-stigma strategies would lead to more positive change compared to a control group, but that contact and education would be the most effective in improving outcomes.
Section snippets
Participants
Survey participants were recruited using Qualtrics. Qualtrics recruited participants from traditional, actively managed market research panels (i.e., they work with other companies that recruit online panelists). Qualtrics also employs social media to gather respondents. This web survey methodology was chosen because it allowed for a wide range of potential participants across the United States. In addition, it is an effective method for studying personal opinions discreetly in a confidential
Preliminary analyses
The majority of the respondents were Caucasian and female with an age range of 18–78. There was a roughly equal division between participants who personally knew someone who stutters and those who did not. Additional respondent characteristics and descriptive statistics for questions related to familiarity with stuttering are presented in Table 1. Before the primary analysis could proceed, analyses were conducted on the items making up certain variables. Cronbach’s coefficient alpha was
Discussion
The hypotheses for this study were that all three anti-stigma strategies would lead to more positive attitude changes compared to a control group, but that contact and education would be the most effective in improving outcomes. The hypotheses of the study were mostly supported as it was shown that contact, education, and protest led to significantly greater improvements in attitudes (reduced stereotypes), affect (reduced negative emotions), and behavioral intentions (reduced discriminatory
Acknowledgments
This research was supported by a grant from the National Stuttering Association awarded to the first author. Thanks to Mark Thomas for providing voice-overs for the education, protest, and control videos.
Michael P. Boyle, Ph.D., CCC-SLP, is an Assistant Professor and Director of the Fluency Disorders Laboratory in the Department of Communication Sciences and Disorders at Montclair State University. His research focuses on understanding public and self-stigma experienced by people who stutter and identifying strategies for reducing stigma and increasing empowerment.
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Michael P. Boyle, Ph.D., CCC-SLP, is an Assistant Professor and Director of the Fluency Disorders Laboratory in the Department of Communication Sciences and Disorders at Montclair State University. His research focuses on understanding public and self-stigma experienced by people who stutter and identifying strategies for reducing stigma and increasing empowerment.
Lauren Dioguardi, M.A., is currently working on her master’s degree in Speech-Language Pathology at Montclair State University. She has a master’s degree in Education of the Deaf and Hard of Hearing and Elementary Education, and bachelor’s degrees in Education of the Deaf and Hard of Hearing and Psychology from the College of New Jersey.
Julie E. Pate, B.A., is currently working on her master’s degree in Speech-Language Pathology at Montclair State University. She has a bachelor’s degree in Speech-Language-Hearing Sciences from Hofstra University.