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. . . . . Rural Populations . . . . .
Urban-Rural Differences in Motivation to Control
Prejudice Toward People With HIV/AIDS:
The Impact of Perceived Identifiability
in the Community
Janice Yanushka Bunn, PhD;1 Sondra E. Solomon, PhD;2 Susan E. Varni, MA;2 Carol T. Miller, PhD;2
Rex L. Forehand, PhD;2 and Takamaru Ashikaga, PhD1
H
IV/AIDS appeared in the United States
primarily in metropolitan areas,
and most research has focused on
HIV-infected individuals living in
metropolitan epicenters. HIV/AIDS is
now occurring with increasing frequency in small
towns and rural areas. The Centers for Disease Control
and Prevention estimate that as of 2005, over 50,000
individuals were living in non-metropolitan
communities when diagnosed, accounting for over 5%
of the individuals diagnosed with AIDS in the United
States.1 Because many people with HIV/AIDS live
outside of major metropolitan areas, it is important to
examine issues relevant to individuals from
non-metropolitan areas, and to document the ways in
which their experiences differ from their urban
counterparts.
People with HIV/AIDS often report being
stigmatized, a process by which individuals having
ABSTRACT: Context: HIV/AIDS is occurring with
increasing frequency in rural areas of the United States,
and people living with HIV/AIDS in rural communities
report higher levels of perceived stigma than their more
urban counterparts. The extent to which stigmatized
individuals perceive stigma could be influenced, in part,
by prevailing community attitudes. Differences between
rural and more metropolitan community members’
attitudes toward people with HIV/AIDS, however, have
rarely been examined. Purpose: This study investigated
motivation to control prejudice toward people with
HIV/AIDS among non-infected residents of metropolitan,
micropolitan, and rural areas of rural New England.
Methods: A total of 2,444 individuals were identified
through a random digit dialing sampling scheme, and
completed a telephone interview to determine attitudes
and concerns about a variety of health issues. Internal or
external motivation to control prejudice was examined
using a general linear mixed model approach, with
independent variables including age, gender, community
size, and perceived indentifiability within one’s
community. Findings: Results showed that community
size, by itself, was not related to motivation to control
prejudice. However, there was a significant interaction
between community size and community residents’
perceptions about the extent to which people in their
communities know who they are. Conclusion: Our
results indicate that residents of rural areas, in general,
may not show a higher level of bias toward people with
HIV/AIDS. The interaction between community size and
perceived identifiability, however, suggests that
motivation to control prejudice, and potentially the
subsequent expression of that prejudice, is more complex
than originally thought.
C 2008 National Rural Health Association
1 Department
of Medical Biostatistics, University of Vermont,
Burlington, Vt.
2 Department of Psychology, University of Vermont, Burlington, Vt.
We greatly appreciate the contributions to sample selection and
data collection made by Tracy Nyerges, Joan Skelly, and Barbara
Branch. This research was supported by a National Institute of
Mental Health Grant, “Rural Ecology and Coping with HIV Stigma,”
RO1 MH 066848 obtained by Sondra E. Solomon, PhD and Carol T.
Miller, Ph.D. For further information, contact: Janice Yanushka
Bunn, PhD, Department of Medical Biostatistics, University of
Vermont, 24C Hills Science Building, Burlington, VT 05405; e-mail
[email protected].
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Summer 2008
. . . . . Rural Populations . . . . .
attributes or characteristics that are devalued by others
experience prejudice, discrimination, stereotyping, and
exclusion.2 Because stigma arises from an affected
person’s experiences with unaffected community
members, the extent to which an affected person
perceives stigma could be influenced by prevailing
community attitudes. The more negative community
attitudes are toward people with HIV/AIDS and
groups known or assumed to be at risk for HIV/AIDS,
the more likely it is that people with HIV/AIDS
residing in these communities will perceive that they
are stigmatized.
Heckman and colleagues found that the perception
of discrimination and fear of discovery was greater
among HIV-infected individuals living in rural rather
than urban communities.3 Early studies suggested that
these perceptions may be accurate: rural community
members appear to have more negative attitudes
toward people with HIV/AIDS than those in large
cities.4,5 These studies, however, were conducted
during the first decade of the HIV epidemic, and overt
expressions of AIDS-related stigma appear to have
decreased over time.6,7
While initial reactions to people with HIV/AIDS
may be negative and relatively automatic, responses
can be adjusted, based on the degree of one’s
motivation to control prejudice.8 The ability and
motivation to control automatic responses may be what
is responsible for the difference between prejudiced and
non-prejudiced individuals.9 Many people are
externally motivated by societal norms not to be (or not
to appear to be) prejudiced toward stigmatized groups.
Previous research has demonstrated that expressions of
prejudice depend on whether people are externally
motivated by social disapproval to appear
non-prejudiced and whether their behavior is
identifiable.10-14 Research on the effects of public versus
private expressions of prejudice is important for
understanding differences in how motivation to control
prejudice might affect expressions of prejudice in rural
and urban areas. One aspect of living in small
communities is that people are more likely to know
each other than are people in urban areas. This makes
people more identifiable (less anonymous) in small
communities, which increases the social pressure
people experience. Highly identifiable people may
conform more to social pressures with respect to
prejudice than people who are less identifiable. Thus,
both community size and perceived identifiability
could affect how externally motivated community
residents are to avoid acting prejudiced toward people
with HIV/AIDS.
Higher perceived stigmatization among people
with HIV/AIDS living in rural areas could indicate that
The Journal of Rural Health
rural community norms are more accepting of
behaviors that allow the enactment of HIV/AIDS
stigmatization than more urban communities. Thus,
there may be lower levels of internal motivation to
control prejudice in rural areas than urban areas.
The goal of this study was to compare motivation
to control prejudice toward people with HIV/AIDS
among residents of rural, metropolitan, and
micropolitan communities. We hypothesized that
community size and the degree to which people
perceived themselves to be identifiable within their
communities would be related to whether they were
externally motivated to control prejudice toward
people with HIV/AIDS. In addition, we hypothesized
that people in rural areas might be less internally
motivated to control prejudice toward people with
HIV/AIDS than their urban counterparts.
Methods
Participants. This was part of a larger study in
which we interviewed 203 HIV-infected individuals
residing in Vermont and northern New England. They
were recruited from Comprehensive Care Clinics
providing medical services to individuals with
HIV/AIDS, community-based organizations, including
AIDS Service Organizations, word of mouth, and
advertisements in local media. Eleven to 13 community
members, ages 18-75, were selected for each participant
with HIV/AIDS. The goal was 12 community members
interviewed per participant, providing 95% confidence
to estimate community attitudes within 16%. This
report is limited to data collected from the community
sample.
Procedures. Interviews were conducted with the
CI-3 Computer Aided Telephone Interviewing system15
using a random digit dialing sampling scheme to
identify community members within the 3-digit
telephone exchange of the participant’s telephone
number or the telephone exchange for the participant’s
town of residence. The interview lasted approximately
30 minutes and consisted of a range of questions
regarding attitudes and concerns about various health
issues affecting their communities. Questions about
motivation to control prejudice toward several target
groups, including people with HIV/AIDS, were also
asked. Interviews were carried out between 2004 and
2006. Respondents were not compensated for their
participation in this study, which was approved
by the University of Vermont Institutional Review
Board.
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Vol. 24, No. 3
. . . . . Rural Populations . . . . .
Measures
Statistical Analyses. The analyses were based on
the General Linear Mixed Model, incorporating
adjustments for clustered design.17 Preliminary results
suggested that the pattern of factors influencing
internal and external motivation differed; therefore,
separate analyses were performed. The fixed effects
included size of the community of residence, age,
gender, and identifiability in the community, with
model building to incorporate possible interactions.
Random effects allowed adjustment for the intra-class
correlation among community respondents within the
same community. Reported results are those in which
the covariance parameters are constrained to be
positive. Since effect size (ES) estimates such as partial
eta cannot be calculated with a mixed model, an ad hoc
estimation of effect was calculated as the difference
between the means divided by the standard deviation,
incorporating the adjustment for clustering of
individuals within the community. All analyses were
performed using SAS, version 9.1.18
Motivation to Control Prejudice. Internal and
external motivation to control prejudice scales were
adapted from those devised by Pryor, Reeder and
Landau8 to measure motivation to control prejudice
toward people with HIV/AIDS. We included 3 items
from the original internal scale (eg, “I attempt to act in
non-prejudiced ways toward people with HIV/AIDS
because it is personally important to me.”) and 3 from
the external scale (eg, “Because of today’s politically
correct standards, I try to appear non-prejudiced
toward people with HIV/AIDS.”). Responses were
recorded on a 4-point scale, ranging from 1 (strongly
disagree) to 4 (strongly agree). Scores were calculated
as the mean of the responses to the questions on each
scale, and were computed such that higher values
indicated increased motivation. The alpha coefficients
for the internal and external motivation to control
prejudice scales were 0.82 and 0.74, respectively.
Community Size. The size of the respondents’
residential community was based on that of the
matched participant with HIV/AIDS; thus, each
community member was clustered within the
community of residence. Communities were classified
as metropolitan, micropolitan, or rural using guidelines
set forth by the Office of Management and Budget for
core based statistical areas.16 Metropolitan counties
have at least 1 urbanized area with a population of
50,000 or greater. Micropolitan counties have at least 1
urbanized area with a population between 10,000 and
50,000. All others are classified as rural. Nine
metropolitan (42.4% of respondents), 10 micropolitan
(38.4% of respondents), and 6 rural communities (19.2%
of respondents) were represented in this survey.
Results
The response rate was 68%, resulting in a total of
2,444 completed interviews. Forty-eight percent of the
sample were 40 to 59 years old, 26% were less than 40
years old, and the remaining 26% were 60 years of age
or older. A majority of respondents were female
(64.5%), and, consistent with the racial/ethnic
distribution of Vermont, New Hampshire, Maine and
northern New York, over 95% were white. Over 95%
were high school graduates, with almost 39% having
completed college.
Identifiability in the Community. Respondents’
estimates of the percentage of people in their
community who knew them personally, and the
percentage who knew who they were, but not
personally, differed by community size (F[2, 197] =
24.92, P < .01, F[2, 197] = 37.47, P < .01, respectively),
with metropolitan residents estimating lower
percentage than micropolitan and rural residents. Rural
and micropolitan residents did not differ in
identifiability on either measure. Residents of
metropolitan communities estimated that they were
known personally by 14.5% ± 20.5 (mean ± standard
deviation) of the people in their town, compared to
micropolitan residents, who estimated being known
personally by 22.3% ± 24.3 of town members, and rural
residents who estimated being known personally by
23.5% ± 24.6 of their community. Respondents’
estimates of the percentage of the community who
knew who they were, but did not necessarily know
them personally, were higher at 21.1% ± 24.7,
Identifiability. The interview included 2 questions
regarding respondents’ perception of their
identifiability within their community. Respondents
were asked to estimate (1) what percentage of people in
their town knew them personally and (2) what
percentage of people in their town knew who they
were, but did not know them personally. Responses,
which ranged from 0% to 100%, were dichotomized at
the median response for each question (10% for the
estimate of those who knew the respondent personally,
and 20% for those who knew the respondent, but not
personally).
Other Demographic Characteristics. Standard
survey measures assessed age, gender, marital status,
and race/ethnicity.
Bunn, Solomon, Varni, Miller, Forehand and Ashikaga
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. . . . . Rural Populations . . . . .
2,375] = 102.50, P < .01) and scores decreased with
increasing age (F[2, 2,375] = 36.03, P < .01). External
motivation to control prejudice was higher for women
than men (F[1, 2,377] = 27.24, P < .01), but these scores
did not vary with age (F[2, 2,377] = 0.85, P = .43).
Table 1. Gender and Age Differences in
Motivation to Control Prejudice∗
Toward People With HIV/AIDS
Internal Motivation to External Motivation to
Control Prejudice
Control Prejudice
Mean (SD)∗
Mean (SD)∗
Gender
Females
Males
Age Group
18-39 years of age
40-59 years of age
60 year of age and
older
3.26 (0.49)
3.05 (0.48)
2.65 (0.62)
2.51 (0.56)
3.29 (0.50)
3.19 (0.51)
3.06 (0.44)
2.60 (0.64)
2.58 (0.63)
2.62 (0.52)
Impact of Identifiability in the Community on
Motivation to Control Prejudice.
Being Known Personally. When corrected for age
and gender, neither size of community of residence nor
personal identifiability (being known personally by
10% or more of the community compared to being
known personally by less than 10% of the community)
was related to internal motivation to control prejudice
(Table 2; F[2, 197] = 1.54, P = .22 for community size;
F[1, 2,296] = 0.53, P = .46 for being known personally).
Similarly, external motivation to control prejudice
did not differ with size of the community of residence
(F[2, 197] = 0.18, P = .83). On the other hand, external
motivation to control prejudice was influenced by the
percentage of the community to whom the respondent
was known personally (F[1, 2,292] = 22.83, P < .01,
ES = 0.20), with those known by 10% or more of the
community reporting higher external motivation scores
(2.66 ± 0.61) than the less well-known community
members (2.53 ± 0.60).
Being Known, But Not Personally. The results
differed when the measure of identifiability was the
percentage of the community to whom one is known,
but not necessarily known personally (Table 2). When
corrected for age and gender, community size
interacted with perceived identifiability to influence
internal motivation (F[1, 197] = 3.57, P = .03).
Examination of the simple effects suggests that among
those who perceive themselves to be more well known,
internal motivation to control prejudice is lower for
those living in rural communities than those living in
∗ Responses
on a 4-point scale where higher values indicate
greater motivation.
33.4% ± 28.0, and 36.2% ± 29.9 for metropolitan,
micropolitan, and rural residents, respectively.
Motivation to Control Prejudice. The mean scores
on the internal and external motivation to control
prejudice scales were 3.18 ± 0.50 and 2.60 ± 0.61,
respectively, indicating that the respondents were both
internally and externally motivated to control prejudice
toward people with HIV/AIDS (Table 1). While scores
on the 2 scales were significantly correlated, the size of
the correlation was moderate (r = 0.24, P < .01).
Respondents reported higher internal than external
motivation to control prejudice (F[1, 197] = 1,407.00, P
< .01). Internal motivation varied by both age and
gender of the respondent (Table 1). Females reported
higher internal motivation scores than males (F[1,
Table 2. Effect of Community Size and Identifiability on Motivation to Control Prejudice∗
Known Personally
to Less Than 10%
of the Community
Mean (SD)∗
Known Personally
to 10% or More
of the Community
Mean (SD)∗
Known, but not Personally,
to Less Than 20%
of the Community
Mean (SD)∗
Known, but not
Personally, to 20% or
More of the Community
Mean (SD)∗
Metropolitan
Micropolitan
Rural
3.22 (0.51)
3.18 (0.47)
3.18 (0.51)
3.20 (0.50)
3.17 (0.50)
3.14 (0.49)
3.21 (0.49)
3.15 (0.47)
3.23 (0.49)
3.22 (0.53)
3.19 (0.51)
3.11 (0.50)
Metropolitan
Micropolitan
Rural
2.55 (0.61)
2.50 (0.59)
2.57 (0.57)
2.66 (0.64)
2.68 (0.61)
2.62 (0.57)
2.56 (0.60)
2.52 (0.59)
2.64 (0.58)
2.64 (0.65)
2.67 (0.62)
2.58 (0.57)
Locus of Motivation
to Control Prejudice
Size of
Residence
Internal
External
∗ Responses
on a 4-point scale where higher values indicate greater motivation.
The Journal of Rural Health
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metropolitan (t[197] = 2.49, P = .01, ES = 0.19) or
micropolitan communities (t[197] = 2.23, P = .03, ES =
0.16), with no difference between the metropolitan and
micropolitan residents (t[197] = 0.45, P = .65). Size of
community had no effect among those who perceived
themselves to be less well known (F[2, 197] = 1.32, P =
.27). Examined within community size, the effect of
being known, but not personally, appears to be
important only in rural communities, with those who
perceive themselves to be more identifiable reporting
lower internal motivation to control prejudice than
those who perceive themselves to be known by less
than 20% of their community (F[1, 197] = 5.62, P = .02,
ES = 0.23).
Community size and perceived identifiability also
showed a significant interaction when the outcome
variable was external motivation to control prejudice
(F[2, 197] = 4.03, P = .02). In contrast to internal
motivation, however, external motivation in rural
respondents did not differ with the percentage of the
community by whom the respondent was known (F[1,
197] = 1.40, P = .24). Similarly, this did not affect
external motivation in those residing in metropolitan
communities (F[1, 197] = 3.27, P = .07). The estimated
percentage of people to whom one is known did,
however, affect external motivation scores for those
living in micropolitan communities, with those known,
but not personally, by 20% or more of their community
reporting higher external motivation than those who
were known by less than 20% (F[1, 197] = 10.46, P < .01,
ES = 0.22).
motivation to control prejudice is associated with more
favorable attitudes, while higher external motivation is
associated with more explicit bias.11,14 Similar results
were seen when the target of prejudice were people
with HIV/AIDS.19
To our knowledge, this is the first study to compare
urban-rural differences in community members’
motivation to control prejudice toward people with
HIV/AIDS. Overall, respondents tended to report that
they were motivated to control prejudice toward people
living with HIV/AIDS. This supports the findings of
the national samples studied by Herek and
colleagues,6,20 who suggest that overt expressions of
prejudice toward people with HIV/AIDS are not
endorsed by the majority of non-infected community
members. Interestingly, community size alone did not
predict differences in internal or external motivation to
control prejudice. The lack of a main effect for
community size suggests that community members’
expression of prejudice is influenced by more than the
size of the town in which they live. Indeed, our results
suggest that internal and external motivation to control
prejudice toward people with HIV/AIDS are a function
both of community size and of how identifiable people
believe they are in their community, a relationship that
differs for internal and external motivation.
The influence of perceived identifiability in the
community was dependent upon whether
identifiability was measured as being known
personally by members of the community, or being
known, but not personally. No attempt was made to
examine the accuracy of the respondents’ estimates of
perceived identifiability because our focus was on
community residents perception of how well known
they are, rather than the actual percent of the
community that either knows them or knows who they
are. People who reported being known personally by
10% or more of their community were more externally
motivated to control prejudice. This is consistent with
the conceptualization of external motivation, which
posits that the evaluations and approval of others are
important motivators. Thus, the more people with
whom one interacts directly, the more important it may
become to appear non-prejudiced.
On the other hand, although both internal and
external motivations to control prejudice were related to
the perception that one is recognized, this influence was
dependent upon the size of the community in which
one lived. We had predicted that internal motivation to
control prejudice, stemming from personal beliefs and
values, would be lower in rural than in urban
communities, due to the social conservativism of rural
areas. Instead, we found that although community size
by itself was not related to internal motivation to
Discussion
Internal motivation to control prejudice arises from
individuals’ personal endorsement of egalitarian and
non-prejudiced beliefs. Although those who are highly
internally motivated to control prejudice may harbor
automatic or unconscious prejudiced reactions to
members of a stigmatized group, they are motivated to
bring their beliefs, attitudes, and behavior in line with
their personal non-prejudiced values. In contrast,
external motivation to control prejudice arises from fear
of social disapproval. Although they may not
personally endorse egalitarianism, people high in this
domain strive to present themselves as non-prejudiced.
This study examined motivation to control
prejudice rather than examining prejudiced attitudes
directly. Motivation to control prejudice, however, has
been shown to be correlated with prejudiced attitudes,
and indeed may be what distinguishes prejudiced
individuals from those who attempt to act in an
unbiased fashion.9 Research on African Americans as
targets of prejudice indicates that higher internal
Bunn, Solomon, Varni, Miller, Forehand and Ashikaga
289
Summer 2008
. . . . . Rural Populations . . . . .
control prejudice, rural community members who
reported being relatively well known, but not
personally, were less internally motivated to control
prejudice toward people with HIV/AIDS than rural
community members who reported being less well
known. Being better or less well known by people in
the community was not related to internal motivation
to control prejudice in metropolitan or micropolitan
communities. This finding suggests that in rural areas,
people who are identifiable by greater numbers of
community members may be less likely to control their
expressions of prejudice. Because of their more
identifiable role in the community, the attitudes of this
subset of individuals may be more influential than the
attitudes of those who are less known in the
community. Thus, the reports of greater perceived
stigma by people with HIV/AIDS living in these rural
communities may be a consequence of encounters with
a highly identifiable subset of their community.
Among people living in micropolitan areas, being
known, but not personally, is related to higher external
motivation to control prejudice. This was not found in
the rural communities, however, despite similar
perceptions of community identifiability. Because
micropolitan communities are intermediate in size
between metropolitan and rural locales, people living
in these communities may feel less certain about the
congruence of their internal motivation with those of
the surrounding community, yet more pressured to
conform to prevailing standards. It is possible that
social messages may be more mixed in these
communities, leading residents, particularly those who
perceive themselves to be more identifiable to both
friends and strangers, to be more attuned to social cues.
However, without asking respondents their perceptions
of their towns, or determining social trends in these 3
types of communities (eg, political conservativism,
beliefs about social norms not health related), this
explanation is speculative.
These findings suggest that urban-rural differences
in internal and external motivation to control prejudice
are subtle, with small effect sizes. Because correlations
between motivation to control prejudice and both
implicit and explicit attitudes toward outgroups are
moderate, it is likely that differences in attitudes are
similarly subtle. Ultimately, the interaction of
community members with the targets of prejudice is
what is of interest, but the link between community
prejudice toward people with HIV/AIDS and the
stigma perceived by them has not yet been
demonstrated. Equally unclear is the magnitude of
differences in prejudice that can be perceived by
stigmatized individuals. Thus, it is entirely possible
that small, subtle differences in community prejudice
The Journal of Rural Health
can result in large differences in the perception of
stigma by people with HIV/AIDS. Further research in
this area is essential to understand the environment in
which people with HIV/AIDS reside.
This is one of the few studies to examine
motivation to control prejudice in a community sample.
Because identification of the community sample was
not proportional to the urban-rural distribution of the
population in rural New England, it may not be
representative of this region as a whole. Community
members were, however, selected randomly within
their community; thus, attitudes could be considered
representative of those communities identified for
examination. In addition, at least 1 resident of each
community was HIV-infected, although that may not
have been known to the community member being
interviewed. We recognize that the
metropolitan/micropolitan/rural classification may
oversimplify the variability of the social ecology within
counties. For example, a county identified as
metropolitan may include pockets of rural areas. People
living in these rural areas, however, may possess
attitudes toward people with HIV/AIDS that are
similar to residents of the nearby metropolitan area due
to such things as work travel patterns and use of
services in the urban center. It should be pointed out
that, because this study was conducted in a largely
rural section of New England, the population of the
metropolitan communities is substantially smaller than
the large centers that are normally considered
metropolitan.
While this study was limited to an examination of
motivation to control prejudice, the actual attitudes
toward people with HIV/AIDS were not assessed, thus
limiting our ability to examine possible urban-rural
differences in attitudes. While both internal and
external motivation are independently correlated with
attitudes, previous work examining the exact nature of
the influence does not clarify the combined effect of
both sources of motivation,11,14 making a prediction of
actual attitudes toward people with HIV/AIDS, and
their potential to vary by community size, impossible in
this study. The study was also limited to states with a
low incidence of HIV infection. Thus, generalizability
to larger metropolitan communities with a greater
prevalence of HIV infection is limited.
In summary, our findings indicate that rural areas
may not necessarily have a higher level of bias toward
people with HIV/AIDS, at least as estimated by
community motivation to control prejudice. However,
there may be a few key residents in rural areas with
relatively little internal compunction about being
prejudiced who have disproportionate effects on the
overall level of prejudice in a community. This might
290
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. . . . . Rural Populations . . . . .
explain why people with HIV/AIDS in rural areas
report more perceived stigma than those living in other
areas.
10.
11.
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