AIDS Attitude Scale

1. Abstract

The AIDS Attitude Scale (AAS) is an established, multidimensional psychometric instrument developed by Jacque Shrum, Norma Turner, and Katherine E. Bruce at the University of North Carolina at Wilmington to measure societal and individual attitudes toward Acquired Immunodeficiency Syndrome (AIDS) and individuals living with Human Immunodeficiency Virus (HIV) infection. Originally published in 1989, the instrument was conceptualized during an era marked by intense public health panic, institutional homophobia, and widespread misinformation regarding viral transmission vectors. The scale comprises 54 self-report items evaluated on a 5-point Likert response format ranging from Strongly Agree to Strongly Disagree.

Psychometrically, the AAS assesses three core, interconnected dimensions: (a) Contagion and Casual Contact Concerns, measuring irrational fears of transmission through benign physical presence and non-vector interactions; (b) Moral and Religious Judgments, assessing punitive perceptions, moralistic attributions of guilt, and anti-homosexual stigma; and (c) Legal and Social Welfare Policies, evaluating support for punitive public health actions (e.g., quarantine, sanitariums, job termination, breaches of medical confidentiality) versus protective civil liberties. Scoring standardizes raw responses to a 0–100 continuum, with higher scores reflecting greater empathy, tolerance, and human rights endorsement.

The scale demonstrates exemplary internal consistency, exhibiting a Cronbachu2019s alpha of .96 in its initial psychometric evaluation (Shrum, Turner, & Bruce, 1989) and .94 in subsequent cross-validation studies (Bruce & Reid, 1998). Factor analyses demonstrate stable multi-factor structures accounting for over 40% of total variance. Extensive construct, known-groups, convergent, and predictive validities have been confirmed across academic, clinical, and longitudinal paradigms. The AAS remains an indispensable psychometric baseline for behavioral health researchers, public policy evaluators, and sociomedical scholars examining structural stigma and health-related prejudice.

2. Keywords

AIDS Attitude Scale, HIV stigma, health-related prejudice, psychometrics, scale validation, public health attitudes, homophobia, social stigma, contagion fear, sexual health education

3. Authors

The AIDS Attitude Scale was designed and validated by an interdisciplinary team of researchers based at the University of North Carolina at Wilmington (UNCW):

• Jacque Shrum, M.S.: Department of Health, Physical Education, and Recreation, University of North Carolina at Wilmington, Wilmington, North Carolina, United States.
• Norma Turner, Ph.D.: Health educator and faculty researcher, University of North Carolina at Wilmington, Wilmington, North Carolina, United States.
• Katherine E. Bruce, Ph.D.: Department of Psychology, University of North Carolina at Wilmington, 601 South College Road, Wilmington, NC 28403, United States. Correspondence concerning the scale, its development, and licensing inquiries can be addressed directly to Katherine Bruce via institutional email at [email protected].

4. Purpose

The primary clinical and sociological purpose of the AIDS Attitude Scale is to quantify affective, cognitive, and policy-oriented orientations toward individuals infected with HIV or diagnosed with AIDS. Developed during the zenith of the 1980s HIV/AIDS epidemic in the United States, the AAS was engineered to address a severe methodological gap: the lack of comprehensive, standardized psychometric instruments capable of isolating rational health appraisal from moralistic condemnation, social paranoia, and discriminatory institutional inclinations.

Historically, the emergence of HIV/AIDS triggered what sociologists termed an u201cepidemic of signification,u201d in which biomedical contagion became conflated with preexisting marginalization targeting men who have sex with men (MSM), intravenous drug users, and sex workers. As a consequence, public health initiatives encountered systemic resistance driven by social intolerance, ostracism, and coercive legislative proposals. The AAS serves as a diagnostic, educational, and experimental measure designed to differentiate empathic, scientifically informed individuals from those harboring high levels of punitive animosity, contagion-related avoidance, and discriminatory tendencies.

In applied research, the AAS has found extensive utility across multiple empirical contexts:

• Evaluation of Educational and Interventional Curricula: The instrument is deployed pre- and post-intervention to assess the efficacy of university-level health education, medical training, and public awareness campaigns aimed at dismantling HIV stigma and clarifying transmission vectors.
• Healthcare Professional Training: Applied across nursing, allied health, and medical cohorts, the AAS identifies covert biases and reticence toward providing ethical, standard-of-care clinical management to HIV-positive patients.
• Sociological and Longitudinal Tracking: The scale has served as a benchmark across decades to track generational shifts in societal attitudes from the pre-antiretroviral therapy (pre-ART) era into modern biomedical paradigms (Bruce & Walker, 2001).
• Predictive Behavioral Modeling: AAS scores have proven predictive of health-protective behaviors, information-seeking practices following high-profile public disclosures (such as Earvin u201cMagicu201d Johnsonu2019s 1991 HIV announcement; Bruce, Pilgrim, & Spivey, 1994), and support for human-rights-oriented public health policies versus punitive measures like mandatory isolation or quarantine.

5. Psychological Construct

The psychological construct evaluated by the AIDS Attitude Scale is multifaceted, encompassing emotional empathy, cognitive appraisal, and behavioral intentions within a centralized framework of health-related stigma. Unlike unidimensional knowledge assessments, the AAS targets deep-seated affective evaluations and ideological worldviews across three principal conceptual dimensions:

Contagion Concerns and Casual Contact Apprehension

This sub-construct operationalizes irrational fears regarding casual, non-vector transmission of HIV. During the early epidemic, misapprehensions regarding fomites, airborne transmission, saliva, and casual touch were widespread. This dimension captures behavioral avoidance patterns grounded in biological anxiety and disgust sensitivity.

Specific manifestations include apprehension about shaking hands, hugging, sharing restrooms, attending classroom environments with infected peers, or undergoing routine medical and dental procedures due to unfounded fears of instrument contamination. Illustrative items capturing this construct include: u201cPeople should not be afraid of catching HIV from casual contact, like hugging or shaking handsu201d (Item 5, tolerant), u201cIt would not bother me to attend class with someone who has AIDSu201d (Item 24, tolerant), and u201cPeople should avoid going to the dentist because they might catch HIV from dental instrumentsu201d (Item 13, intolerant).

Moral, Religious, and Heteronormative Judgments

This dimension evaluates the intersection of biomedical illness with moral blameworthiness, religious fundamentalism, and prejudice against sexual minorities. Rooted in the attribution of personal culpability, high scores on intolerance within this domain reflect the conviction that HIV is a retributive punishment for u201cdeviantu201d or u201cunnaturalu201d lifestyles.

This sub-construct isolates the extent to which an individual views AIDS through the lens of moral failure, anti-gay sentiment, and retributive justice. Exemplary items measuring these dynamics include: u201cThe u2018gay plagueu2019 is an appropriate way to describe AIDSu201d (Item 17, intolerant), u201cHIV infection is a punishment for immoral behavioru201d (Item 35, intolerant), u201cPeople get AIDS by performing unnatural sex actsu201d (Item 27, intolerant), and u201cNo one deserves to have a disease like HIV infectionu201d (Item 23, tolerant).

Legal, Institutional, and Social Welfare Issues

The third dimension assesses support for public policy, civil liberties, legal protections, and institutional discrimination. It delineates between respondents who endorse punitive state interventions and exclusionary practices versus those who advocate for systemic protections, confidentiality, and equitable healthcare access.

This component investigates whether an individual favors draconian containment strategiesu2014such as quarantine sanitariums, mandatory public registries, civil rights deprivations, and employment terminationu2014over legal non-discrimination, guaranteed healthcare access, and medical privacy. Exemplary items include: u201cPeople with AIDS should be sent to sanitariums to protect others from AIDSu201d (Item 50, intolerant), u201cA list of people who have HIV infection should be kept by the governmentu201d (Item 45, intolerant), u201cHIV blood test results should be confidential to avoid discrimination against people with positive resultsu201d (Item 34, tolerant), and u201cAn employer should have the right to fire an employee with HIV infection regardless of the type of work s/he doesu201d (Item 25, intolerant).

6. Theoretical Framework

The construction of the AIDS Attitude Scale is grounded in foundational social-psychological and sociological frameworks, most notably Erving Goffmanu2019s pioneering conceptualization of social stigma (1963), Attribution Theory formulated by Bernard Weiner (1985, 1988), and the Theory of Reasoned Action introduced by Martin Fishbein and Icek Ajzen (1975).

Goffmanu2019s Stigma Framework

Goffman defined stigma as an attribute that is deeply discrediting, reducing an individual from a whole, usual person to a tainted, discounted one. In the context of HIV/AIDS, the stigma is compounded by multiple overlapping classifications:

• Blemishes of individual character: Perceived moral failings, promiscuity, substance dependence, or violations of societal sexual norms.
• Tribal stigma: Spillover stigmatization of groups historically associated with early epidemics, including gay and bisexual men and intravenous drug users.
• Abominations of the body: Aversion toward visible terminal physical deterioration, bodily fluids, and contagious disease vectors.

The AAS measures respondentsu2019 propensity to enact or reject these stigmatizing categorizations, quantifying whether respondents internalize a u201cspoiled identityu201d narrative regarding people living with HIV/AIDS.

Attribution Theory and Perceived Controllability

Weineru2019s attributional model of social conduct postulates that emotional reactions and helping behaviors are determined by causal attributions regarding the controllability of an individualu2019s condition. When an adverse health state is perceived as controllable (e.g., voluntary engagement in unprotected anal intercourse or needle sharing), observers are prone to attribute moral blame, experiencing anger and disgust rather than empathy, leading to retributive or punitive impulses.

Conversely, when an illness is perceived as uncontrollable (e.g., congenital transmission, medical blood transfusions), observers demonstrate pity, empathy, and supportive behavior. The AAS directly taps into this dynamic by assessing moral culpability: items explicitly referencing u201cinnocent peopleu201d (Item 42) versus those stating individuals u201cgot what they deservedu201d (Item 11) test these attributional bifurcations.

The Theory of Reasoned Action (TRA)

Fishbein and Ajzenu2019s framework posits that behavioral intentions are direct functions of attitudes toward the target behavior and subjective normative beliefs. Under this model, personal attitudes toward interacting with an HIV-positive person (e.g., attending a university class, retaining an employee, renting an apartment) serve as the primary cognitive antecedent to behavioral discrimination or supportive advocacy. The AAS operationalizes these attitudinal precursors, identifying the cognitive and normative belief structures that govern discriminatory public actions.

7. Validity

The AIDS Attitude Scale has been subjected to rigorous psychometric validation, establishing extensive content, construct, known-groups, concurrent, and predictive validities across clinical, educational, and general population cohorts.

Content and Face Validity

Content validity was established during initial scale generation through an initial pool of 94 candidate items written by undergraduate nursing and health education students, supplemented by reviews of emerging medical literature and clinical interviews with AIDS specialists. An expert panel consisting of four professionalsu2014a practicing social worker, a university health educator, an academic health education faculty member, and an experimental psychometricianu2014systematically reviewed the pool for conceptual coverage, readability, and clarity. Only items achieving unanimous panel consensus were retained, yielding 67 candidate items. Subsequent item analysis using point-biserial and item-total correlations with 164 undergraduate students retained 54 items demonstrating statistically significant discrimination between high and low scorers ($p < .001$; Shrum et al., 1989).

Construct and Known-Groups Validity

Construct validity was validated by testing hypothesized differences across targeted demographical and institutional cohorts. Bruce and Moineau (1991) administered the AAS to patients attending outpatient sexually transmitted disease (STD) clinics and compared them to general undergraduate university cohorts. The AAS successfully differentiated these populations: STD clinic attendees, who navigated firsthand biomedical vulnerability, exhibited distinct attitudinal profiles characterized by divergent risk perceptions and social tolerance levels.

Furthermore, across over two decades of replicated administrations, the AAS reliably identifies consistent demographic differences: female participants score significantly more tolerantly than male participants across college samples (Bruce & Walker, 2001), corroborating broader sociological literature on gender differences in empathy, nurturing roles, and health-related prejudice.

Convergent, Concurrent, and Predictive Validity

Bruce and Reid (1998) examined the construct validity of the AAS against established instruments measuring homophobia, general prejudice, and dogmatism. AAS scores demonstrated strong, statistically significant negative correlations with homophobia indices (such as the Index of Homophobia) and authoritarianism, verifying that anti-HIV hostility is intimately entwined with heteronormative intolerance and systemic conservative ideology.

Predictive validity was verified in a real-world naturalistic experiment conducted by Bruce, Pilgrim, and Spivey (1994). The authors assessed campus-wide attitudes and information-seeking behaviors before and after professional basketball player Earvin u201cMagicu201d Johnsonu2019s public revelation of his HIV-positive diagnosis. AAS scores predicted university studentsu2019 engagement with formal AIDS informational campaigns, blood donation willingness, and shifting attributions regarding the perceived vulnerability of heterosexual populations.

8. Reliability

The AAS demonstrates exceptional internal consistency and temporal reliability across multiple independent empirical investigations.

Internal Consistency

In the initial psychometric standardization by Shrum, Turner, and Bruce (1989), the 54-item instrument was administered to a sample of 135 university undergraduates to compute split-half reliability and internal consistency. The total instrument yielded an overall Cronbachu2019s alpha of .96, indicating strong item redundancy and measurement precision across the unified construct of AIDS attitudes.

In a subsequent cross-validation study involving an independent sample of 278 college students, Bruce and Reid (1998) reported a Cronbachu2019s alpha of .94. Replications across subsequent temporal cohorts reported in longitudinal analyses spanning from 1986 to 2000 confirmed that internal consistency remained consistently high ($lpha ge .93$) despite changing societal knowledge and epidemiological realities (Bruce & Walker, 2001).

Standard Error of Measurement

Given the scaleu2019s high reliability ($lpha = .94 ext{–}.96$), the Standard Error of Measurement ($SEM$) is minimal across the standardized 0–100 scale:

$$SEM = SD \times \sqrt{1 – \alpha}$$

With standard deviations typically ranging between 12.0 and 15.0 in collegiate and general population samples, the calculated $SEM$ is approximately 2.4 to 3.0 points. This precision makes the AAS sensitive to small shifts in individual attitudinal variance, supporting its use in pre- and post-intervention educational trials.

9. Factor Analysis

The structural dimensionality of the AAS has been confirmed via exploratory (EFA) and confirmatory factor analyses across several studies (Shrum et al., 1989; Bruce, Shrum, Trefethen, & Slovik, 1990; Bruce & Reid, 1998).

Factor Extraction and Variance Explained

Principal Axis Factoring and Principal Components Analysis with Varimax and Promax rotations consistently identify three primary factors accounting for over 40% of the total variance across the 54 items:

• Factor 1: Contagion Concerns and Interpersonal Proximity: Encompasses items measuring affective discomfort, behavioral avoidance, and unsubstantiated contagion fears during casual social interaction. This factor accounts for the largest proportion of common variance (~22u201325%). Items such as Item 4 (u201cI would quit my job before I would work with someone who has AIDSu201d), Item 16 (u201cI would not want to be in the same room with someone who I knew had AIDSu201d), and Item 37 (u201cIf I discovered that my roommate had AIDS, I would move outu201d) show primary factor loadings ranging from .55 to .78.
• Factor 2: Moral and Homophobic Judgments: Captures punitive moral attribution, religious retribution beliefs, and animosity toward the gay community. This factor accounts for approximately 10u201312% of the variance. High-loading items include Item 11 (u201cI think that people with HIV infection got what they deservedu201d), Item 17 (u201cThe u2018gay plagueu2019 is an appropriate way to describe AIDSu201d), Item 35 (u201cHIV infection is a punishment for immoral behavioru201d), and Item 39 (u201cThe best way to get rid of HIV infection is to get rid of homosexualityu201d), with loadings between .50 and .81.
• Factor 3: Legal, Policy, and Social Welfare Measures: Centers on state sanctions, healthcare discrimination, quarantine, and legal penalties. This factor accounts for approximately 6u20138% of the variance. Items loading prominently on this dimension include Item 20 (u201cA list of people who have HIV infection should be available to anyoneu201d), Item 25 (u201cAn employer should have the right to fire an employee with HIV infection regardless of the type of work s/he doesu201d), Item 45 (u201cA list of people who have HIV infection should be kept by the governmentu201d), and Item 50 (u201cPeople with AIDS should be sent to sanitariums to protect others from AIDSu201d), with loadings ranging from .45 to .72.

While these three dimensions provide informative diagnostic subscales for specific interventional targets, the high inter-factor correlations ($r = .52 ext{ to }.68$) support the utilization of the unweighted composite standard score as a robust global index of AIDS-related tolerance versus stigma.

10. Instrument / Measurement Tool

• Instrument Name: AIDS Attitude Scale (AAS)
• Authors: Jacque Shrum, M.S., Norma Turner, Ph.D., and Katherine E. Bruce, Ph.D. (University of North Carolina at Wilmington)
• Construct Measured: Attitudes, empathy, tolerance, moral judgments, contagion fears, and policy stances regarding HIV/AIDS and people living with HIV/AIDS
• Target Population: Originally standardized on undergraduate university students; subsequently validated for adult community populations, clinic outpatients, and healthcare trainees
• Administration Format: Self-report questionnaire (paper-and-pencil or digital interactive interface)
• Number of Items: 54 Likert-type statements
• Completion Time: Approximately 10 to 15 minutes
• Response Scale: 5-point Likert scale formatted with options:
  • SA: Strongly Agree With the Statement
  • A: Agree With the Statement
  • N: Neither Agree nor Disagree With the Statement
  • D: Disagree With the Statement
  • SD: Strongly Disagree With the Statement
• Scoring and Directionality:
  • Tolerant / Empathic Items (25 Items): Items 2, 3, 5, 6, 9, 12, 14, 15, 19, 21, 22, 23, 24, 26, 28, 31, 32, 34, 36, 38, 41, 46, 51, 52, and 53 are scored directly:
    • Strongly Agree (SA) = 5
    • Agree (A) = 4
    • Neither Agree nor Disagree (N) = 3
    • Disagree (D) = 2
    • Strongly Disagree (SD) = 1
  • Intolerant / Stigmatizing Items (29 Items): Items 1, 4, 7, 8, 10, 11, 13, 16, 17, 18, 20, 25, 27, 29, 30, 33, 35, 37, 39, 40, 42, 43, 44, 45, 47, 48, 49, 50, and 54 are reverse-scored:
    • Strongly Agree (SA) = 1
    • Agree (A) = 2
    • Neither Agree nor Disagree (N) = 3
    • Disagree (D) = 4
    • Strongly Disagree (SD) = 5
• Standardized Score Calculation:

  To standardize the total attitude score onto a 0 to 100 metric and account for missing data in properly completed instruments, the following formula is applied:

  $$\text{AAS Score} = \frac{(X – N) \times 100}{N \times 4}$$

  Where:

  • $X$ = The sum of all item responses after reverse scoring intolerant items.
  • $N$ = The total number of items properly completed by the respondent ($N le 54$).

  Scores range strictly from 0 to 100. Higher calculated scores reflect greater empathy, tolerance, and human rights endorsement, whereas lower scores reflect greater stigma, fear of contagion, moral condemnation, and endorsement of punitive social measures.

11. Permissions & Fee and Test Year

The AIDS Attitude Scale was officially published in 1989 in the journal AIDS Education and Prevention (Shrum, Turner, & Bruce, 1989). The instrument is published in its entirety within the public academic literature and is considered an open-access psychometric tool for non-profit academic, educational, and clinical research purposes.

No licensing fee or commercial purchase is required to administer the scale for non-commercial investigations. However, formal professional courtesy dictates acknowledging the authors in all resulting publications and scientific reports. For modifications, electronic adaptations, or clinical trial implementation, correspondence regarding permissions should be directed to the corresponding author, Dr. Katherine E. Bruce, Department of Psychology, University of North Carolina at Wilmington, Wilmington, NC 28403 (E-mail: [email protected]).

12. References

The following publications document the initial development, psychometric evaluation, and empirical application of the AIDS Attitude Scale:

• Bruce, K. E., & Moineau, S. (1991). A comparison of sexually transmitted disease clinic patients and undergraduates: Implications for AIDS prevention and education. Health Values: The Journal of Health Behavior, Education & Promotion, 15(1), 5u201312.
• Bruce, K. E., Pilgrim, C., & Spivey, R. (1994). Assessing the impact of Magic Johnsonu2019s HIV positive announcement on a university campus. Journal of Sex Education and Therapy, 20(4), 264u2013276. https://doi.org/10.1080/01614576.1994.11074127
• Bruce, K. E., & Reid, B. C. (1998). Assessing the construct validity of the AIDS Attitude Scale. AIDS Education and Prevention, 10(1), 75u201389. https://doi.org/10.1521/aeap.1998.10.1.75
• Bruce, K. E., Shrum, J., Trefethen, C., & Slovik, L. (1990). Studentsu2019 attitudes about AIDS, homosexuality, and condoms. AIDS Behavior and Prevention, 2(3), 220u2013234.
• Bruce, K. E., & Walker, L. J. (2001). College studentsu2019 attitudes about AIDS: 1986 to 2000. AIDS Education and Prevention, 13(5), 428u2013437. https://doi.org/10.1521/aeap.13.5.428.20455
• Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Addison-Wesley.
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Shrum, J., Turner, N., & Bruce, K. (1989). Development of an instrument to measure attitudes towards AIDS. AIDS Education and Prevention, 1(3), 222u2013230. https://doi.org/10.1521/aeap.1989.1.3.222
• Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92(4), 548u2013573. https://doi.org/10.1037/0033-295X.92.4.548
• Weiner, B., Perry, R. P., & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55(5), 738u2013748. https://doi.org/10.1037/0022-3514.55.5.738

13. Items of the Scale (Questionnaire)