A Sociolinguistic-enabled Web Application to Develop Precision Health Intervention for African Americans
Phase: NA
Conditions: Colorectal Cancer
Sponsor: University of Florida

IRB 202001790 
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University of Florida IRB-01 
Protocol 
Title: A sociolinguistic-enabled web application to develop precision health intervention for African 
Americans 
Investigators: Melissa Vilaro, PhD (PI), Kevin Tang, PhD, Janice Raup-Krieger, PhD, Benjamin Lok, PhD, , 
Eric Cooks, PhD, Alexis Davis, Vaughan James, PhD 
 
1. Abstract: 
 
This pilot study will explore the preliminary efficacy of a colorectal cancer (CRC) screening 
intervention delivered by virtual health assistants (VHAs). Participants will include 750 patients in 
the US between the ages of 45 and 75 recruited through Qualtrics panels: 375 who are non-
adherent to CRC screening guidelines, and 375 patients who are adherent to CRC screening 
guidelines. The main research question is: How does the integration of different levels of dialect 
density of the linguistic features of African American English (AAE) influence the perceived 
credibility of a Black VHA? Four types of VHAs will be presented to our patients: a VHA with 
Standardized American English (SAE) linguistic features, a VHA with a low level of African 
American English (AAE) linguistic features integrated, a VHA with a high level of African American 
English (AAE) linguistic features integrated, and a text-only control condition. Survey questions 
will be used to obtain credibility judgments about VHAs post-interaction. 
2. Background: 
 
B.1. Vocal characteristics of VHAs for African American patients. Krieger, Lok, and colleagues 
(Zalake, Wilson, and Vilaro) collaborated to develop and conduct user-testing on a CRC screening 
intervention facilitated by a VHA. The team developed a male and female VHAs for African Americans and 
Caucasians (see Figure 1). The VHAs were developed through a series of focus groups and individual 
interviews were held with male and female African American patients (N=78) to review the visual and 
verbal characteristics of the VHAs.24,25 Focus group participants identified a number of important vocal 
characteristics that influenced perceived credibility. Rate of speech was important; voices that were too 
fast, too slow, or sounded like a salesperson were criticized. One voice was described as sounding “Black,” 
and participants responded positively. Speech characteristics were linked to the VHA being perceived as 
credible, friendly, and likeable. For example, one participant said: “Her voice was so convincing. You could 
just ease right into it” (P34, FG7, VER3). Another said, “His voice was knowledgeable and patient, um, kind 
of has some authority, but not like, he wasn’t judgemental.” Another expressed a similar perspective: 
 
…she seemed like a real doctor…talkin’ to a real patient…I was listenin’ to her voice and how she 
was takin’ time and explainin’ step by step…She seemed like a real person that was really there 
talkin’ to you [about] what’s goin’ on with your body, and you need to be checked. I wasn’t thinkin’ 

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about she was no video person. She was a real person, like I’m talkin’ to my doctor. It was like, “Oh, 
yeah, thanks, doctor, for helpin’ me out…Yeah, I’m gonna go be checked…” (P138, FG7, VER3) 
 
While patient responses were generally positive to the VHA, the importance of how the VHA sounded was 
consistent across groups. One limitation of this preliminary work is that participants were only exposed to 
sample voices from Black actors speaking Standardized American English. Thus, the current work builds 
on this limitation by exploring whether some patient populations will perceive a VHA whose speech 
incorporates linguistic features of African American English as more credible.  
B.2. African American English. Over the last 60 years or so, a profusion of scientific inquiry performed 
mainly by African American linguists and scholars has provided a nuanced look into the mosaic of African 
American language use (Lanehart & Malik, 2015). The main goals of this linguistic endeavor were to dispel 
racist myths of linguistic deficiency, explicate the legitimate, systematic, and rule-governed nature of the 
linguistic varieties of many African Americans, and dismantle the linguistic discrimination and institutional 
racism which had produced disparate harm for speakers in realms such as education, job procurement, 
and healthcare (Baugh, 2018). For the purpose of this pilot study, three main aspects are relevant. First, 
researchers have identified specific pronunciation, sound, and grammatical structures from the speech of 
various groups of African Americans across the United States and throughout various time periods that do 
not appear in Standardized American English (SAE). Together, these structures, along with other linguistic 
features, have traditionally been termed African American English (AAE)1 (Green, 2002). These linguistic 
features are not inferior or flawed versions of SAE counterparts, an idea that white supremacist narratives 
baked into U.S. society and the U.S. education system promote (Lippi-Green, 2012), but rather display the 
normal traits of all languages and linguistic varieties, play an important role in social interactions and 
identity building (King & Rosa, 2019), and are a part of the speech of 80-90% of African Americans at 
some level (Rickford, 1999; Smitherman, 1998). Second, AAE is not a delimiting set of structures that 
defines all African American speech. The speech of individual African Americans may or may not contain 
the linguistic features of AAE, along with SAE and also other language varieties. Third, the speech of 
individual African Americans is influenced not only by racialization but also by the intersections of various 
social identities (King & Rosa, 2019) such as gender, age/generation, education, sexuality, occupation, 
religion, ability status, social/socioeconomic class, and regional background (Alim & Reyes, 2011).2 All of 
these layers contribute to larger linguistic repertoires that vary by individual and may be consciously or 
subconsciously drawn upon as African American speakers “shape and engage in processes and projects 
of identification” (Alim, 2016) in various contexts and social situations.  
The speech of African Americans, then, is a mosaic, rather than a monolith. At the same time, however, 
Black linguists and scholars estimate that between 80-90% of the African American population retain and 
utilize a selection of the linguistic features of AAE at varying level as they weave through the various 
interactions in their lives (Smitherman, 1998; Rickford, 1999; Hutcheson, 2018). We find it plausible, 
therefore, that many of the participants in this study may utilize these features at some level as well and 
may find our VHA’s linguistic accommodation appealing.  
B.3. Linguistic accommodation. The connection between dialect density and cancer screening 
adherence has to do with trust and accommodation. Accommodating to a shared linguistic style improves 
communication effectiveness, understanding, and trust, which can lead to message compliance (Giles et 
al., 2007). Both objective and perceived language similarities enhance perception of credibility, 
competence, and persuasiveness (Aune & Kikuchi, 1993). In the clinical setting, healthcare providers who 
 
1 The term African American Vernacular English (AAVE), among others, has also widely been used. 
2 African American English is also not limited to the African American community but can be the first 
language of any person. 

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match their communication style to that of patients are considered most appropriate (Bourhis, Roth, & 
MacQueen, 1988). This is especially salient among racial ethnic minorities, who may maintain or 
accentuate linguistic features tied to racial identity in order to protect their racial identity (Bourhis & Giles, 
1977, Giles & Johnson, 1987). For example, racial minorities might view “standard” language as more 
socially desirable but find the “non-standard” similar accent persuasive (Giles, 1973). Therefore, making an 
African American healthcare provider option with shared linguistic features is not cultural insensitivity, but 
rather a potential accommodation to those whose speech patterns also have non-standard linguistic 
features.  
Accommodating to various African American patients’ speech is equivalent to communicating with patients 
competently, through appropriate (not offending others) and effective (meeting the goal) means (Cupach & 
Spitzberg, 1983). In communication, all humans navigate identity and solidarity with interlocutors through 
linguistic accommodation. If we feel connected to someone, we speak more like they do; if we don’t, we 
dissociate our speech from theirs. This has been shown to be true with doctor-patient interactions as well, 
particularly with African American doctors and patients using AAE (Tamasi, 2008; Wood, 2019). Our hope 
is to understand if the use of AAE by our virtual doctors increases trust and comfort with this screening 
process or not.   
Previous research done by this team has shown a clear positive effect of racial identity via appearance on 
the response of patients of color. When patients of color were paired with a virtual health professional that 
matched their racial identity, patients were much more likely to follow-up with colorectal cancer screenings. 
Building off these findings, we plan to investigate whether the adjustment of linguistic features will have a 
positive, neutral, or negative effect.   
3. Specific Aim: 
African Americans are at risk for a number of health inequities, including increased morbidity and mortality 
due to colorectal cancer (CRC) as compared to White Americans. While the reasons for this inequity are 
complex, the disparity can be reduced through regular screening. Unfortunately, adherence to CRC 
screening guidelines is low, especially among African Americans. One strategy for reducing CRC 
screening disparities is to develop strategic communication interventions about the fecal immunochemical 
test (FIT), a low-cost, non-invasive screening method that alleviates common patient barriers to CRC 
screening and is equally effective as colonoscopy screening in reducing CRC incidence and mortality. 
Interventions that use tailored messages are effective for improving CRC screening. However, two 
important questions must be answered before tailored screening interventions can be implemented in 
healthcare systems. One is the degree to which message content must be tailored to be effective and 
another is how to effectively engage participants. The current project is an extension of an existing project 
that uses mobile virtual human technology (VHT) to deliver tailored CRC screening messages for African 
Americans to improve screening within guidelines. Interventions using VHT offer numerous advantages, 
including the capability to be customized to the linguistic preferences of the patient. As such, the use of 
virtual technology could help reduce CRC screening barriers such as cultural mismatch and low self-
efficacy among African American patients.  
The purpose of this proposal is to investigate to what extent the incorporation of AAE linguistic features 
increases, decreases, or has no effect on the perceived credibility of VHAs. This pilot study is meant to be 
exploratory in nature. We seek to explore the following specific aim:  
● Examine how tailoring the dialectal variety of the speech of VHAs influences their perceived 
credibility. Approach: Each participant will interact with a VHA that differs in speech containing 

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either: (1) strictly linguistic features of SAE, (2) a low level integration of AAE linguistic features, (3) 
a high level integration of AAE linguistic features, or (4) a voiceless, text-only control. Post-
interaction, participants will be asked to judge how credible they felt the VHA was through survey 
questions.  
 
4. Research Plan: 
 
6.1. Pilot study design. This pilot study will use a posttest-only, 3 (SAE: Standardized American English / 
low level AAE: African American English / high level AAE) x 2 (Introduction / No introduction) with a control 
group (i.e., no voice) randomized experimental message design. Patients (N=750) will be recruited from a 
national panel by Qualtrics. In order to be included in the study, participants must be between the ages of 
45-75, and have health insurance. We will recruit equal numbers of male and female patients. 
 
After providing informed consent, participants will be randomly assigned to a VHA. Participants will be 
assigned at random to a Black, gender-matched VHA that speaks SAE, AAE (low level), or AAE (high 
level). Each VHA will also either include an introduction from the voice actor/actress or will not include an 
introduction. The control group will be the same intervention content delivered via text-only (e.g., photos of 
the Black VHA). After completing the intervention, participants will complete a questionnaire with 
dependent measures and potential mediators. This questionnaire will solicit participant opinion on the 
credibility of the VHA and also gauge the participant’s intent to screen for CRC. Participants will receive 
monetary compensation which will credited to their Qualtrics member account on the site.   
 
6.2. National panel recruitment information 
According to Qualtrics’ IRB Information Sheet, “Participants are recruited from various sources, including 
website intercept recruitment, member referrals, targeted email lists, gaming sites, customer loyalty web 
portals, permission-based networks, and social media, etc.” With regards to how panel members are 
invited to a survey, “Panel members are sent an email invitation or prompted on the respective survey 
platform to proceed with a given survey. The typical survey invitation is generally very simple and generic. 
It provides a hyperlink which will take the respondent to the survey as well as mention the incentive 
offered.” More information is available in the Qualtrics’ IRB Information Sheet attached under Section 3.0 of 
the “Miscellanous Attachments” page in the IRB smartform system. 
 
6.3. Informed consent process 
The first page of the Qualtrics survey will display the information outlined in the informed consent form 
document. Specifically, the following passage will be included on this informed consent page, “Completion 
and return of the survey implies that you have read the information in this form and consent to take part in 
the research. Please keep this form for your records or future reference.” 
 
6.4. Timeline. The proposed pilot study is funded through the CTSI. As such, the study team is required to 
receive UF IRB approval prior to the procedures being submitted to NCATS for additional review. The 
additional review required by NCATS is expected to take two months. Thus, it is important for the study 
team to receive SRMC approval for the randomized message design experiment that was funded by the 
CTSI as soon as possible.  
 
6.5. Stimuli. The speech of the VHA will be manipulated by varying its Dialect Density Measure (DDM) 
which is the number of dialectal features that are specific to AAE within an utterance in proportion to the 
number of words spoken in that given utterance. At the pronunciation level, this may include features such 

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as -g dropping, as in, “I’m gettin’ a cold.” At the grammatical level, this may include features such as the 
zero copula/auxiliary (“be” verb) as in, "How you feeling today?”  
 
The scripts with different levels of dialectal density will be read by professional voice actors/actresses. 
Specific instructions and speech samples illustrating our target AAE features will be provided to the voice 
actors to ensure a natural and native production of AAE. The instructions will be designed by our team’s 
linguists who have experience conducting linguistic fieldwork and communicating with laypeople without 
using technical terminologies. 
  
AAE linguistic features to be added will be drawn from linguistic literature and scholarly research (as 
outlined in Section B.2.). Further, to ensure that each feature is an authentic representation of AAE, the 
Corpus of Regional African American Language (CORAAL) (Kendall & Farrington, 2020) will be consulted 
on the particular feature in question to ascertain whether the feature actually appears in the speech of 
various African Americans. CORAAL is a corpus of over 150 hours of recordings of interviews with African 
Americans from around the country and over time. CORAAL is especially beneficial in this process as it 
contains the speech of African Americans who differ in gender, age, and regionality, and the recordings 
span the late 1960s to the late 2010s. As much as possible, actual audio snippets of African American 
speakers using the linguistic feature in question will be included in the script via hyperlink both as an 
accountability mechanism to ensure the scripts avoid incorrect, stereotyped language and also to offer 
voice actors/actresses real life examples of the features to assist them in producing the most authentic and 
natural voice recording possible.   
 
6.6. Measures. The primary outcome in the current pilot study is credibility score. We expect that source 
credibility is the mechanism through which intentions to screen will be strengthened. Source credibility will 
be measured using a series of semantic differential items (e.g., “Please rate your virtual health assistant on 
the following dimensions”: Trustworthy/Untrustworthy, Honest/Dishonest, Expert/Inexpert, 
Competent/Incompetent). Further, we will measure whether the integration of AAE linguistic features 
impacted credibility through the use of useability questions (e.g., “How would you describe your virtual 
health assistant on the following scales:” “Is similar to me/Is different from me”, “Speaks like me/Does not 
speak like me”). Given that the primary manipulation in this study is speech characteristics associated with 
ethnic group membership, we will also assess strength of ethnic identity using the Multi-group Ethnic 
Identity Measure.39   
             
6.7. Sample size justification and statistical analysis plan. As this is a pilot study, our main purpose is 
preliminary information collection and exploratory analysis instead of hypothesis testing, a formal sample 
size calculation is not necessary. The study sample size is determined by budget. 
Descriptive statistics for credibility score including mean, standard deviation, median, and inter-quartile 
range (IQR) will be calculated (1) in the overall study cohort and (2) within each of the 7 groups. Similarly, 
descriptive statistics for intention to CRC screen including frequency and proportion will be calculated (1) in 
the overall study cohort and (2) within each of the 7 groups. Such information will serve as preliminary 
estimates to facilitate future powered studies. We will also generate descriptive statistics of collected 
demographic and clinical variables (e.g., age, gender, etc.). Graphical illustration will be provided if 
applicable. One-way ANOVA or Kruskal-Wallis test will be used to test difference of credibility score among 
7 groups and two-sample t-test or Wilcoxon rank sum test will be used for post-hoc pairwise comparison. 
Chi-squared test or Fisher exact test will be used to test difference of intention to CRC screen among 7 
groups and pairwise comparison. As this is a pilot study, all statistical analysis is exploratory. Therefore, 
multiple comparison adjustment will not be considered. 

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6.8. Patient-centeredness. The proposed intervention will test different levels of linguistic variation. To 
maximize patient centeredness, the investigators will conduct formative research with members of the 
intended patient population during the period in which the current study is under review at NCATS. The co-
PI (Krieger) currently has an open protocol in which focus groups are being used to ensure patient 
acceptability of all aspects of the VHAs. For more details on focus group procedures, please see our recent 
manuscript published in Psycho-Oncology (see Vilaro et al., 2020). Krieger will conduct additional focus 
groups to examine patient perceptions of the different levels of linguistic variation and use this feedback to 
finalize how the stimuli are presented in the experiment to maximize patient centeredness.   
 
5. Possible Discomforts and Risks: 
● As with any behavioral intervention, there is the possibility of minimal emotional discomfort from 
being presented with individual risk factors for a disease. However, the probability of any 
physical, psychological, or social harm is minimal to none. 
 
Adverse Event Reporting 
● The data is collected by Qualtrics, so we will not have any direct contact with participants. The 
adverse event we will potentially encounter is someone sharing something concerning in the 
written feedback section. If this occurs, we will contact Qualtrics so they can reach out to the 
participant.  
 
Data Sharing Plan 
● We will share data associated with the trial by depositing these data in Dropbox, a file sharing 
system approved by UF Integrated Risk Management and providing access to the relevant files 
with outside investigators. Data include participant responses to survey questions and 
information about participant interactions with the intervention. Data are deidentified by 
Qualtrics and we do not have access to anything personally identifiable for participants.  
● Data will be shared with investigators working at other accredited universities for the purposes 
of analysis. The names and Institutions of persons either given or denied access to the data, 
and the bases for such decisions, will be recorded. Participants will acquire IRB approval from 
their home institution to review data. 
6. Possible Benefits: 
● There are no direct benefits from participating in this study. However, participants may have 
garnered valuable information on their individual risk of developing colorectal cancer. They also 
learned how to screen for colorectal cancer. 
7. Conflict of Interest: 
● There are no real or potential conflicts of interest in regards to this research project for any 
members of the study team. 
 
8. Bibliography 
Aune, R. K., & Kikuchi, T. (1993). Effects of Language Intensity Similarity on Perceptions of Credibility 
Relational Attributions, and Persuasion. Journal of Language and Social Psychology, 12(3), 224–
238.  

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