Survey instrument data
The descriptive analysis of survey responses revealed that the most frequent tailoring strategy was matching intervention schedules with participants’ availability (76.5%). Another prevailing strategy was delivering the intervention in accessible locations to participants or meeting their transportation needs (64.7%).
Half of the HMC projects tailored the interventions based on formative research. In addition, 8 studies (47%) reported that their interventions were delivered by individuals who were knowledgeable of the cultural views and values of participants (it is worth noting that the descriptive data did not capture details or examples of such cultural views and values; ).
Percentage of HMC Projects (n=17) by Intervention Tailoring Strategy
Almost 2 thirds of the HMC studies developed intervention contents that met the literacy level of the target population (). All interventions were delivered in English, and only one reported having an interpreter in the intervention classes.
All 17 projects included some ethnic minority participants. The average percentage of ethnic minority inclusion was 40.18%, and the range was from 6% to 100%, with only one study having all participants from an ethnic minority group ().
Percentage of Ethnic Minority Participants by Study (n=17)
Follow-up Interview Data
Three major themes emerged from data obtained through the follow-up interviews: the importance of formative research in cultural tailoring, intervention cultural components, and main lessons learned.
The intervention tailoring process in 3 projects was informed by formative research including literature searches, focus groups, interviews, theatrical testing, and pilot testing:
“You can read the literature, but unfortunately, even the African American community is not homogeneous. So if you were dealing with Caribbean Americans, African Americans, or Africans, people who have lived in the North versus the South, there really are some differences that need to be taken into account. The only way to really get at those nuanced differences is by doing some in depth formative work” (Study 1).
Study 2 began the formative process by searching the literature for “some insights into things that we should consider changing from the parent program [The Mediterranean Lifestyle Program]. There could be some factors unique to Latinas that would make a difference in terms of learning self- management procedures. In that literature we frankly didn’t find anything that was very profound.”
Study 2 also conducted focus groups, but again “we were left with the sense that the overall format in the parent program was feasible for implementation with Latinas. Childcare and transportation were 2 of the areas the participants thought we should be sensitive to because they thought the intervention would be rather demanding.”
Study 1 conducted 2 pilots assessing the feasibility and cultural appropriateness of the program: “The pilot studies were sort of a dress rehearsal. We went through all the procedures, including randomization, and we delivered our intervention, and at the end of each intervention session, that’s when we requested specific information about the session. Were the activities appropriate? Were the health educators appropriate?”
Study 2 also pilot tested shortened versions of the intervention: “We were able to pilot the measures to see if they were clear and could be understood by the women--whether the literacy level was appropriate. We piloted the recruitment procedures. Probably the biggest thing we learned from the pilot was that we needed to add a family component to the intervention.”
Study 3 conducted interviews and focus groups to find out women’s perceptions about their experiences with mammography screening.
Study 1 used theatrical testing “where we had members of the community actively participating as consultants in each of the components of the study, and then evaluated it for its appropriateness, in terms of linguistic and cultural relevance.”
The interviewees highlighted the main components they included to make the interventions culturally sensitive. These components were related to the demographic characteristics, cultural norms, and social environment of participants.
Demographic characteristics of delivery agents and participants were matched in some of the studies. Study 1 hired health educators who were African American females, and about 95% of the research team was also African American. Study 2 presented intervention materials in English and Spanish and had bilingual staff.
Although Study 3 did not plan to match gender characteristics of interventionists and participants, the intervention counselors were of mammography-seeking age, a similar age of participating women: “We wanted to have telephone advisors and counselors who were mature and who could relate to women.”
Taking into account the cultural norms of the target population was also relevant in studies 1 and 2 when selecting intervention activities and materials:
“We wanted to look at symbolism because clearly that is an important cultural component. Even the logo that we eventually used was symbolic of African culture” (Study 1).
Study 2 also took into account Hispanic cultural symbolism in some group activities, in which “all the decorations had a fiesta style.”
In Study 1, the researchers emphasized the importance of cultural congruence:
“For example, in our study one of the key themes was to be safe for yourselves, your family, and your community. In African American communities young women are important, not only to their family, but to their community. So the whole issue of altruism, collectivism, which is an African American trait, was emphasized” (Study 1).
Studies 2 and 4 included ethnic foods of the target population. In Study 4, interventionists taught African Americans “ways to either avoid fried food or preparing that food in ways that didn’t involve so many extra calories.”
In studies 1 and 2, culturally sensitive music and poetry were also incorporated into the intervention. The researcher from Study 1 stated the intervention included materials from African American artists such as the musician Lauren Hill and the poet Maya Angelou. Study 2 introduced music that participants would like: “We definitely had a Latin flavor to the music that we used for the physical activity sessions. We had salsa dancing at our different functions.”
The social context of the target population was another intervention component in 3 studies:
“Our intervention addressed the realities of being an African American woman. What are the threats in the community? What are the barriers to practicing safer sex? We also addressed future orientation as perceived by African Americans. A lot of them don’t perceive they have a future. You also have to address gender norms, critical issues that not only in African-American communities are prominent, but in general” (Study 1).
Study 2 included social support groups for participants and also met their transportation needs to attend sessions: “Women came together at the end of each of our group sessions, and had an opportunity to socialize and talk about their successes and failures with the program, which we felt was a critical element in maintaining their involvement in the program.”
In Study 4, the weight-control specialist provided nutrition advice to participants based on their cultural background or the neighborhood: “Our whole approach to weight-control programs is focused much more on the food environment and much less on the psychological characteristics of our participants. There were was a big difference between African Americans and Caucasians in terms of the food environment. That was at least partly based on the fact that in general the African Americans came from lower social economic levels and lived in different neighborhoods; therefore they had less money to spend on healthy foods and healthy foods were less available to them.”
Main Lessons Learned
Two themes emerged as common lessons among interviewees: the tailoring process has to be individually oriented and is time-consuming.
“I think that is one reason why our interventions are not nearly as effective as they could be, because they are so broad. By designing a really broad intervention it is really targeted at no one” (Study 1).
The PI of Study 1 also mentioned that researchers need to understand the target population and involve individuals from this population in the intervention design, implementation, and evaluation: “The more tailoring you do and the more personalized you make it, the better it is. So there are different levels of tailoring. Tailoring is not a yes or no issue. Think of tailoring as a continuum. Your intervention has to target an individual, not a group.”
The main lesson for researchers in Study 2 was acknowledging the heterogeneity of the target population:
“If you have a group of Latinas living in Denver, in terms of acculturation and nationality there is a lot of diversity. I think the main lesson is that with tailoring you have to be extremely flexible. We incorporated family night because of our pilot study participant feedback, but there were some women who said, ‘I don’t care what my family thinks, I’d rather have an evening where they stay at home and I can just enjoy my time with the other women here.’ In terms of language and bilingualism, we have monolingual Spanish speakers, monolingual English speakers, and people who are bilingual. I think the lesson is to not make narrow stereotyped assumptions because there is so much diversity in each ethnic group” (Study 2).
For researchers of Study 3, the culturally sensitive process “is laborious and time consuming.” Additionally, in retrospective Study 3 researchers would have oversampled racial and ethnic minorities in order to “do some better comparisons across race and ethnicity.”
The PI of Study 4 also emphasized the importance of an individually oriented tailoring process:
“We have to realize that our interventions don’t work very well with everyone. But I don’t think it has anything to do with tailoring. It has to do with the huge difficulty everyone has in changing their habits, food choices, given that we are living in an extremely unhealthy food environment. So when you think about behavior modification procedures, they are all about tailoring to begin with. In other words, the whole idea is teach general principles, but then help people apply those principles to their particular life situations, and that is true regardless of who they are. Participants want a helper who addresses their particular challenges, as opposed to just applying a one size fits all” (Study 4).