AHRQ Innovations Exchange | Expert Commentary: Culturally Tailored Cessation Program Significantly Reduces Tobacco Use Among Members of American Indian Tribe

Cultural Tailoring:  Does It Improve the Health of Racial and Ethnic Groups?

By Ken Resnicow, PhD, Professor, University of Michigan School of Public Health

Health behavior specialists have been working for the past 25 years with various ethnic and cultural groups including African-Americans, Latinos, and to some degree Asians, to modify the format and content of health interventions to match the group’s cultural and/or ethnic background. Cultural tailoring differs from cultural competence, which refers to the ability of clinicians to effectively relate to an individual or group from a different ethnic or cultural background.    

Cultural tailoring has evolved in the past 15 years from focusing on more superficial components of cultures to a deeper integration of values. Initially, cultural tailoring addressed ethnic and cultural groups by modifying images, color schemes, portrayals of food and music, and occasionally language. More recently, cultural tailoring has tapped into the deeper cultural, historical, and environmental forces that shape an individual’s core beliefs and behaviors. These forces include ethnic identity, spirituality, collectivism, time orientation, and historical issues such as cultural mistrust.  

We also recognize that within ethnic and cultural groups there is tremendous individual heterogeneity. For example, 16 ethnic identity types were identified among African-Americans participating in a study[1] involving the development and testing of the Black Identity Classification Scale. On one end of the spectrum, were assimilated Blacks who identified more closely with being an American or even a Cub fan than their race, and on the other end, were Blacks who  identified highly with their race. The identity types were correlated with unique health attitudes and behaviors, which we then used in crafting dietary messages.[2]           

The results implied that the group targeted health communications approach where everyone receives the same materials and messages is inadequate to capture individual variation among African-Americans. We concluded that individual differences need to be measured in the target population and interventions should be adapted to reflect those differences. However, this highly segmented cultural tailoring is more time-consuming and expensive than the traditional group cultural tailoring approach. Individual level tailoring is most appropriate when the outcome (e.g., diet, exercise, medical adherence) is related to the particular variable(s) of interest.

The featured programs in this issue of the Innovations Exchange illustrate the use of “deep” cultural tailoring at primarily the group level. A population that requires a high degree of tailoring is Native Americans. For example, the Fond du Lac Smoking Cessation Program offers culturally tailored support to members of the Reservation of the Fond du Lac Band of Lake Superior Chippewa who want to quit smoking. The curriculum is based on the American Lung Association’s “Freedom from Smoking” curriculum, and incorporates cultural and historical characteristics from the band, including the potentially tricky topic of ceremonial tobacco use. The deep tailoring involved integration of stories and traditions about the sacred use of tobacco in ceremonies and prayer offerings, and clearly distinguished that from the abuse of commercial tobacco. The program resulted in significantly less tobacco use driven in part by high engagement and satisfaction, and free pharmacotherapy.

Another example of deep cultural tailoring is the Heart Healthy and Ethnically Relevant Lifestyle Program at the University of South Carolina. Low-income African-American women at risk for cardiovascular disease received lifestyle counseling from primary care physicians and nurses using culturally tailored materials and techniques. The program’s components were framed within the cultural context of family responsibilities and social roles, and cultural beliefs regarding food, physical activity, and body weight.   

The three year randomized controlled trial, which included up to 14 phone counseling sessions with a health educator, was funded by a $2.1 million grant from the National Heart, Lung and Blood Institute. To replicate the study and facilitate funding, the number of sessions may need to be pared down.

The third featured program provided medication treatment and/or culturally tailored therapy and support to low-income Hispanics with diabetes and symptoms of depression. The 8-week culturally tailored psychotherapy program was led by trained bilingual social workers and developed by the Los Angeles County Department of Health Services and the University Of Southern California School Of Social Work. In addition to the use of Spanish language, cultural tailoring was further achieved by the social workers integrating cultural values into their counseling. For example, they frequently used culturally appropriate sayings or "dichos" during sessions, in addition to handouts, written in both Spanish and English that included examples consistent with the patients' cultural background.

AHRQ Innovations Exchange Expert Commentary: Culturally Tailored Cessation Program Significantly Reduces Tobacco Use Among Members of American Indian Tribe

The randomized controlled trial, funded with a $2.9 million grant from the National Institute of Mental Health, improved long-term adherence to antidepressant medication, reduced depression-related symptoms, and increased patient satisfaction with depression care. In addition, after 18 months, social-worker based depression care proved to be highly cost-effective.
Questions have been raised about the effectiveness of cultural tailoring due to study design limitations. To isolate the effects of cultural tailoring, ideally the culturally tailored intervention is compared to an intervention of similar dose and content that differs only by the cultural component.  

About the Author:

Ken Resnicow, PhD, is the Irwin Rosenstock Professor of Health Behavior and Health Education at University of Michigan School of Public Health. His research interests include: the design and evaluation of health promotion programs for special populations, particularly chronic disease prevention for African Americans; tailored health communications; understanding the relationship between ethnicity and health behaviors; substance use prevention and harm reduction; and training health professionals in motivational interviewing.

Disclosure Statement:  Dr. Resnicow disclosed no conflicts of interest.

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[1] Davis R, Alexander G, Calvi J, Wiese C, Greene S, et al. A new audience segmentation tool for African Americans: The Black Identity Classification Scale. Journal of Health Comm 2010; 15(5): 532-554.

[2] Resnicow K, Davis R, Zhang N, Tolsma D, Alexander G, Wiese C, et al. Tailoring a fruit and vegetable intervention on ethnic identity: Results of a randomized study. Health Psychol 2009;28(4):394-403.