Health Education Research, Vol. 16, No. 4, 503-505,
August 2001
© 2001 Oxford University Press
LETTERS TO THE EDITOR |
Response to Kreuter and Skinner
Prevention Sciences, Northern California Cancer Center, PO Box 5033, Union City, CA 94587-3106, USA
I am grateful for Kreuter and Skinner's call for consensus regarding use of the terms targeting and tailoring (Kreuter and Skinner, 2000
), having suffered the frustration of trying to identify a commonly agreed upon meaning for these words as they relate to health communications. Indeed, not having succeeded in that endeavor, my colleagues and I developed a set of definitions in 1996 (Pasick et al.1996). Kreuter and Skinner similarly advance definitions, and I write now to suggest where further areas of consensus might be found.
There are two relatively recent changes in our field that are entirely independent of one another but converge to render this discussion both important and complex. One is the increasing diversity of the US population, and the desire in health education and behavioral science to understand and to be highly responsive to cultural factors. The other is advances in technology that only recently gave us the capability to develop individually tailored printed material. These are highly compatible developments, and hopefully confusion over terms will not distract us from the exciting work of developing, testing and delivering high quality, culturally appropriate tailored messages.
By way of background, my colleagues and I have defined targeting as `the process of identifying a population subgroup (defined by parameters relevant to health promotion goals and objectives) for the purpose of insuring exposure to the intervention by that group' and tailoring as `the adaptation of the intervention and/or total redesign to best fit the needs and characteristics of a target audience'. Taking this a step further, we defined cultural tailoring as `the development of interventions, strategies, messages and materials to conform with specific cultural characteristics' (Pasick et al.1996). While we did not anticipate it at the time these definitions were written, as part of the current NCI-funded Pathfinders project, we have developed and are testing individually tailored print pieces targeted to a multi-ethnic, multi-lingual low-income population of women in Alameda County California. These `Personal Health Guides' (PHGs) are culturally tailored to include themes, messages and graphics found to be consistent with values, beliefs and preferences shared by subgroups of African-American, Cantonese, Filipina, Latina and white women from the communities targeted by our intervention.
Kreuter and Skinner have suggested the following definition for tailoring: `any combination of information or change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assessment' [italics in original] (Kreuter and Skinner, 2000). This is at once a refinement, in the inclusion of specific elements and methods of tailoring, and a narrowing of the term in the restriction that tailoring apply only to individuals, as opposed to groups, programs or other entities. Thus, as suggested by Kreuter and Skinner, adaptations made to interventions or messages designed for specific groups are not to be regarded as tailoring, but rather as targeting, or `the development of a single intervention approach for a defined population subgroup that takes into account characteristics shared by the subgroup's members' (Kreuter and Skinner, 2000).
Kreuter and Skinner's emphasis is the need for a simple term that distinguishes individual tailoring from other forms of tailoring, and their discussion is very useful in this regard. However, their proposed solution seems to raise other problems. Attenuating the meaning of a word or term can enhance precision and thus clarity, but attempting to reframe the meaning of a commonly used term in a manner not entirely consistent with its conventional use runs the risk of causing more rather than less confusion. It appears that Kreuter and Skinner, in an effort to narrow the meaning of tailoring, are assigning targeting as the repository for that which has been deleted from tailoring, i.e. customizing for groups. According the American Heritage Dictionary (1996), targeting means `to make a target of; to aim at or for; to establish as a target or goal'. This term refers to an objective rather than a process. On the other hand, to tailor is `to make, alter, or adapt for a particular end or purpose: a speech was tailored to an audience of business leaders' [italics in original] (American Heritage Dictionary1996), not only for an individual. In sum, there is a potentially problematic narrowing in the definition of tailoring and a rather oblique addition in meaning to the term targeting. Kreuter and Skinner have not really explained why it is necessary to go to these lengths to redefine common words rather than simply use the term `individual tailoring' to make this distinction.
A second problem with the proposed definitions comes with consideration of tailoring on the basis of cultural characteristics. By definition, culture refers to values, beliefs, etc., that are shared with a significant community of others. If something is not shared, such as a psychological characteristic, it is not cultural. Therefore, cultural tailoring must be based on subgroup characteristics, which would be manifest in any given individual. While individuals may have varying levels of certain cultural beliefs, to be cultural is to be shared. Therefore, it would seem that customization based on some aspect of culture has no place in the Kreuter and Skinner definition of tailoring. Here is where there is often confusion between race/ethnicity and culture. For example, few cultural factors are shared by all African-Americans. Rather, there are cultural subgroups within the African-American community. Depending on what cultural factor is in question, an individual may or may not be a member of that subgroup. So if an AfricanAmerican holds a highly individualistic outlook as opposed to a more collectivist outlook, that person could be considered a member of a different cultural subgroup. Or if a Latina is very acculturated to a mainstream American lifestyle, his/her values would not be the same as more traditional Latinos; again two different cultural subgroups. It is therefore confusing to imply that culture can be an individual-level factor. It seems more appropriate to place the emphasis for cultural tailoring, a term that engenders massive confusion in our field, on the identification and incorporation of truly cultural factors (as distinct from demographic and other factors).
In fact, Kreuter and Skinner use an example from our Pathways project in which my colleagues Perez-Stable et al. (Perez-Stable et al., 1996) targeted low-income Latinas in the San Francisco Mission neighborhood (the delineation of a specific population segment) and then tailored the booklet Mujer y el Cancer to certain cultural characteristics of that community. The booklet could simply have been a translated version of something similar developed for Anglos but it was not. It was developed entirely on the basis of preferences of women representing the target population. Thus it was targeted to a specific population and then culturally tailored at the subgroup level for that community. We are using many of the same concepts in our Pathfinders PHGs, where combinations of messages are put together based on individual assessments. Therefore, the PHGs are both culturally and individually tailored.
Related to this last point, it seems really inaccurate to say that individual tailoring is the use of `different content for each person'. All messages in tailored communication are chosen based on subgroup analyses and then applied to all members of that subgroup. For example, we could say that a message is individually tailored for a woman at the precontemplation stage of adoption for genetic testing for breast cancer. However, that message is typically based on research among many women at that same stage and indeed all women at that stage will receive the same message. Furthermore, the only thing that is truly individualized is addressing a woman by her own name. Not even a given combination of individually tailored messages can be said to be unique since it is entirely plausible that, except for the individuals' names, more than one person might receive the same combination of messages.
I agree wholeheartedly with Kreuter and Skinner's point that consensus around key terms is much needed in this field, and admire their pioneering work in the field of tailored communication. I also appreciate the challenge they have undertaken to seek out standardization for our terminology. I hope these comments move us closer to attaining a shared meaning for these important terms.
References
American Heritage Dictionary of the English Language, 3rd edn (1996) Houghton Mifflin, New York.
Kreuter, M. W. and Skinner, C. S. (2000) Tailoring, what's in a name? Health Education Research, 15, 1–4.
Pasick, R. J., D'Onofrio, C. N. and Otero-Sabogal, R. (1996) Similarities and differences across cultures: questions to inform a third generation for health promotion research. Health Education Quarterly, 23 (Suppl.), S142–S161.
Perez-Stable, E. J., Otero-Sabogal, R., Sabogal, F. and Napoles-Springer, A. (1996) Pathways to early cancer detection for Latinas: En Accion Contra el Cancer. Health Education Quarterly, 23 (Suppl.), S41–S59.
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