BOX 6Exemplar study 1: comparison of adapted and standard interventions

Kreuter et al. 2005.293 Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers

Study design

This RCT was one of the few studies we identified that directly examined an intervention with and without a component of cultural adaptation. The study population was lower-income African American women (n = 1227) and the health promotion topic was mammography in the older population (aged 40–65 years) and increasing fruit and vegetable intake in the younger population (aged 18–39 years); we focused on the latter group

This was a four-arm study with three intervention groups and a control group. The intervention arms were delivered through a women’s health magazine and the magazine was developed with BCT, CRT or both (BCT + CRT). Each magazine contained 10 items focusing on fruit and vegetable intake and four items on general topics that were chosen according to the demographics of the women to increase the magazine’s appeal. The control group received no materials during the intervention but were sent a full set of the magazines once the intervention was completed

The BCT was based on diet-related knowledge, self-efficacy for change, perceived barriers to eating fruit and vegetables, perceived importance of eating fruit and vegetables, levels of interest in starting to eat more fruit and vegetables and actual dietary practice


The CRT was based on four cultural concepts identified in the formative work as being pertinent to African American women. These concepts were:

  • religiosity (a range of dimensions from church attendance and prayer to participation in religious ceremonies, spirituality and beliefs about God as a causal agent)
  • collectivism (belief that the basic unit of society is a family or group and not the individual)
  • racial pride (holding positive attitudes about one’s race)
  • time orientation (related to a person’s tendency to think and act according to consequences that are primarily immediate or primarily distal)

The CRT elements were measured in a baseline questionnaire to determine the tailoring and the magazine was tailored on the two cultural constructs on which the women scored the highest. This approach takes into account the individual in terms of how relevant the cultural concepts are to them, which may alter according to people’s priorities and perceptions and their level of acculturation. This study demonstrates a degree of specificity to the individual’s culture and cultural expression that was not observed in many of the included studies

In terms of adaptation the magazines also contained artwork from local African American artists and stories of local African American history. Extensive consultation was carried out in the development and formative evaluation of the materials with the population of interest

Outcomes and insights

The results showed that women who received BCT + CRT magazines were more likely than those in the BCT, CRT and control groups to have greater increases in the number of fruit and vegetable servings consumed daily. This suggests that the CRT required behavioural constructs to be effective and also that messages based on BCT alone were effective for some participants only when placed in certain cultural contexts. The authors suggest that there is an important link between culture, behaviour and communication that needs to be investigated and pursued further

From: 6, Systematic review of adapted health promotion interventions

Cover of Adapting Health Promotion Interventions to Meet the Needs of Ethnic Minority Groups: Mixed-Methods Evidence Synthesis
Adapting Health Promotion Interventions to Meet the Needs of Ethnic Minority Groups: Mixed-Methods Evidence Synthesis.
Health Technology Assessment, No. 16.44.
Liu JJ, Davidson E, Bhopal RS, et al.
Southampton (UK): NIHR Journals Library; 2012 Nov.
© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

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