Adapting tailored intervention message libraries for ...

Health Education Adapting tailored intervention message libraries for new populations Celette Sugg SkinnerAdam BuchananMatthew W. KreuterCheryl HoltDawn BucholtzTara Smith Strigo

Article information: To cite this document: Celette Sugg SkinnerAdam BuchananMatthew W. KreuterCheryl HoltDawn BucholtzTara Smith Strigo, (2003),"Adapting tailored intervention message libraries for new populations", Health Education, Vol. 103 Iss 4 pp. 221 - 229 Permanent link to this document: http://dx.doi.org/10.1108/09654280310485555

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Introduction


Adapting tailored intervention message libraries for new populations Celette Sugg Skinner Adam Buchanan Matthew W. Kreuter Cheryl Holt Dawn Bucholtz and Tara Smith Strigo The authors Celette Sugg Skinner is an Associate Professor, Adam Buchanan is a Health Educator and Tara Smith Strigo is Project Manager, all at the Duke University Medical Center, Duke Comprehensive Cancer Center, Durham, North Carolina, USA. Matthew W. Kreuter is an Associate Professor, Cheryl Holt is a Research Assistant Professor and Dawn Bucholtz is a research Coordinator, all at the Health Communication Research Laboratory, Saint Louis University, St Louis, Missouri, USA. Keywords Health, Education, Personal needs, Computer software, Dissemination Abstract This paper demonstrates that a message library ± the computer-tailored intervention component that contains all potential versions of tailored content ± can be adapted for use in a new setting at reasonable cost and effort. A message library developed for one population was adapted to enable its use with a second population in a different geographic region. Concludes that adapting message libraries for new populations need not be a barrier to disseminating tailored interventions and designing message libraries with dissemination in mind creates tailored interventions that can be adapted for use with different populations. Electronic access The Emerald Research Register for this journal is available at http://www.emeraldinsight.com/researchregister The current issue and full text archive of this journal is available at http://www.emeraldinsight.com/0965-4283.htm Health Education Volume 103 . Number 4 . 2003 . pp. 221-229 # MCB UP Limited . ISSN 0965-4283 DOI 10.1108/09654280310485555

During the last decade, computer-tailoring of health education materials has moved from the realm of innovation to being fairly common practice among intervention researchers. At the time of writing (fourth quarter, 2002), the National Institute of Health (NIH) has more than 200 studies in its active grants portfolio using some kind of tailoring (National Institute of Health, 2002). A literature search yielded hundreds of published reports on tailoring (National Center for Biotechnology Information, 2002), and the National Cancer Institute (NCI) offers online assistance for tailoring health communications (Glassman, 2002). Nonetheless, tailored intervention programs with demonstrated effectiveness lie dormant on researchers' computer drives and tailored print materials, telephone counseling scripts, videos, and CDs containing tailored interactive computer programs are stored in office file cabinets rather than being used by the public (Caburnay et al., 2001). Why have not more tailored interventions been adopted into clinical and community practice? At least part of the answer is that tailored communications are, by their very nature, highly customized for particular populations. The best ones contain libraries of messages designed to address a range of issues relevant to different members of a given population, and to do so in a way that is meaningful in the broader context of their lives. At the same time, messages addressing issues unimportant to members of the target population are not included in the message libraries. Take, for example, message libraries developed for a tailored exercise promotion intervention for older adults in Miami versus Minneapolis. Some messages, such as those touting different health benefits of exercise valued by different individuals, might be similar in tailored message libraries for both populations. Other messages, such as those addressing barriers to exercising, would likely be quite different. Messages in the Minneapolis library might address barriers associated with cold weather and snow; there would be no reason for such messages in the Miami message library. This work was supported by grant #CA-81872 from the National Cancer Institute. Received June 2002 Accepted for publication following revisions April 2003

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Adapting tailored intervention message libraries for new populations

Health Education Volume 103 . Number 4 . 2003 . 221-229

Celette Sugg Skinner et al.

Hence, if practitioners in Minneapolis wanted to use the Miami tailoring program in their population, the message library would first have to be modified. In theory, this is a strength of tailored computer programs. As Dijkstra and De Vries wrote:


Once a tailoring system is systematically built, it can be updated periodically and, therefore, used for many years (Dijkstra and De Vries, 1999).

In practice, however, the effort required for such adaptation has been considered one of the main barriers to transferring effective tailored programs from one population to another. The actual complexity of this task has been difficult to gauge, as no serious attempts to adapt a tailored message library have previously been reported. This paper will demonstrate that message libraries can be adapted for use in multiple settings ± a major breakthrough in efforts to gain broader adoption of tailored message interventions. We will illustrate how adaptation was accomplished with the Reflections of You intervention, a tailored cancer communication system that generates behaviorally and culturally tailored magazines promoting mammography use and fruit and vegetable consumption for lower-income African-American women. The program's original message library was designed specifically for African-American women aged 18-65 in a major US city in the Midwest (St Louis, MO); it was adapted for use among African-American women of the same age, but from a less urban setting in a different region of the country (Durham, NC). By demonstrating that such adaptation is possible and describing a step-by-step process for doing it, we hope that more tailored message programs with demonstrated efficacy will be modified for use in other settings and other populations, and disseminated systematically to others who could use them. Tailored message interventions Tailored health communications have been defined as: Any combination of information and behavior change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcomes of interest, and derived from an individual assessment (Kreuter et al., 1998).

They differ from targeted communications in that tailoring produces different combinations

of intervention messages for each individual, rather than one common approach that is the same for all members of a given population subgroup (Kreuter and Skinner, 2000). Tailored communications are customized in relation to the characteristics of each individual, not on a characteristic shared by a group (as in targeted communications for, for example, all older African-American women). Because of their individual focus, tailored communications can address individuals' differences in a manner that targeted communications cannot. Message libraries A tailored message library is a computer file containing all possible texts, graphics, images, video and audio clips and animation for a tailored communication delivered via any medium. In most tailoring interventions, message libraries are stored in a database and linked to participant data (stored in a separate database) by a tailoring computer program. Using pre-set algorithms, the tailoring program evaluates participant data and determines which messages and combinations of messages should be selected from the library for a given recipient. For example, consider a woman over 40 who does not get regular mammograms because of transportation difficulties. The message selected for her from the message library might be: Not having a car can be inconvenient. There are some places I just can't go without a car. Either the bus does not go there or the journey would take too long. So you know what I have done? I have made getting a ride to the mammogram place a little project for me each year.

Another woman with a different mammography barrier ± being too busy ± might receive this message: Most of us are too busy . . . or we think we are too busy to take time for health care. It is easy to think this way when nothing is wrong yet. But the two hours spent on getting a mammogram now are nothing compared with the number of hours that will have to be spent seeking health care if a problem is found later rather than sooner.

These two women could share many characteristics, but one difference in their survey responses leads to different tailored messages. Tailored communications can be delivered through a variety of media. Text written for a message library may ultimately be printed in newsletters, brochures, booklets or magazines, read from a script by a telephone

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counselor, or delivered via a computer program or interactive video. Message libraries, participant databases, tailoring computer programs, and the process of tailoring program development are described in detail elsewhere (Kreuter et al., 2000). In this project, we had the opportunity to adapt a message library developed for African-American women in urban St Louis, Missouri for use among African-American women in the very different geographical setting of Durham, North Carolina. Messages for this project were tailored both on behavioral constructs from prominent health behavior theories (Strecher and Rosenstock, 1997) and on cultural constructs shown to be important to African-American populations (Nobles, 1991; White and Parham, 1990; Grills and Longshore, 1996; Thompson, 1991; Jagers and Smith, 1996; Landrine and Klonoff, 1995; Akbar, 1991). Our goal was to adapt messages in the library so that they could be assigned using the original tailoring computer program and its algorithms. Thus, we needed to adapt and contextualize all messages from the original library that were unlikely to be perceived as personally relevant among members of the new population group. If we believe that tailoring works because it enhances relevance (Skinner et al., 1999; Kreuter et al., 1999), and that relevance enhances cognitive processing (Petty and Cacioppo, 1981), this process is key. Adaptation of a message library to a new population is done under the assumption that the original population had enough variation to warrant tailoring and that a theoretical model that delineates the range of variables on which tailoring is needed was developed. As long as the new population has similar variability, contextualization should suffice to adapt the original model to this population. What sort of adaptation is needed when messages are applied to a different population? A primary feature of tailored communications is that each individual receives combinations of material uniquely relevant to her or him. Adapting a message library for a new population involves replacing less-relevant content with more-relevant material. As we explain below, degrees of adaptation vary depending on how similar populations are on factors such as culture, beliefs, attitudes and locality. Amount of adaptation can also be

affected by the style and language of the original messages. Culture If the new population has different cultural characteristics from the original, adapting messages on some of these characteristics will help enhance relevance. It stands to reason that messages written to appeal to a group of Wall Street brokers would not be nearly as appealing to apple-pickers in Washington State. Instead of featuring messages that discuss ways to avoid smoking while waiting for the stock-market to open, a library for the latter population would include messages on avoiding smoking while taking breaks from picking apples. This example is extreme, but even cultural groups that seem relatively similar may hold different beliefs and attitudes regarding the target health problem or behavior. For example, Matthews et al. (1994) found that African-American women breast cancer patients from rural North Carolina commonly described their cancer tumors' growth, spreading and treatment using plant metaphors. White women from the same area were familiar with the metaphors but did not understand their meaning in the same way. Before adapting the plant metaphor messages developed for rural African-Americans to a message library for urban African-American women, it would be important to determine whether they shared the understanding of their rural counterparts. Beliefs and attitudes Most tailoring studies conducted to date have included message libraries that address a range of beliefs and attitudes associated with health behaviors. For example, messages are written to address particular barriers to action (Strecher and Rosenstock, 1997), or to increase self-efficacy (Prochaska et al., 1997) for a desired behavior. When adapting a message library for a new population, one must ensure that the range of potentially important beliefs for the new population is addressed in the new message library. Populations may hold different beliefs and attitudes about the same health behavior. For example, one population may find discussions of future benefits of preventive behaviors to be irrelevant ± whatever happens will happen, it is beyond population members' control. Thus, messages in this population's library would address this belief, called fatalismo in Latino communities (Perez-Stable et al., 1992). However, another population may be more likely to believe

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current behaviors can have a positive influence on future health. An adapted library for this population would replace discussion of fatalismo with future-oriented content. Message style The way messages are written can also affect their relevance for different populations. This may be reflected in examples used to emphasize message themes. If family members are found to influence health behaviors within the original population more than in the new one, a message recommending quitting smoking by telling how a relative accomplished this feat would not be as relevant in the latter population. Adaptation may involve not only message context, but also message phrasing. Using language appropriate to a particular region, cultural or social group is another way to adapt a library for a population. The very format of a message may need to be adapted. A message set up to resemble e-mail would not be appropriate for someone who does not use e-mail. A mock advice column would be irrelevant for someone who does not read magazines or newspapers. Locality Some populations are quite similar in culture, beliefs and attitudes, and would find similar message styles appropriate. This does not mean, though, that adapting a message library for such a similar population would be unnecessary. Most tailored messages contain information pertaining to the target population's locality. For example, a set of messages on how to find places to obtain fresh fruits and vegetables might contain references to farmers' markets found in the region surrounding the target population. Even if a message were appropriate for another population's culture, beliefs and attitudes, and message style, references to places or locations unique to a particular population would still have to be adapted. Nutrition messages that discuss local restaurants, mammography messages that direct women toward local clinics, and smoking cessation messages listing local ``smoke-free'' entertainment venues are examples of such references to locality.

Methods The methods described below outline our procedure for adapting the Reflections of You

message library originally developed for a population in St Louis, Missouri to a population in Durham, North Carolina. Types of tailoring All messages, graphics and layout templates were originally developed to create magazines for low-income African-American women in St Louis urban health centers. Goals of the bi-monthly magazines were to promote mammography and fruit and vegetable intake. Most tailored communication interventions to date (Skinner et al., 1999) have used behavioral construct tailoring (BCT), using tested health behavior theories as the bases for tailoring. For example, some interventions are tailored on variables from the health belief model (HBM), which purports that individuals, who perceive themselves to be susceptible to an adverse outcome believe that that outcome would be severe for them, and see more benefits than barriers to making the change, are most likely to take preventive actions (Strecher and Rosenstock, 1997). HBM-based interventions tailor messages to individuals' barriers to performing the desired health behavior, misunderstandings about causes or severity of the unhealthy behavior, and perceived benefits of the healthy behavior. In addition to behavioral constructs, some messages in the Reflections of You project were tailored on cultural constructs found to be relevant to African-Americans, including: . collectivism ± in which the basic human unit is the group or family (Nobles, 1991; White and Parham, 1990); . ethnic identity (Grills and Longshore, 1996; Thompson, 1991); . religiosity and spirituality (Jagers and Smith, 1996; Landrine and Klonoff, 1995; Nobles, 1991); and . perception of time ± present vs. future orientation (Nobles, 1991; White and Parham, 1990; Akbar, 1991). Participants received magazines tailored using one of three approaches: (1) behavioral construct tailoring (BCT); (2) culturally relevant tailoring (CRT); or (3) a combination of BCT and CRT. Different messages were written for each tailoring type. Thus, the message library, which was stored and revised in FileMaker Pro 5.0v3 software (Filemaker, Inc., 2002), contained four files of messages related to project outcomes:

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(1) behaviorally tailored; or (2) culturally tailored mammography messages; and (3) behaviorally tailored; or (4) culturally tailored messages on fruit and vegetable intake. In addition to these messages addressing behavioral outcomes of interest, the message library contained a fifth file of non-outcome-related messages (NORMs). These messages were intended to enhance interest and relevance of the Reflections of You magazines by including articles on topics women cited as appealing (e.g. parenting, finance, local black history, gardening). In all, the tailoring system for St Louis women created six different issues of each of the three magazines (i.e. BCT, CRT, and BCT + CRT). Given limitations of time and resources, the adaptation study involved only the first three issues of the BCT + CRT magazines. Adaptation process Which messages should be adapted? To determine which messages to adapt, we reviewed all parts of the message library to be used in Durham. Project staff read each message text and viewed each graphic, identifying candidates for change based on differences in culture, beliefs and attitudes, message style, or locality, as described above. We defined candidate for change as any phrase, graphic or piece of information that might not be appropriate for the new target population. Because identifying candidates for change takes some knowledge of the target population and can be subjective, more than one person read all messages and made these determinations. After highlighting all message candidates for change, we convened an advisory panel from the local community. The panel helped with final decisions about which messages needed adaptation, as well as giving input about how to adapt specific messages. Instead of reviewing each text message ± there were 539 messages, each 100-300 words long ± panel members answered a list of questions regarding message topics. Questions were developed by project staff and referred to specific message content. For example, one St Louis dietary message discussed restaurants in which people could find a variety of fruits and vegetables. Thus, we asked the advisory panel to identify Durham restaurants, popular

among the target population, that have salad bars. We could then adapt the original message with the locally relevant information. The advisory panel's responses to questions such as ``Where can uninsured women go to get free or reduced-cost mammograms?'' and ``Who are famous and respected local AfricanAmericans in the following areas: schools, books, churches, music, arts, newspapers, and hospitals?'' resulted in information we needed for message adaptation. We mailed each panel member a packet of questions before the advisory panel meeting. During the meeting, panel members discussed their answers to these questions. This discussion determined which messages to adapt to the Durham site and suggested types of content that should replace original graphics or text. The next step was to research exactly how to adapt each message. Background research Although panel recommendations informed many revisions, some messages involved adaptations extensive enough to necessitate more research. For example, when our advisory panel suggested popular local restaurants with salad bars, we then visited each restaurant to compare prices and quality. Panel members recommended interesting historical events: project staff located information on these events and developed text for the message library. The panel identified relevant transportation and childcare services: project staff obtained contact and schedule information to write message texts. The panel recommended local celebrities to interview on mammogram barriers and diet: project staff conducted the interviews and developed them into messages. In short, the advisory panel helped identify which messages to adapt and directed us toward materials and strategies for making the adaptation. The original messages were built on frameworks listing the message type (behavioral, informational, motivational or a mixture) and topic (e.g. mammogram barriers or individualized dietary habits). By using these same frameworks, revised messages could address the same constructs, allowing them to fit into the original tailoring computer program. For example, the St Louis versions of the Reflections of You magazines featured a series of interviews with local AfricanAmerican celebrities on why women do not have mammograms. Frameworks labeled

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these as behavioral messages on the topic of mammogram barriers. Each message is tailored to a single mammogram barrier. Sample message titles include `Àre X-rays dangerous?'' and `À little pain is worth it.'' The message consists of a question about a particular barrier (e.g. ``What would you say to a woman who doesn't want to get a mammogram because she's afraid it will hurt?'') and the responses of two or three celebrities. Adapting these messages while maintaining consistency with the original framework (behavioral message about mammogram barrier) simply involved interviewing local African-American celebrities on the same topic and using their responses to replace the original text. Interviewees reviewed and approved messages in which they were featured. By researching information for types of changes suggested by the advisory panel and by using message frameworks to guide message revision according to original tailoring variables, the message library was systematically adapted. Changes were made directly in the text of a duplicate copy of the original message library. We used the original algorithm coding system to produce correctly tailored magazines without requiring adaptations to the computer program. Graphics revisions Many messages were paired with a corresponding graphic. Examples include a photograph of a produce stand accompanying a message about fruits and vegetables and a photograph of a mammogram machine accompanying text about breast cancer screening. As with messages, all graphics were reviewed and candidates for change were identified. Examples are photographs of St Louis locations and photos of celebrity interviewees. We revised the graphics library using graphic design software.

(51/282) of the graphics were revised or replaced. Recall that our library contained two main types of messages: outcome and non-outcome. Outcome messages addressed the behaviors of interest ± mammography and fruit and vegetable intake. Non-outcome-related messages (NORMs) were meant to enhance interest in the magazines by discussing general topics of interest (e.g. parenting, local black history, gardening). Although NORMs constituted a larger proportion of the message library (Figure 1), most revisions were made on outcome message texts (Figure 1). This trend of revising outcome messages more than NORMs did not apply to graphics. Non-outcome message graphics were as likely to be revised as were outcome message graphics (Figure 2). Type of adaptation Of the four types of revisions discussed earlier (culture, beliefs and attitudes, message style, and locality), an overwhelming majority of message revisions were of the locality type. Some locality-specific information identified as candidates for change included mammogram facility hours, menus of local restaurants, and references to local AfricanAmerican history. One example of message style adaptation was using the phrase ``downFigure 1 Comparison of proportion of revised vs. unchanged texts

Figure 2 Comparison of proportion of revised vs. unchanged graphics

Results How much was adapted? Not every message was adapted for the Durham population and 193 messages (36 per cent of total messages) were revised due to changes suggested by the advisory panel. Of these, 49 involved significant text message revision, meaning that at least one paragraph was completely re-written and 18 per cent

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home cooking'' in Durham messages to describe the type of food called ``soul food'' in St Louis. No message revisions were needed based on culture or beliefs and attitudes. All revisions in graphics were ``locality revisions.'' Cost and time of adaptation Adaptation for the Reflections of You magazines was conducted by two Master's-level staff members (project manager and health educator). Background research and message revision constituted the two main categories of staff time for this process. Background research included: . identifying, recruiting and soliciting input from the advisory panel; . researching local historical events via meetings with community contacts; . visiting local museums and libraries; studying books and Internet Web sites; . contacting no- or low-cost mammography facilities; . setting up and conducting celebrity interviews and photography sessions; and . visiting and photographing local restaurants and produce stands. Staff time for this background research phase was approximately ten hours per week over the course of a year (500 hours total). Once background research was complete, the health educator began the task of revising messages that were relevant for the new population but could be assembled via the tailoring program developed for the original population. This task was more time-intensive, necessitating nearly 40 hours per week for the following three months. Non-salary adaptation costs totaled less than $5,000.

Discussion Is adapting a message library a major barrier to dissemination of tailored interventions? Our experience shows that this need not be the case if the task is approached systematically. The process of adapting the St Louis message library for the Durham population was not overly labor-intensive. Additionally, non-salary adaptation costs were quite reasonable. Recall that only the message library ± not the tailoring computer program ± was adapted. The adapted messages were assembled by the original tailoring program. No tailoring algorithms were rewritten. The process would have

naturally been much costlier and more difficult if the tailoring computer program had been adapted. Easing message library adaptation Two factors ± type of changes made and original message format ± eased the adaptation process. Locality changes (made because Durham, NC is in a different place from St Louis) were predominant. Although research for these changes was occasionally extensive, with multiple meetings and cultural center visits necessary to gather information for Durham African-American history messages, most locality research was conducted quickly via telephone and the Internet. Thus, the message library was easier to revise than would have been the case with many changes of other types. Additionally, the original messages were written in such a way that small, discrete pieces could be changed while leaving the bulk of message content unchanged. Recall that few messages needed substantial adaptation. The piece of information to be changed ± sometimes as simple as replacing ``St Louis'' with ``Durham,'' or changing a St Louis farmers' market to a Durham one ± could usually be revised without affecting the remainder of the message. Together these factors minimized the extent of message library adaptation. The fact that original outcome messages featured more locality-specific information than the non-outcome-related messages (NORMs) explains why a greater proportion of outcome messages was revised. For example, dietary outcome messages focused on such things as where to buy produce and when local fruits are in season. Mammography messages addressed state Medicare coverage and where to get mammograms. Although some NORMs contained similar locality-specific information ± such as local African-American history and where to find quality child care ± the majority of NORMs contained general information tailored on variables that did not differ by site. For example, one set of NORMs was tailored on age and interests. If a woman listed music as an interest, she received an age-appropriate music message (e.g. top ten song list from when she was 16 years old). This message did not change according to locality. The similarity in proportion of revised graphics for outcome messages vs. NORMs is explained by the fact that most of the original graphics

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for each message type contain images that could apply to either population. Factors other than type of change and original message format can contribute to the difficulty and expense of adapting a tailored message library. In general, highly tailored interventions will necessitate more adaptation, and at greater cost. This paper has focused on the unique challenge of modifying a message library for use by a population other than the one for which it was originally intended. It is also possible to modify the overall focus or objectives of a tailoring intervention. For example, practitioners may find that the program architecture (e.g. assessment questions, algorithms, message library, tailoring computer program) of a tailored smoking cessation intervention might be adapted to promote exercise. Although the tailoring computer program and algorithms would remain the same, messages that formerly discussed tips for quitting smoking would now give advice for increasing exercise. This sort of adaptation ± altering messages to address a different behavior ± would lead to a more substantial revision of the message library. Limitations This paper describes only the process and feasibility of adaptation of a tailored message library, not the resulting effects of the modified program. These outcomes are being evaluated, and will provide some evidence ± albeit imperfect ± of the success of our adaptation. In St Louis, 1,227 women were randomly assigned to a control group, or to receive one version (BCT, CRT, or BCT + CRT) of the Reflections of You magazines. In Durham, 399 women were randomly assigned to a control group or to receive BCT + CRT magazines. If the BCT + CRT magazines are effective in St Louis but not in Durham, we will not necessarily know why this difference occurred, but must assume it is at least in part a failure of adaptation. If both are effective, we cannot necessarily attribute it to adaptation because we do not know how women in North Carolina might have responded to the original unedited St Louis version. However, this latter uncertainty seems more conceptual than actual, as it would make no sense to give North Carolina women magazines suggesting they go to inner-city clinics in St Louis to get

mammograms or to the Soulard Farmers' market on the Mississippi River to shop for produce. Another adaptation limitation is that we did not survey the second target population to determine whether it differed substantially from the original population regarding the four cultural constructs (collectivism, ethnic identity, religiosity and spirituality, and perception of time) before we began the adaptation process. Although this could have been a significant limitation, data collected after message library adaptation showed that the two populations were similar with regard to these constructs. In future studies, we recommend more extensive formative research with the second population prior to message library adaptation.

Conclusion The adaptation described in this paper highlights the importance of creating message libraries that can be modified with limited effort. Doing so creates tailored interventions that can continue to be used in different settings, with different populations. Designing a particular intervention for diffusion ± a process with considerable initial cost ± will enhance cost-effectiveness each time it is adapted to a new population. Thus, we call upon researchers and funding agencies to establish formal mechanisms, not only for sharing computer program architecture and message libraries, but also for building interventions in ways that facilitate adaptation. This may include any of the following strategies: For funders: . Require or reward investigators to design for diffusion when creating interventions. . Require or reward dissemination plans built into proposals. . Establish and make available special translation and dissemination resources to interventions with demonstrated efficacy. . Establish a means of assuring that developers' intellectual property will not be misused and that appropriate credit and control of interventions will rest with developers. . Provide technical assistance or fund centers whose focus is translation and dissemination.

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For developers/developers' institutions: . Reward dissemination: is an effective intervention that gets adopted locally, regionally, or even nationally less important or less of a contribution than a published manuscript?


References Akbar, N. (1991), ``The evolution of human psychology for African Americans'', in Jones, R.L. (Ed.), Black Psychology, Cobb and Henry, Berkeley, CA. Caburnay, C.M., Kreuter, M.W. and Donlin, M.J. (2001), ``Disseminating effective health promotion programs from prevention research to community organizations'', Journal of Public Health Management and Practice, Vol. 7, pp. 81-9. Dijkstra, A. and De Vries, H. (1999), ``The development of computer-generated tailored interventions'', Patient Education and Counseling, Vol. 36, pp. 193-203. FileMaker, Inc. (2002), The FileMaker Family of Products, available at: www.filemaker.com/products/ index.html Glassman, B. (2002), Health Message Tailoring: First Cut, available at: http://dino.nci.nih.gov/public/ glassman/TailoringGuide/ Grills, C. and Longshore, D. (1996), `Àfricentrism: psychometric analyses of a self-report measure'', Journal of Black Psychology, Vol. 22 No. 1, pp. 86-106. Jagers, R.J. and Smith, P. (1996), ``Further examination of the spirituality scale'', Journal of Black Psychology, Vol. 22 No. 4, pp. 429-42. Kreuter, M.W. and Skinner, C.S. (2000), ``Tailoring: what's in a name?'', Health Education Research, Vol. 15 No. 1, pp. 1-4. Kreuter, M.W., Bull, F.C., Clark, E.M. and Oswald, D.L. (1999), `Ùnderstanding how patients process health information: comparing tailored and untailored weight loss materials'', Health Psychology, Vol. 18 No. 5, pp. 487-94. Kreuter, M.W., Farrell, D., Olevitch, L. and Brennan, L. (2000), Tailoring Health Messages: Customizing Communication with Computer Technology, Lawrence Erlbaum Associates, Mahwah, NJ. Kreuter Marshall W., Lezin, N.A., Kreuter, Matthew W. and Green, L.W. (1998), Community Health

Promotion Ideas that Work, Jones and Bartlett, Boston, MA. Landrine, H. and Klonoff, E.A. (1995), ``The AfricanAmerican acculturation scale II: cross-validation and short form'', Journal of Black Psychology, Vol. 21 No. 2, pp. 124-52. Matthews, H.F., Lannin, D.R. and Mitchell, J. (1994), ``Coming to terms with advanced breast cancer: black women's narratives from eastern North Carolina'', Social Science and Medicine, Vol. 38 No. 6, pp. 789-800. National Center for Biotechnology Information (2002), PubMed, available at: www.ncbi.nlm.nih.gov/ PubMed/ National Institute of Health (2002), Computer Retrieval of Information on Scientific Projects (CRISP), available at: http://commons.cit.nih.gov/crisp3/ Crisp.Generate_Ticket/ Nobles, W.W. (1991), "African philosophy: foundations for black psychology", in Jones, R.L. (Ed.), Black Psychology, 3rd ed., Cobb and Henry, Berkeley, CA. Perez-Stable, E.J., Sabogal, F., Otero-Sabogal, R., Hiatt, R.A. and McPhee, S.J. (1992), ``Misconceptions about cancer among Latinos and Anglos'', JAMA, Vol. 268 No. 22, pp. 3219-23. Petty, R.T. and Cacioppo, J.T. (1981), Attitudes and Persuasion: Classic and Contemporary Approaches, Wm. C. Brown, Dubuque, IA. Prochaska, J.O., Redding, C.A. and Evers, K.E. (1997), ``The transtheoretical model and stages of change'', in Glanz, K., Lewis, F.M. and Rimer, B.K. (Eds), Health Behavior and Health Education: Theory, Research, and Practice, 2nd ed., Jossey-Bass, San Francisco, CA, pp. 60-84. Skinner, C.S., Campbell, M.K., Rimer, B.K., Curry, S. and Prochaska, J.O. (1999), ``How effective is tailored print communication?'', Annals of Behavioral Medicine, Vol. 21 No. 4, pp. 290-8. Strecher, V.J. and Rosenstock, I.M. (1997), ``The health belief model'', in Glanz, K., Lewis, F.M. and Rimer, B.K. (Eds), Health Behavior and Health Education: Theory, Research, and Practice, 2nd ed., Jossey-Bass, San Francisco, CA, pp. 41-59. Thompson, V.L.S. (1991), "African-American race consciousness and racial identification", The Western Journal of Black Studies, Vol. 15 No. 4, pp. 154-8. White, J.L. and Parham, T.A. (1990), The Psychology of Blacks: An African-American Perspective, Prentice-Hall, Englewood Cliffs, NJ.

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