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Screen for Life: Using targeted health messages to increase participation in a state colorectal cancer screening program.

Authors: Katherine Eddens, Matthew Kreuter, Robin Snider
Corresponding Author: Katherine Eddens, Saint Louis University School of Public Health, keddens@gmail.com

Abstract

Introduction: Sixty percent of deaths from colorectal cancer could be prevented by regular screening in those ages 50 and older; only 50-60% of Missourians in this age group report annual screening.

Objective: To increase participation in the Missouri Screen For Life program.

Background: Screen for Life, a CDC-funded demonstration project, provides free colorectal cancer screening and treatment to age-and income-eligible Missourians in the St. Louis metropolitan area. The Health Communication Research Laboratory collaborated with the Missouri Department of Health and Senior Services to create and evaluate new targeted recruitment materials for the program.

Description of initiative: Existing recruitment materials were simplified in content, improved in appearance, and adapted for each of four different race-ethnicity groups. By random assignment, potential participants received either the new targeted recruitment materials or the enhanced non-targeted materials. After three months, targeted letters elicited a 14% response and generic letters elicited a 10% response (p<.06). Applied statewide, a 4% increase translates to an additional 64,384 responses from Missourians ages 50 or older.

Discussion: Simple, low-cost targeted communication may increase participation in colorectal cancer screening programs

Background

Colorectal cancer (CRC) is the second leading cause of cancer mortality in the United States, and the third most common site of new cases of cancer in men and women.1 Screening by fecal occult blood test (FOBT) or colonoscopy can help detect colorectal cancer early when treatment can be most effective, and can find precancerous polyps that can be removed before developing into cancer.2 Both tests are recommended beginning at age 50, with FOBT performed annually and colonoscopy every five years.3 If all men and women ages 50 and older were regularly screened, up to 60% of deaths from colorectal cancer could be prevented.4 In Missouri, incidence and mortality rates for CRC are higher than U.S. averages, and highest among African Americans.5,6 About 1,200 Missourians die from CRC each year, and only 50-60% of adults ages 50 and older in Missouri report annual CRC screening.5

The Centers for Disease Control and Prevention's (CDC's) ongoing Screen for Life campaign was launched in 1999 to inform men and women ages 50 and older about the importance of having regular colorectal cancer screening tests. In 2005, as part of the campaign, CDC funded, through a competitive process, five demonstration programs to increase CRC screening among low-income, underinsured and uninsured adults. The Missouri Department of Health and Senior Services (MDHSS) was awarded one of the five demonstration programs to serve a five-county area in metropolitan St. Louis, MO.7 In short, the Missouri Screen for Life program provides CRC screening free of charge for eligible adults, as well as diagnostic follow-up and treatment, where necessary.

This case study describes a collaborative effort between MDHSS and the Health Communication Research Laboratory at the Saint Louis University School of Public Health to increase participation in the Missouri Screen for Life program. Specifically, we applied principles of audience segmentation and customized communication to create different recruitment materials for racial and ethnic population sub-groups in the St. Louis area. In a randomized field trial, we compared these targeted materials to existing (non-targeted) materials used by the program to determine which elicited a greater response from potential program participants. By identifying communication strategies that increase participation in CRC screening programs, we can help reduce the burden of colorectal cancer.

Program overview

Potential participants in Missouri Screen for Life are referred to the program by health centers, hospitals, cancer coalitions and other community health organizations serving the St. Louis metropolitan area. Interested individuals are asked to contact a program coordinator who mails them a packet of forms to complete and return. Based on information provided on the forms, the program coordinator determines an individual's eligibility (based on age, income, health insurance status, county of residence, personal and family history of CRC or polyps, and personal CRC screening history) and notifies them accordingly. For those who meet eligibility criteria, most are mailed an FOBT kit to use and return, although some are scheduled for a colonoscopy, based on need. Program partners read the FOBTs and provide colonoscopies, and when necessary provide diagnostic follow-up, treatment, and management of complications. The program is free to eligible participants.

The problem

Missouri Screen for Life staff had received complaints from CRC screening providers and a local cancer coalition that potential participants found the program's eligibility forms to be overly complicated, difficult to read and generally a burden to complete. According to these partners, the forms were a major obstacle to program participation among members of the target audience. In addition, the program director openly recognized that creating health communication materials, such as those used in recruitment efforts, was a not a strength of his program team.Furthermore, because Screen for Life was available only in St. Louis and the program director was housed 134 miles away in Jefferson City, MO, program staff felt that current Screen for Life recruitment materials could be improved with input from others who worked locally and had more experience reaching low income, minority populations in St. Louis. Adding to the challenge were budget limitations and time constraints. In short, MDHSS had no funding available to revise the eligibility forms and recruitment materials, and any changes made had to be completed and integrated into the program within 31 days to meet a required program deadline.

The collaboration

The Screen for Life program director described the program and his concerns to the HCRL team, and asked for advice on how to improve the program materials. The HCRL team, based in St. Louis, had extensive experience in communication development, particularly with local lower-income minority populations. Furthermore, as a member of the national Cancer Prevention and Control Research Network (CPCRN), the HCRL shares the CPCRN mission of increasing the application of evidence-based cancer control in public health practice.

In a series of telephone and in-person meetings, MDHSS and HCRL collectively mapped out the Screen for Life program process and identified three distinct steps where written communication was central to program success: (1) recruitment and referral to the program, (2) design and usability of program forms, and (3) instructions for home use of an FOBT kit. At the request of MDHSS, the HCRL team critically reviewed existing materials used by the program in each of these steps, and determined that all could be improved by applying principles from established best practices in health communication.

The Screen for Life team had three major criteria for evaluating the HCRL recommendations: they wanted to make only those changes that could be sustained, any changes made had to be consistent with CDC requirements for the program, and changes had to be capable of being executed immediately to meet the tight program timeline. The Screen for Life team asked the HCRL to lead the process of revising materials, but had extensive input, ultimate veto power, and provided final approval of all changes.

Improving program materials

Due to the extremely short timeline for completing revisions, it was not possible to conduct new formative research with members of the target population to guide communication development efforts. Rather than ignore audience research altogether, the HCRL drew upon findings from its extensive and recent formative and evaluative cancer communication research with low income minority populations in St. Louis.8-15 In short, this work was highly community-involving and identified important cultural themes, communication approaches and visual design preferences that have led to better received and more effective print and electronic cancer communication. Based on this and other experience, the HCRL and Screen for Life teams made major revisions to the program's eligibility and history forms and to promotional materials that were to be used in an upcoming recruitment effort.

Eligibility forms

Figure 1. Sample Text from the Original
Eligibility (A) and History (B) Forms

Figure 1

It is widely recognized in health literacy studies that overly complicated or burdensome health and medical forms keep many individuals from seeking or receiving health care services.16 In Missouri Screen for Life, the original eligibility and history forms were separate and both were complicated, crowded, difficult to read and used a very small font size (< 10 point typeface). As can be seen in sample text from the original eligibility and history forms (Figure 1) and full size versions of each (Appendix A 1, Appendix A 2, Appendix A 3), neither form adhered to key concepts and principles of health literacy that make written communication materials easy to read, comprehend and retain. These principles include using at least 12 point sized font and a serif typeface to make materials easier to read, using large print or bolding but not capitals, underlining, quotation marks or italics to emphasize an idea or word, using headings and other organizational cues such as bullets and lists, using short lines of text and ample white space, and using color for visual appeal or for navigation.17-21

To improve the forms, we: (1) incorporated both forms on a single 11"x17" folded sheet, (2) increased the font size to 12 point typeface, (3) used colors to distinguish different sections of the form, (4) simplified skip patterns and instructions with colors and arrows, and (5) color-coded yes (green) and no (red) responses for consistency throughout the form. These changes were designed to make the forms easier to understand, simpler to use and more aesthetically pleasing and inviting to potential program participants. Under normal circumstances, the extent to which these goals were achieved would be evaluated in audience research, however that was not possible in this case due to the Screen for Life's time constraints. Also, the number and wording of questions on the forms was standardized by CDC and could not be altered. Sample text from the improved form can be found in Figure 2, and the full form is included in Appendix B.

Figure 2. Sample Text from the Revised
Eligibility (A) and History (B) Form

Figure 1

Recruitment materials

As part of recruitment efforts for Missouri Screen for Life, program leaders identified past participants in the Show Me Healthy Women program as a promising target audience for colorectal cancer screening. Show Me Healthy Women is Missouri's Breast and Cervical Cancer Control Program (BCCCP), and many of its participants would meet the age, income and health insurance criteria for eligibility in Missouri Screen for Life. In addition, the participant database from Show Me Healthy Women was available for contact by Missouri Screen for Life because the same office in the State Department of Health and Senior Services operated both programs. Prior to the collaboration described in this case study, Screen for Life team members had developed a recruitment letter to send to these women. In addition to appealing to the women themselves, the letter suggested women tell their friends or spouse about the program in hopes of reaching a larger and more gender balanced population. Over 1,400 women in the Show Me Healthy Women database met the residency and age requirements for Missouri Screen for Life.

Team members from HCRL and Screen for Life determined that the goal in revising this original recruitment letter was to make it more appealing and accessible to women who might have a lower literacy level. By adapting its content, we reduced the letter's Flesch-Kincaid reading level21 from 12th to 8th grade. We enhanced the visual appeal of letter by maximizing white space and including a colored border and large heading at the top, which invited women to participate in the program. This revised letter (hereafter "enhanced standard letter") was approved by Screen for Life staff for mailing to Show Me Healthy Women participants. The original and enhanced standard letters can be found in Appendix C 1 and Appendix C 2.

Because Show Me Healthy Women participants are racially and ethnically diverse, we further adapted the content and format of the enhanced standard letter for White, African American, Hispanic and multi-ethnic women (hereafter, "targeted letters"). It was possible to deliver race/ethnicity targeted letters because the Show Me Healthy Women database included this information about each participant.

Figure 3. Race/Ethnicity-Appropriate Photographs
Used in the Targeted Letters

Figure 1
These three race/ethnicity groups accounted for virtually all women in the database, and the HCRL had experience developing health communication interventions for both African American and Hispanic populations.22Targeted letters contained the same core content as the enhanced standard letter, but the format was changed to draw readers' attention to the most important details and messages, and each letter included a race/ethnicity-matched color photograph of a couple over 50 years old. An example letter targeted to African Americans is included in Appendix D. In the multi-ethnic letter, the photograph showed an African American and White couple. Using images of a given group's members to enhance the perceived relevance of a health communication has been termed a "peripheral" approach to achieving cultural appropriateness,23 and is believed to enhance a group's receptivity to and acceptance of health messages.24 Photographs used are from stock photography and are shown in Figure 3.

Sample text from both the enhanced standard letter and the targeted letters is shown in Figure 4. The text in both letters contains the same information, but is formatted in the targeted letter to increase readability. Interestingly, the formatting in the latter increased the number of words and sentences read by the Flesch-Kincaid reading level test, and therefore reduced the reading level from 8th to 6th grade. We wanted the enhanced standard letter to remain as true as possible to the original written material, but both HCRL and Screen for Life team members agreed that doing so would be unethical, so the revisions made reduced the reading level from 12th to 8th grade. While comparing letters of different reading levels may confound the effect of targeting on race-ethnicity in this case study, the comparison of targeted materials to standard practice is actually highly conservative due to the many enhancements made to the Screen for Life's original standard letter.

Evaluating the new program materials

To determine the relative effectiveness of the enhanced standard letters and targeted letters in stimulating interest in the Missouri Screen for Life program, we designed and carried out a simple randomized trial. A Missouri Screen for Life employee randomly allocated women in the Show Me Healthy Women database to either an experimental (n=542) or control group (n=670). Those in the control group received the enhanced standard letter along with a generic color postcard insert containing a multi-ethnic photograph (Figure 5) and presenting additional information about CRC and the Screen for Life program. Those in the experimental group received a targeted letter - matched to their race/ethnicity - and an identical color insert, except that the photograph was also matched to the woman's race-ethnicity. Missouri Screen for Life provided an African American specific postcard upon which the other postcards were modeled. See Figure 6 for an example of the Latino specific postcard. All targeted postcards are included in Appendix E 1, Appendix E 2, and Appendix E 3. All letters were produced by the HCRL and mailed to potential participants by Missouri Screen for Life in July 2006.


Figure 4. Sample Text from the Enhanced Standard Letter (A)
and the Targeted Letter (B)

Figure 1

In order to track response rates while maintaining participants' confidentiality, control letters were given a pink border and experimental letters were given a blue border. When letter recipients called Screen for Life to request an eligibility form, a program staff member asked them the color of the letter they received and recorded their response and the date on a standardized tracking sheet. Using this information, it was possible to calcuate the proportion of all targeted and enhanced standard letters that resulted in a call to the program. A simple chi-square test was used to determine whether the difference in proportions between the two groups was statistically significant. Analyses included calls received through October 2006. Missouri Screen for Life staff could only verify that letters were sent to African American and White participants, therefore only data from these groups, which make up 97% of the eligible women in the database, was examined.

Findings

The response rate was higher among those who received targeted letters than those who received enhanced standard letters (14% vs. 10%; c2 = 3.69, d.f. = 1, p =.055). The 491 targeted letters mailed to women in the experimental group led to 70 calls to the Missouri Screen for Life program office to request eligibility forms. In contrast, the 621 enhanced standard letters mailed to women in the control group led to 65 calls to the program office. While these findings didn't meet the p < .05 threshold for statistical significance, the effect is in the expected direction and should be viewed in the proper context - as derived from a small, rapidly developed and opportunistic pilot study.

Discussion

The 2002 Institute of Medicine report, Speaking of Health, concluded that there is little evidence as to whether "diversity strategies" increase the effectiveness of health communication.25 Findings from this evaluation add to a growing literature suggesting that indeed they do. Moreover, the findings indicate that diversity strategies need not be overly complicated to achieve some effect. For example, in contrast to much more intensive culturally-tailored communication found to increase use of mammography and intake of fruits and vegetables in African American women,26 this project used minimal customization with images only.

Although a 4% absolute difference between the response rate to targeted and enhanced standard letters seems modest, its impact in a statewide screening program would be substantial. Applied to Missouri's population, that additional 4% would translate into 64,384 more inquiries to the Screen for Life program from Missourians ages 50 or older. Based on Missouri's colorectal cancer incidence and death rates, this could lead to the discovery of 37 new cases of CRC, including 5 cases in African Americans, and could potentially prevent 14 deaths, including 3 among African Americans. The level of customization in the targeted letters was minimal and the cost of improving and producing all program materials (not just the letters) was only $4,620. Once developed, the targeted letters cost no more to produce than the enhanced standard letters, and only nominally more to distribute (due to staff time required for matching letters to recipients' race/ethnicity). Given the potential benefit of increased participation and detection of new cases of colorectal cancer, this excess cost seems quite low.

Ideally, an evaluation of the targeted letters would include not just the initial phone call response, but also the completion and return of eligibility forms and (for those who are eligible) the use of an FOBT kit or colonoscopy. Although Missouri Screen for Life is tracking these outcomes, the data are not available for analysis in this project. It is also possible that the difference in reading level (8th vs. 6th grade) or formatting between the two letters, rather than the targeting, accounts for the differences found. While this detail is critical from a communication science perspective, its practical significance is somewhat diminished by the very low cost and simple nature of the three combined changes. In other words, the relative savings of choosing only to lower the reading level or change the format or add a targeted image vs. doing all three would be minimal.

It is increasingly important for health communication scientists and practitioners to determine what types of diversity strategies are capable of stimulating which outcomes. Relative to standard materials, simply adding a photograph matched to a person's race/ethnicity is probably insufficient to bring about changes in complex health behaviors, but as this evaluation shows, it may be enough to stimulate greater information seeking behavior like making a phone call. In this way, the findings support Slater and colleagues' (2006) assertion that even very simple, low cost audience segmentation strategies can improve communication effectiveness.27

Lessons learned

It is imperative to recognize that this is a pilot study. It would be important to replicate these findings in a larger study that may overcome some of the limitations of a small sample size, such as the non-significant chi square statistic. Addressing and revising critical limitations such as the differences in reading level in the two letters and ensuring a proper randomization would be helpful. Even after inquiry to seek clarification, we were not able to ascertain the method of randomization for recipients, nor were we able to understand why only African American and White participants were tracked correctly. The resources available to this program to promote screening are probably inadequate to do the best job possible. What this pilot showed is that through minimal investment and simple manipulation, response rates can be improved. If a future study, after addressing these issues, found this process to be effective, we could then put the program in place on a larger level, such as for statewide recruitment.

One of the main weaknesses of this study was the inability to do any formative research or audience testing of our materials. While this is the backbone upon which developing health communications is based, we felt that to work within our one-month time frame, we were comfortable using prior research conducted with low-income, minority women communities in St. Louis. Both the HCRL and MDHSS agreed that this was the best approach available to us. The second major weakness was the inability to evaluate letters sent to Hispanic participants. Unfortunately, this was beyond the capacity of the HCRL to change, as the mailing and tracking of race-ethnicity occurred in the MDHSS program office. Perhaps better communication between all of the collaborators and within the staff of the program would have led to more rigorous execution and evaluation of the program.

Another weakness exists within the differences between the non-targeted and targeted letters. The difference in reading grade level may have contributed to the differences in response independent of the targeting. In a future program, we would ensure that the reading levels of both materials are equal. Additionally, the differences between the responses from the targeted and non-targeted groups were not statistically significant. We feel that with a larger sample size we would have seen a greater difference, and hope to continue to evaluate this program. However, as letters were sent in early July of 2006, calls past October 2006 that originated from program participants have decreased substantially. St. Louis ConnectCare still tracks calls received from program participants, and provides the HCRL with that information. We don't believe there have been subsequent mailings, but the project director of Screen for Life during this collaboration with is no longer with MDHSS, making efforts at continuing the pilot program difficult. For this same reason it was not possible to ascertain the randomization method used to distribute targeted and non-targeted materials. In a future program, we would again do our best to ensure that these processes were executed more rigorously.

This initial collaboration between HCRL and Screen for Life provided valuable insight into the resources, capabilities and priorities of each organization. For example, while the HCRL was enthusiastic about comparing the original and improved eligibility forms in an experimental design, Screen for Life staff argued effectively that it was more important that their program provide clear and simple materials (i.e., the improved forms) to all than it was to formally compare them to what they viewed as obviously inferior products. Screen for Life staff learned that in a short amount of time and with minimal resources, public health communication experts can improve the quality and appearance of information materials, simplify their language to increase accessibility to low-literacy audiences, and customize them for different sub-groups in a larger population.

From a research perspective, HCRL scientists were reminded of the tremendous and largely untapped resources that lie within a state department of health. Having access to a database of thousands of BCCCP participants provides a unique and valuable opportunity to evaluate effects of health communication among socio-economically disadvantaged populations. In turn, Screen for Life staff realized that a rigorous evaluation of program efforts may require greater precision with data management and detailed implementation protocols when program materials are not the same for all participants. Future collaborations will build on these lessons.

Acknowledgement

This project was supported by funding and resources from the National Cancer Institute and U.S. Centers for Disease Control and Prevention through the Cancer Prevention and Control Research Network (3 US48 DP000060-01S1) and Centers of Excellence in Cancer Communication Research (1 P50 CA 095815). The authors thank Heather Jacobsen, Chris Casey, Theresa Samways, and Debbie Pfeiffer for their assistance in preparing targeted recruitment materials.

References

  1. Centers for Disease Control and Prevention. Cancer - Colorectal Cancer Death Rates. July 2006. Department of Health and Human Services, Atlanta, GA. http://www.cdc.gov/cancer/colorectal/statistics/death_rates.htm.
  2. Centers for Disease Control and Prevention. Colorectal Cancer: Let's Break the Silence. May 1999. CDC publication #099-6010. Department of Health and Human Services, Atlanta, GA.
  3. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: Recommendations and Rationale. July 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm.
  4. Centers for Disease Control and Prevention. Cancer - Colorectal Cancer Screening Rates. July 2006. Department of Health and Human Services, Atlanta, GA. http://www.cdc.gov/cancer/colorectal/statistics/screening_rates.htm.
  5. Centers for Disease Control and Prevention. State Cancer Burden Data for Missouri. July 2006. Department of Health and Human Services, Atlanta, GA. http://www.cdc.gov/cancer/CancerBurden/mo.htm.
  6. Surveillance Epidemiology and End-Results. Table IV-20: Age-Adjusted Rates & 95% Confidence Intervals For Colon and Rectum Cancer, All Ages SEER 17 Registries for 2000-2003 Age-Adjusted to the 2000 US Std Population. 2006. Surveillance Research Program, National Cancer Institute, Bethesda, MD. http://seer.cancer.gov/csr/1975_2003/results_merged/sect_06_colon_rectum.pdf.
  7. Centers for Disease Control and Prevention. Cancer - Colorectal Cancer Program Fact Sheet: Colorectal Cancer Prevention and Control Initiatives. November 2006. Department of Health and Human Services, Atlanta, GA. http://www.cdc.gov/cancer/colorectal/what_cdc_is_doing/about_cdc_program.htm.
  8. Wiehagen T, Caito N, Sanders Thompson VL, Casey C, Jupka K, Weaver N, Kreuter MW. Applying projective techniques to formative research in health communication development. Health Promotion Practice.  2007: April:8(2):164-172. 
  9. Kreuter MW, Black WJ, Friend L, Booker AC, Klump MP, Bobra S, Holt CL. Use of computer kiosks for breast cancer education in five community settings. Health Education and Behavior. 2006: Oct:33(5):625-42. 
  10. Kreuter MW, Haughton LT. Integrating culture into health information for African American women. American Behavioral Scientist. 2006:49(6): 794-811. 
  11. Kreuter MW, Skinner CS, Holt CL, Clark EM, Haire-Joshu D, Fu Q, Booker A, Steger-May K, Bucholtz DC. Cultural tailoring for mammography and fruit and vegetable intake among low-income African American women in urban public health centers. Preventive Medicine 2005:41(1): 53-62. 
  12. Kreuter MW, Steger-May K, Bobra S, Booker A, Holt CL, Lukwago SN, Skinner CS. Socio-cultural characteristics and responses to cancer education materials among African American women. Cancer Control 2003;10(5): 69-80.
  13. Boslaugh SE, Kreuter MW, Nicholson RA, Naleid K. Comparing demographic, health status, and psychosocial strategies of audience segmentation to promote physical activity. Health Education Research. 2005 Aug;20(4):430-438.
  14. Kreuter MW, Skinner CS, Steger-May K, Holt CL, Bucholtz DC, Clark EM, Haire-Joshu D. Response to behaviorally vs. culturally tailored cancer communication among African American women. Am J of Health Behavior 2004;28(3): 195-207.
  15. Lukwago SN, Kreuter MW, Holt CL, Steger-May K, Bucholtz D, Skinner CS. Sociocultural correlates of breast cancer knowledge and screening in urban African American women. Am J Public Health 2003;93(8):1271-1274.
  16. Institute of Medicine (2004). Health literacy: A prescription to end confusion. National Academies Press: Washington, DC.
  17. National Cancer Institute (2001). Making Health Communication Programs Work (NIH Publication No. 04-5145). Rockville, MD: U.S. Department of Health and Human Services.
  18. Lane, Penny, Mercedes Blanco, Leslie Ford and Holly Smith Mirenda. The Health Literacy Style Manual. Columbia SC: Covering Kids & Families National Program Office, Southern Institute on Children and Families, October 2005.
  19. Plain Language Action and Information Network. Available at www.plainlanguage.gov.
  20. D. Gasser M, Boeke J, Hafferman M & Tan R. Influence of font type on information recall. North American Journal of Psychology. 2005;7(2):181-188.
  21. Kincaid, J. P.; Fishburne, R. P., Jr.; Rogers, R. L.; and Chissom, B. S. (1975); Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Formula) for Navy enlisted personnel, Research Branch Report 8-75, Millington, TN: Naval Technical Training, U. S. Naval Air Station, Memphis, TN.
  22. Pfeiffer, D. Mujer Latina: A breast cancer education kiosk for Hispanic women in Kansas City and St. Louis, poster presentation, Cambio de Colores (Change of Colors) Latinos in Missouri: Everyone Together, Todos Juntos, (April 2, 2007) Kansas City, MO.
  23. Kreuter MW, Lukwago SN, Bucholtz DC, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ & Behavior 2003;30(2):133-146.
  24. Resnicow, K., T. Baranowski, et al. (1999). "Cultural sensitivity in public health: Defined and demystified." Ethnicity & Disease 9(1): 10-21.
  25. Institute of Medicine. Speaking of health: Assessing health communication strategies for diverse populations. Washington, DC: National Academy Press; 2002.
  26. Kreuter MW, Skinner CS, Holt CL, Clark EM, Haire-Joshu D, Fu Q, Booker A, Steger-May K, Bucholtz DC. Cultural tailoring for mammography and fruit and vegetable intake among low-income African American women in urban public health centers. Preventive Medicine 2005:41(1): 53-62.
  27. Slater MD, Kelly KJ, and Thackeray R. Segmentation on a Shoestring: Health Audience Segmentation in Limited-Budget and Local Social Marketing Interventions. Health Promotion Practice. 2006;7:170-173.

Appendix

Appendix_A_1.pdf

Appendix_A_2.pdf

Appendix_A_3.pdf

Appendix_B.pdf

Appendix_C_1.pdf

Appendix_C_2.pdf

Appendix_D.pdf

Appendix_E_1.pdf

Appendix_E_2.pdf

Appendix_E_3.pdf

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