**3. Culture and health**

It is a proven fact that health programs and interventions are more effective when they are "culturally appropriate" for the populations they serve. To effectively and efficiently provide medical care to patients, the impact that culture has on health care must be understood and taken into consideration. In practice, however, the strategies used to achieve cultural appropriateness vary widely [4].

To provide programs and materials that are culturally appropriate, healthcare providers must be able to


Each medical encounter provides the opportunity for the interface of several different cultures: the culture of the patient, the culture of the healthcare provider (e.g., the physician), and the culture of medicine as a discipline. The success of this interaction influences adherence to medical regimens, patient satisfaction, healthcare utilization, and ultimately health outcomes [5].

**Evidential strategies** enable a group to identify with a health problem by demonstrating how it affects that group. Most of the time, this is achieved using as proof, information obtained

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This is put into action, for example, when advocacy for provision of emergency obstetric care facilities within public health centers is made using the following message: "For every 100,000 Nigerian women who get pregnant, 814 will die between pregnancy and 6 weeks after delivery [12]. That is 10% of the global maternal mortality burden. Not only did the country not achieve Goal-5 of the Millennium Development Goals that sought to reduce maternal mortality ratio by 75% by 2015, but it also essentially witnessed a substantial increase in maternal deaths [13]. These women can be saved if the facilities and people who can save them are

**Linguistic strategies** take the common language of the target group into consideration when messages are being composed and disseminated. It is because of the key role language plays in engaging communities that authorities such as Rogler have referred to it as "the lowest

**Constituent-involving strategies** refer to those which are based on the personal experiences of individuals selected from within the group. Adhering to this approach will involve ensuring a high level of participation by community members in the intended program. This enables it to leverage on their "stories" and endues the program with a lot of familiarity from

**Sociocultural strategies** discuss health-related issues in the context of broader social and/ or cultural values and characteristics of the intended target group. It is imperative that this kind of program should be based on a deep understanding of the culture of the people. One should appreciate not just what their cultural practices are but why they behave the way they do. This knowledge makes proper prioritization of activities possible. If, for example, economic wealth is highly regarded in a particular community, it becomes important to study wealth creation opportunities which exist and use them as vehicles of engagement with the target population. Alternatively, the same planners might seek to develop a new program that builds on the population's religious values in a way that is meaningful to that group [4].

Cultural targeting is a term that has been given multiple definitions by various authorities. It has been defined as "the use of a **single intervention approach** for a defined population subgroup that takes into account **characteristics shared by the subgroup's members** [17]." Others have defined it as part of a larger process of audience segmentation in which **appropriate channels for reaching a given group** are identified [18], while another school of thought defines it as "a **single intervention approach** for a defined population subgroup that takes

from within the population.

present in the health centers."

its audience's perspective. [15, 16].

**4.1. Cultural targeting**

common denominator of cultural sensitivity" [14].

**4. Cultural targeting and cultural tailoring**

The World Health Organization (WHO) global strategy on people-centered and integrated health services is a call for a fundamental paradigm shift in the way health services are funded, managed, and delivered [6]. Behind this new approach is a vision of a time when the needs, personal preferences, and safety of target populations are taken into consideration in health program planning. It is also based on the conviction that this is possible while still maintaining the timeliness, quality, effectiveness, and comprehensive content of these services.

It is sad to note that in many instances, culture is not properly evaluated. There seems to be instead a lot of assumptions made about what the culture of a group of interest is. A typical example is the mistake of assuming that all Asians have a single uniform culture or that all members of the Zulu tribe have identical belief systems. Instead that racial entity comprises several cultural subgroups and any one individual may belong to one, none, or several.

If indeed one could categorize all members of a given population into groups that had practically all aspects of their culture in common, one would have gained the advantage of carving out groups with very high levels of homogeneity. However, the process would produce so many groups, some with scanty numbers, that it would no longer be feasible to address the population any more. Which of the myriad of groups should then become the focus?

At the opposite extreme, culture would be assumed and overgeneralized based on more easily identifiable variables such as race [4]. Neither of these approaches is ideal.

Although it is true that certain cultural characteristics may cluster within a given racial or ethnic group, it is at least equally true that substantial differences exist between individuals and subgroups within these populations [7–10]. Somewhere between these two extremes, we might settle for a slightly deeper, albeit imperfect, understanding of culture that is practical enough to be easily applied yet still potent enough to enhance healthcare delivery efforts.

Many authors have previously described strategies to make health promotion programs and materials more culturally appropriate for target populations and these have been divided into five main categories: peripheral, evidential, linguistic, constituent-involving, and sociocultural [4]. It should be emphasized that these categories are for organizational clarity only and are not necessarily mutually exclusive. Besides, it is presently common, and advisable, for practitioners to use strategies from multiple categories when a health program is to be planned and implemented. These approaches are explained below.

**Peripheral strategies** ensure that health programs are culturally appropriate by presenting them based on what the perceived interests of the target group are. This is achieved by matching materials to "surface" characteristics of a target population—as is done using peripheral approaches—the group's receptivity to and acceptance of information and services can be enhanced [11]. For example, materials used for health education can carry national colors or be made from traditionally familiar materials such as "Kente" in Ghana or "Ankara" in Nigeria.

**Evidential strategies** enable a group to identify with a health problem by demonstrating how it affects that group. Most of the time, this is achieved using as proof, information obtained from within the population.

This is put into action, for example, when advocacy for provision of emergency obstetric care facilities within public health centers is made using the following message: "For every 100,000 Nigerian women who get pregnant, 814 will die between pregnancy and 6 weeks after delivery [12]. That is 10% of the global maternal mortality burden. Not only did the country not achieve Goal-5 of the Millennium Development Goals that sought to reduce maternal mortality ratio by 75% by 2015, but it also essentially witnessed a substantial increase in maternal deaths [13]. These women can be saved if the facilities and people who can save them are present in the health centers."

**Linguistic strategies** take the common language of the target group into consideration when messages are being composed and disseminated. It is because of the key role language plays in engaging communities that authorities such as Rogler have referred to it as "the lowest common denominator of cultural sensitivity" [14].

**Constituent-involving strategies** refer to those which are based on the personal experiences of individuals selected from within the group. Adhering to this approach will involve ensuring a high level of participation by community members in the intended program. This enables it to leverage on their "stories" and endues the program with a lot of familiarity from its audience's perspective. [15, 16].

**Sociocultural strategies** discuss health-related issues in the context of broader social and/ or cultural values and characteristics of the intended target group. It is imperative that this kind of program should be based on a deep understanding of the culture of the people. One should appreciate not just what their cultural practices are but why they behave the way they do. This knowledge makes proper prioritization of activities possible. If, for example, economic wealth is highly regarded in a particular community, it becomes important to study wealth creation opportunities which exist and use them as vehicles of engagement with the target population. Alternatively, the same planners might seek to develop a new program that builds on the population's religious values in a way that is meaningful to that group [4].
