To be theoretically sound, cultural adaptation strategies should link culturally influenced variables to specific aspects of treatment process and outcomes. Examples of such possible links from the client and provider per-
Table 6 Potential Links Between Culturally Influenced Client Variables and Treatment Process and Outcomesa
Influences from and interactions between primary reference culture(s) and mainstream culture
Relevant treatment process and outcome variables
Social pressure to lose weight Weight-related health concern Perceived appeal of program Reactions to treatment setting Interactions with provider Interactions with other participants Preferred language
Baseline knowledge, attitudes, and practices
Prior relevant experience
Perceived relevance of program content
Experience of program
Perceived benefits of weight loss
Motivation to seek treatment
Enrollment in treatment
Remaining in treatment (vs. dropping out)
Quality of participation in treatment program
Ability to establish trust and rapport
Active engagement in program (passive participation)
Adoption of weight management behaviors
Learning and skill acquisition while in program
Adherence to recommended short-term behavior changes
Achievement of short-term weight reduction (vs. no loss, or gain)
Long-term behavior change
Motivation for long-term behavior change
Feasibility of long-term behavior change
Maintenance of long-term behavior changes
Continued or maintained weight loss (vs. relapse and regain)
a Cultural influences on these pathways may be magnified or reduced by other relevant variables that influence feasibility or appropriateness of the program (see text).
Source: Ref. 44. Adapted with permission from Dalton, S. ed. Overweight and Weight Management. Chapter 3: Cultural appropriateness of weight management programs. Gaithersburg, MD: Aspen Publishers; 1997; 69-106.
spective are presented in Table 6. For example, body image and other attitudes may have an influence primarily through effects on the motivation to seek treatment initially or to continue with treatment. Outreach to increase enrollment in a program might then employ persuasive strategies to increase awareness of the possible health or functional status benefits of modest weight loss (e.g., on blood pressure, breathing difficulties, or knee problems) as separate from potentially less salient social or physical attractiveness issues. Cultural sensitivity in the way treatment is delivered would be helpful in ensuring that participants fully engage in the process (quality of participation). The distinction between factors affecting initial adoption versus long-term behavior changes is informed by Rothman's proposition that different theoretical models are needed to explain initial adoption and maintenance (116). For example, whereas initial adoption is related primarily to a desire to achieve a favorable outcome and expectations that these outcomes will be achieved, once adopted, behaviors may be maintained by satisfaction with the outcomes that result.
Thus, offering behavior change content in ways that are relevant to the patient's lifestyle issues and accessible from the perspective of language and learning style would be expected to facilitate short-term behavior changes. Contextual factors such as the world view, the general salience of health considerations in making lifestyle choices, and the structural constraints would be most relevant at the level of maintaining long-term change. Ultimately then, the rewards of having lost weight must be sufficiently reinforcing (positively) within the applicable context to motivate continued practice of the altered eating and activity patterns or, rather, according to Bouton, to drown out the inherently strong reinforcement for the prior, original, and culturally embedded behavior pattern. Clinical programs may be able to maintain changes by providing continued reinforcement through continued treatment. On the other hand, given the nature of obesity and its determinants, a better alternative might be to reframe obesity treatment within health promotion paradigms. Health promotion paradigms are broader than clinical paradigms, are more inclusive of contextual issues, and are ahead of clinical paradigms in articulating specific frameworks for addressing cultural variables (88,117). |
B Examples of Cultural Adaptations j?
Table 7 lists variables within each of several aspects of program design or implementation that might be foci for adaptations to improve cultural relevance or sensitivity. Examples from culturally adapted programs § reported in the literature are described in the Appendix. Each of the studies in the Appendix focused on a single ethnic minority population, e.g., African-Americans I
Table 7 Culturally Influenced Programmatic Variables as Possible Targets for Cultural Adaptation
Selection and interpretation of theoretical framework Emphasis on contextual factors Emphasis on cognition over emotion Conceptualization of obesity Provider behavior Type of provider
Role perception, expectations, and needs in the treatment setting
Perception of the ideal client Cultural competency (see Table 3) Cultural distance from clients Delivery system and setting
Research, clinical, or commercial setting Emphasis on functionality or familiarity Psychological and physical accessibility Resources available Focus of treatment Individual Family unit Community Treatment goals
Expected amount and rate of weight loss Inclusion of treatment goals other than weight loss Protocol or client-driven goal setting Program content
Assumptions and messages about body size and shape Attention to emotions and spirituality Language used Format and mode of contact Group, individual, or both Didactic or interactive process Program duration Sequencing of information ''School culture'' (see text) Face to face, telephone, mail
(118-127), Mexican-Americans (128,129), Caribbean Latinos (46), Pima Indians (130), or Native Hawaiians (131).
One strategy for increasing the cultural sensitivity of those providing treatment is to involve peer counselors (122,125,130) instead of or in addition to professional counselors. Some studies provide for explicit attention to family issues through home visits (118) or by framing treatment as for families rather than individuals (123, 128). Changing the setting in which treatment is offered is another common strategy. Churches may be used as the physical setting for program delivery (119,122,129) or as both a physical setting and psychosocial setting (126) through the direct incorporation of spiritual con tent. A strong ''process orientation'' is also evident in some programs, e.g., a deliberate attempt to be flexible and incorporate participant suggestions during the course of the program (118,127). The most commonly reported change in program format cited in programs described as culturally adapted is the use of active discovery learning and nondidactic methods (46,120122). Two studies were identified as culturally based in that core cultural traditions or values were used as the basis for the intervention. In one case, the cultural tradition was a very low-fat, high-carbohydrate diet based on traditional foods of ethnic groups in Hawaii (131). The other example, ''Pima Pride,'' involved discussion focused on attitudes about current lifestyle in the community and invited local speakers to address Pima Indian culture and history (130). This intervention was used as the control condition for comparison with a conventional structured lifestyle change program but had comparable if not better effects than the active intervention.
The reference in Table 7 to ''school culture'' is taken from the Wilcox et al. (98) WHI workshop summary. Participation in clinical trials was viewed as involving skills that are usually learned in school, including '' self-discipline, observing and reporting events, setting long-term goals, and reading and completing forms'' (98:285). The WHI authors noted that these demands may be stressful for study participants who lack these skills. This may also apply to clients who have a strong cultural preference for a different style of learning. The emphasis on active discovery learning and nondidactic approaches in programs that have been culturally adapted for ethnic minority populations may reflect the recognition of the need to minimize the ''school culture'' that is common in conventional programs.
The focus here is on the types of cultural adaptations that have been implemented from a conceptual perspective, i.e., not with respect to the weight losses achieved. As reviewed elsewhere (85), the culturally adapted programs reported in the literature have generally been of relatively low intensity and short duration. These approaches would not necessarily be expected to lead to large initial weight changes, but they were often not continued long enough to determine whether larger effects would have resulted with continued counseling.
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