Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research.

In this article, we examine progress and challenges in designing, implementing, and evaluating culturally sensitive behavioral interventions by tailoring health communication to groups or individuals. After defining common tailoring constructs (i.e., culture, race, and ethnicity), cultural sensitivity, and cultural tailoring, we examine when it is useful to culturally tailor and address cultural sensitivity in health communication by group tailoring or individual tailoring and when tailoring health communication may not be necessary or appropriate for achieving behavior change. After reviewing selected approaches to cultural tailoring, we critique the quality of research in this domain with a focus on the internal validity of empirical findings. Then we explore the ways in which cultural sensitivity, group targeting, and individual tailoring have incorporated culture in health promotion and health communication. We conclude by articulating yet unanswered questions and suggesting future directions to move the field forward. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

"We grew up in the church": A critical discourse analysis of Black and White rural residents' perceptions of mental health.

RATIONALE: Known as the "Black-White mental health paradox," Black Americans typically report better mental health than White Americans, despite chronic exposure to the psychologically harmful effects of racism and discrimination. Yet, researchers rarely examine how mental health is experienced across racial groups in economically distressed rural regions where all residents have disproportionately less access to mental healthcare resources. OBJECTIVE: The purpose of this study was to explore how the racialized social system potentially contributes to the mental health beliefs and attitudes of racially majoritized and minoritized rural residents. METHODS: We conducted a secondary analysis of 29 health-focused oral history interviews from Black American (n = 16) and White American (n = 13) adults in rural North Carolina. Through critical discourse analysis, we found nuanced discourses linked to three mental-health-related topics: mental illness, stressors, and coping. RESULTS: White rural residents' condemning discourses illustrated how their beliefs about mental illnesses were rooted in meritocratic notions of individual choice and personal responsibility. Conversely, Black rural residents offered compassionate discourses toward those who experience mental illness, and they described how macro-level mechanisms can affect individual well-being. Stressors also differed along racial lines, such that White residents were primarily concerned about perceived social changes, and Black residents referenced experiences of interpersonal and structural racism. Related to coping, Black and White rural residents characterized the mental health benefits of social support from involvement in their respective religious organizations. Only Black residents signified that a personal relationship with a higher power was an essential positive coping mechanism. CONCLUSIONS: Our findings suggest that belief (or disbelief) in meritocratic ideology and specific religious components could be important factors to probe with Black-White patterning in mental health outcomes. This research also suggests that sociocultural factors can disparately contribute to mental health beliefs and attitudes among diverse rural populations.

Perceived status threat and health among White Americans: A scoping review.

Previous research on pre-COVID-19 pandemic rising White mortality in the United States suggests that White Americans' perceived decline in relative group status may have influenced worsening mortality. In conjunction with other social and economic indicators, social status threat is one determinant of this population-level health shift, yet it is unclear how perceptions of status threat shape individual health outcomes. Because of this, we sought to identify and synthesize research studies across disciplines that broadly explored how perceived threats to White Americans' social status affect their health. Our research objectives were to (1) examine how status threat (and related constructs) have been measured across the health and social sciences, (2) determine which health outcomes and behaviors are related to status threat, and (3) identify gaps in the existing knowledge base. We systematically searched six multidisciplinary databases. Only 12 studies met inclusion criteria, suggesting that status threat and Whites' health is an understudied topic that warrants continued investigation. Furthermore, there was inconsistency in how threats to status were measured and conceptualized across disciplines. Threat-related indicators evaluated changes in Democratic or Republican vote share, perceived racial treatment, financial status, personal identification with political party affiliation, perceptions of hypothetical "majority-minority" population shifts, racial awareness, and subjective social status. Studies primarily relied on self-rated measures of overall health, mental health status, and social determinants of health. Consequently, there is a gap in the literature concerning which specific health outcomes (besides mortality) are directly affected by status threat. Overall, included studies demonstrated that Whites' can experience negative health effects when they perceive threats in societal conditions, within their interpersonal social experiences, or related to their individual social standing. Moving forward, researchers should consider how Whites' beliefs about their position within social hierarchies potentially affect individual and group-level health outcomes.

Loss of Obstetric Services in Rural Appalachia: A Qualitative Study of Community Perceptions.

Background: As rural hospitals across the United States increasingly downsize or close, the availability of inpatient obstetric services continues to decline in rural areas. In rural Appalachia, the termination of obstetric services threatens to exacerbate the existing risk of adverse birth outcomes for women and infants, yet less is known about how the cessation of these services affects the broader community. Purpose: The purpose of this paper is to explain how the loss of local obstetric services affects perceptions of healthcare among multi-generational residents of a remote, rural Appalachian community in western North Carolina. Methods: An interdisciplinary team of researchers conducted a thematic analysis of health-related oral history interviews (n=14) that were collected from local residents of a rural, western North Carolina community during the summer of 2019. Results: The closure of a local hospital's labor and delivery department fostered (1) frustration with the decline in hospital services, (2) perceived increases in barriers to accessing healthcare, and (3) increased medical mistrust. Implications: Findings suggest that the loss of obstetric services in this rural Appalachian community could have broad, negative health implications for all residents, regardless of their age, sex, or ability to bear children. Community-specific strategies are needed to foster trust in the remaining healthcare providers and to increase access to care for local residents. Results serve as formative research to support the development of interventions and policies that effectively respond to all community members' needs and concerns following the loss of obstetric services in remote Appalachian communities.

Missing Mayberry: How whiteness shapes perceptions of health among white Americans in a rural Southern community.

Elucidating how the racialized social system of whiteness affects the health of white Americans is critically important given current trends. Mirroring the nation, whites in rural North Carolina are currently experiencing increases in early mortality at greater levels than any other racial group in the state. Health focused oral history interviews conducted with whites (n = 13) in an economically distressed, rural community provide insight into potential determinants of this trend. Interview transcripts were coded and analyzed using a modified grounded theory approach. Analysis was guided by the whiteness and health framework, which considers how structural racism is both health promoting and health harmful for whites. Analysis highlighted three key themes: color-blind ideology, belief in the American Creed, and resistance to change. Whiteness influenced these rural whites' beliefs such that they were blind to the experiences of people of color in their community. Their explicit and figurative nostalgia for The Andy Griffith Show's idyllic town of Mayberry (a fictional Southern community devoid of Black American characters and racial tension during the 1960s) exposed color-blind expectations of what it means to have a healthy community. Additionally, interviewees attributed health status to individual effort and health behaviors, rather than considering how macro-level social determinants impact health. Individual level blame and resistance to change influenced interviewees' political views and suspicion of some social programs that could benefit the health of their community. These meritocratic beliefs about hard-work and self-sufficiency have implications for individual and community level health outcomes.