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Nonetheless, households holding no risk assets still account for the majority. While the securities business industry and academics have identified a number of factors impeding household investment in risk assets, the aim of this report is to re-examine household behavior that prevents a move away from a concentration on cash and deposits. Understanding household behavior, such as households' reluctance to hold risk assets and insufficient planning for the future, holds important lessons for future changes in households' portfolio choices, for the debate on institutional reforms and the provision of products, and for the course of financial education.

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Financial System. In comparison, racial and ethnic minorities with low-income had fewer of these strategies applied. Among trials that addressed racial and ethnic minorities who had low-income, low health literacy, and lived in rural areas, evidential and linguistic strategies were used by 75 percent of the trials.

Behavioral health trials, which aim to change health related attitudes and behaviors among participants, are likely more amenable to the application of cultural tailoring than drug or device trials. This may be due to the influence culture has on health behaviors [ 23 ]. While the use of cultural tailoring strategies in trials varies by racial and ethnic minorities, populations with low-income, populations with low health literacy and numeracy, and rural populations, there is substantial use of multiple strategies across these groups.

Further, intersectionality is present among patient populations in more than half of the trials, and highlights the variability in the use of tailoring strategies even among populations that have overlapping identities. While not all trials were designed to address overlapping patient identities, many used cultural tailoring strategies to address the intersections within their enrolled populations.

The following sections discuss cultural tailoring use among the largest priority populations in the analysis, considerations of intersectionality, and the relationship between cultural tailoring and patient engagement. Further discussion includes the implications of research into practice, recommendations for future areas of research, and points for consideration and limitations.

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A variety of cultural tailoring strategies were used among trials to meet the needs of racial and ethnic minorities. The heterogeneity of racial and ethnic groups supports the differences in strategies used. Compared to other racial and ethnic groups in this analysis, all trials targeting Asians, Pacific Islanders, American Indians, and Alaska Natives applied all five cultural tailoring methods. This outcome may be attributed to several factors. Asian Americans, Pacific Islanders, American Indians, and Alaska Natives are extremely diverse in language, English proficiency, socioeconomic status, health status, cultural identity, and knowledge and beliefs regarding causes of disease and modes of treatment [ 24 ].

To address the complexities in these populations and ensure the development of interventions, strategies, and materials that meet their needs, the use of all tailoring strategies were applied in trials. Given that 32 Asian languages are spoken within the United States and over 20 languages are spoken among American Indians and Alaska Natives, trials recognized the need to address linguistic barriers [ 25 , 26 , 27 ]. Additionally, many Asian cultures historically practice Eastern medicine and American Indians and Alaska Natives might also rely on traditional healing practices [ 28 ].

Trials may have implemented sociocultural tailoring strategies to incorporate these cultural medical beliefs and practices into interventions. Constituent-involving cultural tailoring strategies have also been shown to be of importance for Asians, Pacific Islanders, American Indians, and Alaska Natives, as interventions that are not designed in partnership with the community are less likely to be successful for these communities [ 29 ].

The trial aims to recruit Marshallese, 18 years of age or older, with type 2 diabetes and their family members. This trial compares eight sessions of the standard diabetes self-management education DSME intervention delivered by a healthcare professional to eight Family Model DSME sessions delivered in Marshallese. To ensure that the intervention is culturally appropriate and designed to help Marshallese individuals with type 2 diabetes maintain healthy blood glucose levels, a community-based participatory research CBPR approach was used to modify an existing DSME intervention [ 30 ].

The trial is designed to include Marshallese beliefs, attitudes, religion, family structures, and eating habits [ 31 ]. For instance, community representatives suggested honoring spiritual beliefs by integrating the idea that God provides strength to make healthy choices [ 31 ]. In these trials linguistic tailoring goes beyond the translation of intervention materials by incorporating bilingual staff to bridge language barriers between patients, research staff, and providers to facilitate improved care.

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Sociocultural tailoring is also a common tailoring strategy among trials targeting Hispanics and Latinos. Sixty-nine percent of trials in this analysis rely on sociocultural tailoring to integrate the cultural values, norms, religious beliefs, and behaviors of this target group [ 17 ]. It was anticipated that more trials would implement sociocultural tailoring strategies within this population; however, researchers may consider linguistic tailoring strategies sufficient to address the needs of this population.

Trials that implement both linguistic and sociocultural strategies likely understand the important distinction between translation of language and the incorporation of cultural beliefs and values. Research on the effectiveness of cultural tailoring supports the use of these two strategies in combination, as it results in significantly stronger effects, compared to other forms of tailoring [ 32 ].

This psychosocial intervention is a trial for Spanish-speaking Latino patients, 55 years of age or older, with depression and multiple medical conditions [ 33 ]. The control arm of the intervention applies enhanced usual care, which consists of referrals to specialty mental health services and distribution of educational materials on depression and depression treatment to patients.

Patients are matched with a bilingual health professional to accommodate their linguistic and cultural needs. This concordance is maintained throughout counseling sessions and follow-up timepoints to more effectively respond to depressive symptoms. As part of the intervention, patients generate action plans that identify solutions to potential life challenges and participate in activities that alleviate stress.

Both the action plans and activities often integrate sociocultural components, such as religion. The use of these cultural considerations effectively adapts the intervention for the intended population. African Americans represent a diverse population with variation in dialect, literacy, socioeconomic status, and geographical location. The use of sociocultural strategies within clinical trial research ensures the perspectives of a population are respected and adequately addressed within the study design. The limited use of sociocultural tailoring strategies among African Americans may be due to the belief that constituent-involving strategies are sufficient to address sociocultural needs.

Although both sociocultural tailoring and constituent-involving strategies rely on the engagement of individuals from the target population, sociocultural tailoring is a more immersed form of tailoring which integrates the values and beliefs of a population into the intervention. As African American communities are not homogeneous and include complex and varying cultures, use of sociocultural tailoring may be critical for improving interventions delivered to this group.

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Anecdotal information from discussions with research teams suggest that sociocultural tailoring strategies may have been implemented in several trials a posteriori when faced with challenges related to recruitment or retention; however, interviews with research teams and other collaborators were not included in the documentation for this analysis. Linguistic tailoring strategies seek to make interventions and their accompanying materials and messages more accessible by providing them in the dominant or native language of the target group [ 17 ]. Linguistic tailoring includes translating materials into a specific language, as well as calibrating content to the health literacy levels of the intended population.

Given that low health literacy negatively impacts health indicators such as hospitalization rates, emergency care use, medication adherence, and the ability to interpret labels and health messages, trials targeting African Americans should tailor interventions to address low literacy rates [ 34 , 35 , 36 ].

The limited use of linguistic tailoring strategies among trials that target African Americas may be attributed to trials primarily addressing other barriers, such as access to care. Since low health literacy is prevalent among African Americans, linguistic tailoring strategies should be considered to address disparities in health and healthcare in this population [ 34 ]. Low-income or socioeconomic status is a prominent indicator of health and often associated with health risk behaviors [ 37 ]. To address the challenges experienced by individuals with low-income, researchers implemented a combination of cultural tailoring strategies, with constituent involvement being the most frequently used strategy 96 percent.

Gathering knowledge and shared experiences from a group via constituent involvement can be an effective way to build trust among patient populations and better understand behaviors of a group. Evidential strategies were the least applied cultural tailoring method 39 percent in trials targeting populations with low-income.

Evidential strategies include sharing epidemiological data with patients, such as their risk for acquiring certain communicable or chronic diseases. The limited use of evidential strategies among populations with low-income may be due to the association between education and income and the perceived challenges of communicating complex health information to patients [ 38 ]. For individuals with low-income, evidential strategies present an opportunity to create effective interventions that provide targeted health information to patients with high risk for experiencing health and health care disparities.

A patient-centered approach to cultural tailoring considers the intersectionality that may exist within populations at risk for disparities. As an emphasis has recently been placed on treating multiple chronic conditions holistically, rather than on a disease specific level, the same is necessary when treating a patient with intersections of identities. Despite high occurrence of intersectionality among populations, few trends emerged in cultural tailoring strategies for specific intersections of identities.

One trend observed was the use of sociocultural tailoring in 50 percent of trials targeting racial and ethnic minorities who live in rural settings, demonstrate low health literacy and have low-income. When compared to other groups with intersections of identities, this particular group has the lowest rate of sociocultural tailoring. This may be indicative of challenges researchers face when applying sociocultural strategies to meet the needs of complex populations. In , PCORI was authorized by Congress to improve the quality and relevance of evidence available to help patients, caregivers, employers, insurers, and policy makers make better-informed health decisions.

PCORI works to engage patients and stakeholders in every phase of research, with a goal of better understanding treatment effects, which may differ across patient populations [ 18 ]. Within the Addressing Disparities portfolio, constituent-involving strategies, where members of the community are included and engaged in intervention activities, are the most utilized across trials.

These trials include patients of the target population as advisory board members or intervention staff. The high rate of constituent-involving strategies is likely due to the requirement PCORI places on investigators to include patient and stakeholder engagement throughout the research process. In fact, one systematic review has shown that studies with significant findings commonly report constituent-involving strategies, or patient engagement strategies, within their intervention [ 40 ].

This trial engages patients and stakeholders; however, they do not represent patients from the intended target population. In recent years, incorporating cultural beliefs and values into practice has been integrated into national policy. With increasing focus on health policies that advance equity, there is recognition of the influence that intersectionality has on health outcomes [ 40 ]; however, few methods have been created to translate the theory of intersectionality into practical strategies to be implemented by decision makers, researchers, and policymakers [ 42 ].

Further, to date, there are limited policies that take intersectionality into consideration. Findings from PCORI-funded research on cultural tailoring strategies may contribute to the body of evidence that informs policy and practice on how different strategies of cultural tailoring influence health outcomes across conditions, settings, populations with existing intersectionality, and other variables.

Within these populations, more research is needed to understand the most effective type of cultural tailoring strategies to ensure that interventions meet the needs of these patients. With the influence that sociocultural tailoring strategies have on study effectiveness and improvements in health outcomes, future trials should consider prioritizing the implementation of this strategy. Future research should address the impact that sociocultural strategies have on research and outcomes, as well as the influence that the combination of constituent-involving and sociocultural strategies can have in culturally tailored trials.

Within the field of cultural tailoring there exists two approaches to constructing culturally appropriate health messaging and materials: cultural tailoring and cultural targeting. Though these terms are often used interchangeably, the main distinction between the two approaches is the scale at which they are implemented. Cultural tailoring strategies are often applied on an individual level while cultural targeting techniques are commonly carried out at a population level [ 11 ].

The majority of the trials in this analysis engage in cultural targeting, however, there are a small number of studies that engage in cultural tailoring. We applied the term tailoring for this analysis because of the widespread familiarity of the phrase in the field of health services research. Furthermore, while this analysis uses the Common Strategies for Enhancing Cultural Appropriateness model, other models for cultural tailoring exist [ 17 , 45 , 46 ]. If this portfolio of trials were analyzed against an alternate cultural tailoring model, the results of this analysis could vary.

As the current analysis was limited to thirty-three trials, a larger sample of trials could provide additional information and context for the most effective cultural tailoring strategies for specific populations. While the PCORI Addressing Disparities portfolio fills a known gap in the application of cultural tailoring methods beyond racial and ethnic groups, this analysis is limited in how intersectionality is assessed. This analysis was confined to analyzing intersectionality within the six Addressing Disparity priority populations; however, there are many other social and cultural identities that also impact health and healthcare outcomes.

Additionally, racial and ethnic minorities are often defined too broadly. Racial and ethnic minorities as a broad category and even specific racial or ethnic groups may have existing heterogeneity in language, culture, health, and life circumstances [ 11 ]. There are instances where cultural traits are not equally valued within groups that appear to be homogeneous and where common beliefs and values are shared between two distinct groups [ 11 ]. This can be a challenge when identifying and addressing the intersections within a population in research trials and in healthcare practice.

Lastly, most of the trials are ongoing and are not expected to have final research results available for the next three years. Once these trials are complete and their results are published, this analysis can be expanded to address the influence of cultural tailoring on patient-centered, patient-reported, and clinical health outcomes. The PCORI Addressing Disparities portfolio demonstrates how a range of cultural tailoring strategies are used within CER trials to address the needs and intersectionality of patients to reduce health and healthcare disparities.

While several cultural tailoring strategies are used in trials, more work is needed to ensure that all research focusing on populations at risk for disparities incorporates as many strategies as appropriate in their trials. Adopting an approach that uses the five strategies in the Common Strategies for Enhancing Cultural Appropriateness model aligns with principles of patient-centeredness and patient engagement and can result in improved patient response to care, compliance, and connectivity with the health system.

Conceptualization, M. This article is not written on behalf of the Patient-Centered Outcomes Research Institute and does not reflect its views, policies, or positions. National Center for Biotechnology Information , U. Published online Aug Author information Article notes Copyright and License information Disclaimer. Received Jul 13; Accepted Aug Associated Data Supplementary Materials ijerphs Abstract In , Patient-Centered Outcomes Research Institute PCORI was authorized by Congress to improve the quality and relevance of evidence available to help patients, caregivers, employers, insurers, and policy makers make better-informed health decisions.

Keywords: Patient-Centered Outcomes Research Institute, cultural tailoring, disparities, intersectionality, comparative clinical effectiveness research. Introduction Despite substantial improvements in several national health indicators, disparities in health and healthcare outcomes remain pervasive in the United States [ 1 ]. Table 1 Common strategies for enhancing cultural appropriateness [ 17 ]. Open in a separate window. Materials and Methods Clinical trials were selected from the PCORI Addressing Disparities research portfolio to examine the association between cultural tailoring and populations at risk for health and healthcare disparities.

Results 3. Health Conditions Represented across Culturally Tailored Trials Thirty-three trials met the inclusion criteria for this analysis. Table 2 Health conditions represented in the analysis. Application of Cultural Tailoring Strategies All trials in this analysis used two or more cultural tailoring strategies, while the majority of trials used three or more strategies.

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Figure 1. Cultural Tailoring Strategies across Populations at Risk for Disparities When classified by the six Addressing Disparities research priority populations, 88 percent of trials addressed racial and ethnic minorities, 85 percent of trials addressed low-income populations, 55 percent addressed low health literacy and numeracy, and 24 percent addressed rural populations Figure 2.

Figure 2. Figure 3. Cultural Tailoring Use and Intersectionality While few trials included only one priority population, over half of the trials enrolled populations with overlapping identities. Figure 4. Figure 5. Cultural Tailoring among Racial and Ethnic Minorities A variety of cultural tailoring strategies were used among trials to meet the needs of racial and ethnic minorities.

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Asians and Pacific Islanders, American Indians, and Alaska Natives Compared to other racial and ethnic groups in this analysis, all trials targeting Asians, Pacific Islanders, American Indians, and Alaska Natives applied all five cultural tailoring methods. African Americans African Americans represent a diverse population with variation in dialect, literacy, socioeconomic status, and geographical location.

Considerations of Intersectionality across Cultural Tailoring Approaches A patient-centered approach to cultural tailoring considers the intersectionality that may exist within populations at risk for disparities. Connection between Cultural Tailoring and Patient Engagement In , PCORI was authorized by Congress to improve the quality and relevance of evidence available to help patients, caregivers, employers, insurers, and policy makers make better-informed health decisions. Implications of Research into Practice In recent years, incorporating cultural beliefs and values into practice has been integrated into national policy.

Points for Consideration and Limitations Within the field of cultural tailoring there exists two approaches to constructing culturally appropriate health messaging and materials: cultural tailoring and cultural targeting. Conclusions The PCORI Addressing Disparities portfolio demonstrates how a range of cultural tailoring strategies are used within CER trials to address the needs and intersectionality of patients to reduce health and healthcare disparities.

Click here for additional data file. Author Contributions Conceptualization, M. Funding This research received no external funding.


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Conflicts of Interest The authors declare no conflict of interest. Disclaimer This article is not written on behalf of the Patient-Centered Outcomes Research Institute and does not reflect its views, policies, or positions. References 1. Hasnain-Wynia R. Role of the patient-centered outcomes research institute in addressing disparities and engaging patients in clinical research. Nelson A. Safran M. Mental health disparities.

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