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Commentary: Cultural Appropriateness: Working Our Way Toward a Practicable Framework

The article by Kreuter et al. in this issue should be required reading for all who are engaged in the design of health promotion programs. It will be of particular interest to those designing programs cross culturally. What these authors say and do not say is very informative as to the complexity of cultural appropriateness and the difficulty of “getting it right.” As they point out, the importance of cultural factors as influences on health promotion has been established, but there is much room for growth in understanding how such factors can be effectively incorporated. Implicit in their discussion is the special relevance to racial and ethnic minority populations. In fact, although culture influences the health behavior of all populations, the mention of cultural factors in the U.S. context usually takes the mainstream culture as the reference point and defines “cultural issues” as language, attitudes, or behaviors that are different from what is perceived as mainstream. Kreuter et al. frame their discussion from a pragmatic user perspective, that is, one written by and for health professionals who are not students of the root disciplines in which cultural concepts are of primary interest and foci of deep analysis. For example, in commenting on the difficulty of determining what constitutes a cultural group, they include a disclaimer that “a full and definitive response to this question is well beyond the scope of this paper as well as the knowledge of its authors.” Their goal is to offer practical guidance about how to “integrate culture into intervention approaches for health behavior change.” The assumption, and a clear theme of their text, is that one can identify important cultural variables and work with them, programmatically, short of delving into the potentially overwhelming intricacies and complexities from which they arise. One then expects, from the outset, some superficiality in these authors’ consideration of cultural variables in exchange for usable application tools relevant to practice. Their effort to provide a new classification scheme for cultural adaptation strategies can be viewed in this light. They provide groupings that are primarily descriptive of the approaches, focus heavily on labeling, and have only limited commentary on the soundness or relative merits of the approaches from the perspective of cultural understanding. They offer no interpretation with respect to existing health behavior change theories.