Module 4 Text

All about PHI: Insights to Informatics
This work is licensed under a Creative Commons Attribution
4.0 International License by Peace Ossom-Williamson, unless otherwise
stated.
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KINE 3351: Public Health Informatics
Module 4 Text
PEACE OSSOM-WILLIAMSON
Abstract
This text covers the definitions of targeting and tailoring. It also details the
aims and strategies of each activity, including how to communicate
messages so that they are personal to those intended audience members.
Likewise, the text provides examples of integrating these techniques as well
as information about their effectiveness.
Keywords: public health communication; tailoring; health education
Open access under CC BY license.
Introduction
Explosive growth of the Internet has caused an increase in Internet-delivered
interventions for promoting and encouraging a healthy lifestyle with regard to health
risk behaviors. Previous research indicated that factors to improve effectiveness
include high search engine ranking, an appropriate domain name (URL), and perceived
credibility. In terms of Internet-delivered interventions, there are three different aspects
with regard to exposure: (i) a first visit, (ii) staying on the intervention website long
enough to use and process the information and (iii) revisiting the intervention as
needed. Staying long enough is defined as the time in which an individual needs to
process the information provided at a specific intervention.
Tailoring means creating communications in which individualized information is used
to determine what specific content a person will receive, how it’s framed and presented,
and even through which channels it will be delivered. Overall, tailoring aims to enhance
the relevance of the information presented in order to produce greater desired changes
in response to the communications. Segmentation is the degree to which the audience
is divided into increasingly more defined, homogenous groups, and customization is
the degree to which the messages (a combination of content, source, graphics, interface,
etc.) an audience receives reflect relevant its members’ individual characteristics.

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This work is licensed under a Creative Commons Attribution 4.0
International License by Peace Ossom-Williamson.
For example, consider that a smoking cessation public service announcement (PSA)
makes some assumptions about its audience, intending to reach adult smokers in the
United States, rather than teens or adults in other countries, and constructs its message
accordingly. What is usually called targeted communication is merely more specific in
its segmentation and customization (perhaps to US males, 25–39 years of age). Using
information about particular individuals (typically described as tailoring) may
customize to a yet more specific segment but it’s not really a different strategy. No
matter how many individual attributes are assessed, or whether the measures are
demographics or individually-reported motives, messages are not in fact written for
each individual but targeted for members of that general segment—individuals with
similar knowledge, attitude, efficacy, barriers, behavioral pattern, etc.
Furthermore, greater degrees of segmentation and customization increase cost and
effort. In general, pushing toward the limits of segmentation and customization and
linking the two will be worth the effort when there is a high level of variability or
diversity within the target and a reasonable mechanism for gathering data from or about
the intended audience and then providing customized messages. Because this is often
not feasible and can be argued to be further targeting, we define the tailoring to be a
continuum of specificity toward individuals’ characteristics and needs. Targeting is
then defined as the method of reaching a group. Targeting is used to draw in an
audience, and tailoring is used to communicate with them in a way that is
meaningful to and understandable for them.
Goals
Knowledge is often the core determinant of health education campaigns. Knowledge
as a determinant is of additional importance as proximal determinants of health
behavior, such as attitude, subjective norm, risk perception and self-efficacy, often
begin with knowledge. Therefore, tailoring often aims to make it easier and more likely
that the individual will process the message. Second, tailoring focuses its efforts on the
immediate behavioral determinants or causes of the outcome goal.
Three basic tailoring strategies are typical for achieving these goals: (i) overt
demonstrations or claims of ‘personalization’, (ii) ‘feedback’ to recipients of what is
known about them and (iii) ‘content matching’ based on recipients’ personal data. The
resulting 2 × 3 goals-by-strategies matrix provides a wide range of specific tailoring
tactics by which strategies might affect goals and thus suggests a richer and more
precise understanding of the particular tailored health communication to be applied in
program development and evaluation.
Tailoring Strategies
Personalization, feedback, and content matching are three distinct strategies through
which the above tailoring goals can be achieved. Personalization strategies are
generally used to enhance processing of a message, though it may also affect behavior.
Feedback and content matching strategies primarily stimulate particular intermediate
impacts, but they may also affect processing. Although consideration of their pros and
cons should take place before implementation, they are almost always combined in

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practice. Selection of specific strategies and tactics should be purposeful, guided by
theory and/or empirical evidence and with consideration of the advantages and
disadvantages of each approach.
Personalization
Although tailoring overall is about various forms of individualization, personalization
attempts to increase attention or motivation to process messages by conveying,
explicitly or implicitly, that the communication is designed specifically for you. Tactics
for personalization neither need to be directly linked to the behavioral outcomes of
interest nor do the resulting tailored messages need to provide the recipient with new
information about herself. Rather, by saying or implying that the communication is ‘for
you,’ personalization strategies call attention to behavioral information or make it seem
more relevant and meaningful to the recipient. Three of the most common
personalization tactics are identification, raising expectation, and contextualization.
Identification
Identifying the recipient by name, integrating pictures of the recipient, or recognizing
the recipient’s birthday or other personal details within a message are all examples of
identification. This can be also utilized for homogenous groups, like using names and
images reflecting the people from a particular ethnic, gender, age, or religious group.
They are thought to make exposure more likely or increase attention paid to
information, though this is largely untested. Identification is often used in mail
communication and, although there has been evidence of effectiveness, there have also
been other studies that found no effect.
Raising expectation of customization
This involves overt claims of customization, such as “The following health information
has been created especially for you.” Webb and colleagues proposed that such
statements create positive expectations of information to follow. As with identification,
expectations can be raised without actually providing content matching, but doing so
raises an ethical issue.
In a study of what was termed placebo tailoring, smokers randomly received one of
three booklets of smoking-related content that varied only in degrees of claimed
customization, which directly influenced favorability of smokers’ responses to the
booklets. That is, those expectations of customization may have an effect regardless of
whether there was actual content that was specific to the individual. Placebo tailoring
has become prolific in online contexts, in various fields, and individuals may be
skeptical of claims of relevance that are unsubstantiated. Professionals must judge for
themselves whether this level of deceit is warranted in health communication contexts.
Contextualization
A third tailoring tactic for increasing attention, interest, and motivation to process
information is to frame your message in a context that is meaningful to the recipient.
The methods and results are the same as when journalists use framing tactics such as
finding a local angle to make a non-local story more relevant to viewers or readers.
Messages contextualized within a person's subjective reality may be perceived as
personally relevant and the tailoring agent as more familiar and credible.
An example of contextualization is how one researcher measured women's perceived
identity as a new mother and used this information to tailor messages promoting

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healthy pregnancy and parenting skills to rural women. Similarly, we include here
tailoring that matches message source to the receiver's demography or preferences.
Other contextualization variables used in tailoring have included family structure (e.g.
framing dietary messages differently for parents of children in different age categories),
residential status (e.g. framing messages on home injury prevention differently for
those in freestanding houses versus those in apartments), ethnicity/culture and personal
interests. In contrast to feedback and content matching strategies that attempt to directly
alter determinants of a target behavior, contextualization tactics seek instead to frame
this information in ways likely to increase motivation for message processing.
Despite the widespread use of contextualization tactics in tailored communication, only
a few studies have evaluated their unique contribution to tailoring effects. Kreuter and
colleagues compared cancer prevention magazines for African-American women that
were tailored on behavior, culture (a contextualization tactic) or a combination of both.
Women who received magazines tailored on both constructs were most likely to report
getting mammograms and to have increased fruit and vegetable consumption. Tailoring
on contextual variables alone may not be sufficient to bring about changes in behavior
but might enhance the effects of other tailoring strategies on impact variables.
These personalization tactics—identification, raising expectations and
contextualization—are summarized in Table 1. Although presented as distinct
approaches, they are often used in combination with one another, and multiple tactics
within a single category are often combined.
Table 1. Personalization tactics

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Feedback
Feedback involves presenting individuals with information about themselves, obtained
during assessment or elsewhere. Where personalization seeks to promote attention and
processing, feedback strategies target psychosocial determinants of health behaviors.
Similar to the three personalization tactics, descriptive, comparative, and evaluative
feedback are frequently combined in tailoring programs and even within individual
messages. Although Table 2 and the accompanying discussion suggest some
hypotheses about variation in consequences, research as yet provides little evidence
comparing the three approaches (see also [12] for an alternative categorization that
combines types of feedback with intermediate goals).
Table 2. Feedback strategies in tailored health communication programs
Descriptive feedback
Tailored health communication often reports back to individuals with summaries of
their attitudes, beliefs or behaviors—from their personal assessments or from
observational data. Descriptive feedback ranges from simply restating or
acknowledging information (e.g. ‘You said you smoke a pack of cigarettes per day.’)
to providing information based on more complex processing of their responses (e.g.
‘Based on your answers, we determined that you eat 24 grams of fat per day.’).
Descriptive feedback may influence determinants of health behavior by stimulating
self-referential thinking about or otherwise focusing attention on specific beliefs,
behaviors, or environmental constraints related to the outcome of interest. It may also
produce non-specific effects such as ‘feeling acknowledged’ or ‘feeling understood,’
which could build rapport and favorably influence interpretation of the tailoring agent's
motives or lower resistance to persuasion.
Comparative feedback
By comparing a person's attitudes, beliefs, or behaviors to those of others, tailored

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feedback is generally assumed to provide social comparison information that may
focus effortful processing on self-evaluation and normative comparison to stimulate
changes in perceived norms, attitudes, or beliefs. Tailored comparative feedback may
also validate or reinforce beliefs, with messages such as ‘You tried to quit before, but
you went back to smoking. On average, ex-smokers try to quit at least three times
before succeeding.’ Comparative feedback may be especially effective among
individuals for whom normative beliefs are important determinants of a given behavior.
Another comparative feedback tactic gathers data from the same individuals over time
and messages report on progress over time (i.e. self-comparison).
Evaluative feedback
Tailored evaluative feedback adds a level of interpretation, judgment, or inference
about an individual's attitudes, beliefs, or behaviors and is a common tactic in tailored
health communication programs (e.g., ‘You said you intend to start exercising
regularly. That could be a good way to lower your blood pressure.’). Evaluative
feedback is often used to introduce content matching in tailored health communication
programs. For example, evaluative feedback (e.g., ‘You need to eat more fruits and
vegetables.’) can be followed by content matched to the unique combination of
determinants that affect the receiver's motivation or ability to make the recommended
change (e.g. ‘Here's how to do it…’). Similarly, tailoring to enhance decision making
has combined feedback about predispositions to take action with information on the
pros and cons of particular action.
Although differences between the three feedback tactics are subtle in practice, it seems
possible that some might be more effective for certain individuals under certain
circumstances. Identifying these conditions would allow for more precise and efficient
message tailoring.
Content matching
Content matching, often thought of as the essence of tailoring, attempts to direct
messages to individuals’ status on key theoretical determinants (knowledge, outcome
expectations, normative beliefs, efficacy and/or skills) of the behavior of interest. For
any given individual, content matching seeks to act on those intermediate determinants
of intentions on which change is most needed or most likely to produce success.
Prior to the development of computerized tailoring technology, an encyclopedic
approach provided a large amount of content (often informational in nature) in a
brochure or a website, leaving recipients to self-navigate and find what was relevant to
them from this sea of content. Even if highly motivated individuals were willing to
search for pertinent content, the content itself was not written specifically for them, but
rather for a broader audience, thus requiring additional work to apply it. Content
matching strategies seek to minimize this search process by first assessing key
determinants of a given behavior for a specific individual and then using a set of
decision rules or algorithms to select matching content that directly addresses those
determinants.
Ideally, if someone has a strong intention to perform a given behavior and has the
necessary skills and abilities, and if there are no environmental constraints to prevent
behavioral performance, then the probability of the behavior is high. But when one or
more of these conditions are not present, program developers can respond to those gaps
by content matching tailoring. If the person has the intention but is not performing the
behavior, a tailored communication might focus on skill building or on teaching how
to avoid, remove, or overcome various barriers to behavioral performance—in other

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words, a tailored communication would be designed to help the individual act on his
or her intention. On the other hand, if the person has not yet formed a strong intention
to perform the behavior, the tailored intervention might focus on developing or
strengthening the intention through changing attitudes, perceived norms or self-
efficacy.
For example, in a program designed to help people quit smoking, the following may
be key influencers in the effort: confidence in one's ability to quit (i.e., self-efficacy),
expected outcomes of quitting, and beliefs about what relevant others think about one's
smoking (i.e., normative beliefs). These determinants can be measured for individuals
and content for each different individual can be matched to his or her responses. A
smoker who believed quitting would lead to unwanted weight gain would receive
different messages than a smoker who felt quitting would decrease one's ability to
concentrate but was unconcerned about weight gain. Deciding which, how many and
what combinations of determinants need to be measured and utilized in a tailored
communication requires a detailed understanding of factors that influence the
behavioral outcome of interest. There should be a clear rationale for how each attribute
will increase the effectiveness of the message.
Combining personalization, feedback and content matching strategies
As noted at the outset of this section, the three tailoring strategies are frequently used
in combination with each other and can even occur within a single message. Consider
the following tailored message to promote increased physical activity:
Based on the information you provided, you are not getting the amount of physical
activity recommended by the Surgeon General. You mentioned that you would like to
be a better role model for your two young children, but you are having trouble finding
the time for regular exercise. You also mentioned that you are concerned about getting
injured while exercising. Given your concerns about lack of time and potential injury,
here is a list of possible strategies that might help you overcome these issues….
This message combines personalization tactics of raising expectation (‘Based on the
information you provided’), contextualization (‘your two young children’), and
descriptive feedback (‘you are not getting the amount of physical activity
recommended’; ‘you would like to be a better role model’; ‘you are having trouble
finding time for regular exercise’; ‘you are concerned about getting injured’), and
content matching (‘we have provided a list of possible strategies that might help you’).
Targeting Strategies
Many cognitive psychological theories describe the way new information is processed.
Text comprehension is the degree to which the information in the text becomes part of
the reader's personal knowledgebase. Readers attempt to comprehend a text by seeking
links between the new information and their own prior knowledge. This is a process of
inference which takes place in working memory. Working memory has a limited
capacity; however, when readers understand the information, a successful connection
is made between the new information and prior knowledge. This link is then stored in
the personal knowledgebase in long-term memory. It is important to note that these
inference processes make relatively heavy demands on the cognitive resources of the
reader, and, hence, interfere with text comprehension. Many also describe techniques
for improving the processes by which new information is added to the reader’s existing

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knowledge. Principles such as text coherence, integration of text and pictures, and
highlighting of important features of the text all positively contribute to text
comprehension and might thus be useful in designing an informational website.
Text coherence
Text coherence is the logical and consistent structure of a text. A text can be coherent
on two levels, namely, the macro-level and micro-level. A text is coherent at the macro-
level when the topics in the text follow a logical order. Headings that are styled with
similar font and color, for example, can facilitate coherence at the macro-level because
the structure of the text is made clear and easy to follow. A text is coherent at the micro-
level if, within a paragraph, each sentence is explicitly related to the next. This can be
done by inserting connections between sentences, by starting a sentence with
previously mentioned information, and by mentioning the subject of the verbs
explicitly, rather than ambiguous pronouns which can make the subject less clear. For
example, ‘it is dangerous’ being replaced with ‘alcohol is dangerous.’ Additionally,
argument overlap improves by using words or terms from a previous sentence in the
subsequent sentence. This makes it easier for readers to relate new information to old
information. Inserting connections between sentences, such as words like ‘following’
and ‘consequently’, to explain the sentences’ relationships and presenting new
information along with information mentioned earlier can make the message sequence
more clear.
Illustrations
According to dual code theory, there are two cognitive subsystems that process
information, namely, a verbal and a visual system. The dual code theory claims that
readers are best able to build connections between these two systems when the
corresponding text and picture are in the working memory at the same time. Material
that is easy to understand is information that can be easily held in working memory. A
principle derived from this theory is that information is better recognized or recalled
when presented in both an auditory and a visual manner. Combining text with
illustrations increases recollection and comprehension of the information. The extent
to which an illustration is comprehended depends also on the properties of the
illustration. An important property of an illustration is a clear reference to the
illustration in the text.
See the example in Figure 1 to see the effect of the insertion of an illustration into an
information source that discusses the effects of a hangover on the brain, with a clear
reference to the picture in the text.
Fig 1. Implementation of the Use of Targeting Strategies - Illustrations
Original
A muzzy feeling; listlessness; pounding headache; tendency to vomit; dry tongue and the enormous thirst
after a night out are familiar symptoms of a hangover. A hangover is caused by different factors.
Dehydration due to alcohol is the main factor. Alcohol dispels fluid. Alcohol promotes the production of
Antidiuretic Hormone. As a result, the kidneys are required to work harder, and this causes the body to
lose more fluid than normal. Also, between your brain and skull is a thin layer of fluid. When alcohol is
consumed, this fluid is withdrawn, resulting in a pounding headache, which you feel the following day.
This is your brain bumping against the skull.

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Modified
Alcohol can cause dehydration. Dehydration leads to various symptoms.
A hangover is caused by different factors, and dehydration from
drinking alcohol is the main factor.
How dehydration occurs:
As illustrated on the left, alcohol both dispels fluid and promotes the
production of Antidiuretic Hormone (ADH), a hormone that
conserves the fluid volume of your body by reducing the amount of
water passed into your urine. As a result, the kidneys have to work
harder, causing the body to lose more fluid than normal.
Symptoms:
Hangover symptoms can include
• muzzy feeling
• listlessness
• tendency to vomit
• dry tongue
• ravaging thirst
• pounding headache
Why a headache? A thin layer of fluid is present between your brain
and skull. After the consumption of alcohol and the resulting
reduction of fluid in your body, your brain has less protection against
your skull, leading to a pounding headache the following day.
Pop-out effects
In order to be prioritized and remembered, a key item should receive sufficient
attention. Research has shown that when the mind conducts a visual search, such as the
scanning of text, items that do not match the specific features of the surrounding
environment, such as color, shape or form, pop out and draw attention. This implies
that important headings or pieces of text should be different from the rest of the text.
These parts of the text should pop out with a different size and/or color in order to be
more likely to get attention and thus be remembered.
Following modifications to increase text coherence and the integration of text and
illustrations, important sections of text were highlighted in accordance with the feature
integration theory [24]. For example, in the original version of the brochure, a link to
a Web site was incorporated in the text and presented in the same font as the rest of the
text. In the revised version, the link was presented in a larger and bolder font. By doing
this, more attention was drawn to the Web site link, thereby increasing the likelihood
that the link would be remembered by readers. This example is illustrated in Figure 2.
Fig 2. Implementation of the Use of Targeting Strategies – Pop-out Effects
Increased
ADH
Kidneys
work harder
Increased
urination
Loss of fluid

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Original
The alcohol quiz is part of the student campaign. We invite every first-year student to do the quiz. The
questions can be found on the participant form on the Contact page. Select your answers and submit
your form. This page provides instructions to help you answer the questions. For more information and
for an opportunity to participate in future campaigns, visit www.exampleurl.org. The campaign and quiz
end on December 1, 2020. If you have answered all the questions correctly, you are eligible for a national
first prize of $1,000. The recipient of this prize will be determined by a national raffle. The other
participants who have answered correctly will receive t-shirts. The prize winners will be notified by
January 1, 2021.
Modified
The alcohol quiz is part of the student campaign. We invite every first-year student to do the quiz. The
questions can be found on the participant form on the Contact page. Select your answers and submit
your form. This page provides instructions to help you answer the questions. For more information and
for an opportunity to participate in future campaigns, visit
www.exampleurl.org
The campaign and quiz end on December 1, 2020. If you have answered all the questions correctly, you
are eligible for a national first prize of $1,000. The recipient of this prize will be determined by a national
raffle. The other participants who have answered correctly will receive t-shirts. The prize winners will be
notified by January 1, 2021.
Ultimately, credibility of the source of information is highly correlated with
achievement of desired behavior outcomes. Those involved in communicating vital
health information should ascertain that theyare credible sources of information among
the public. All content to be communicated should be thoroughly verified in order to
avoid misinformation.
Intended Outcomes
Attention
Obviously, a message not attended to can have little or no effect, so it should be no
surprise that a common aim of tailoring is simply to increase attention (either the
likelihood of processing the message at all or how far through the communication the
receiver persists), thus presumably increasing comprehension, itself necessary to
effects. This is generally achieved by communicating to the receiver that messages
address their attributes, preferences and needs, and indeed, early studies showed that
tailored messages were more likely than non-tailored messages to be read and
remembered.
Effortful processing
A related idea is that tailoring, perhaps again by enhancing perceived relevance and
thus personal involvement, elicits what the elaboration likelihood model (ELM) refers
to as ‘central route’ processing or elaboration: careful consideration of persuasive
arguments and more systematic utilization of the receiver's own schemas and

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memories. In a randomized study, tailored messages stimulated greater processing of
weight control information than did two different types of non-tailored messages.
Central processing typically also leads to deeper and more persistent persuasion than
does peripheral processing. On the other hand, the ELM also points out that persuasion
in the central route poses its own challenges. Effortful processing is more likely to
include counterarguing, evaluations of credibility, and other processes that may lessen
message effects. To minimize such adverse reactions, one must develop strong
arguments that can stand up to the scrutiny of central processing. Tailoring can also
assess and address individual differences in likely cognitive effort, such as measures
of need for cognition.
Peripheral/emotional processing
We theorize that tailoring could instead sometimes operate by enhancing peripheral (or
‘heuristic’) processing. Rather than increasing the likelihood that one will engage in
central processing, tailoring could borrow from typical mass communication practices
aiming to reduce motivation or ability to elaborate and thus increase the likelihood that
heuristic processing will occur or that other peripheral cues (variables affecting
persuasion without affecting argument scrutiny) will be used to influence acceptance
or rejection of a given message. For example, tailoring could increase the perception
‘the sender understands me,’ which could enhance source credibility and lead to the
reader following recommendations with little critical analysis. As another possibility,
tailoring could be used to create an emotional response such as fear, hope, or anxiety.
Since positive emotions tend to reduce effortful processing and negative emotions
enhance it, emotion arousal could elicit varying cognitive processing.
Self-reference
A further extension of effortful processing is that tailoring may encourage self-
referential thinking by the receiver. To the extent that tailoring encourages receivers to
focus on themselves, they may identify discrepancies between, for example, their
actual and ideal behaviors. Such self-referential thinking may also increase the
likelihood of central processing. In a study of weight loss materials, those receiving
tailored messages generated significantly more ‘personal connections’ to the
materials—defined as any thought or idea linking the weight loss information to the
recipient's personal situation or experience—than did those receiving non-tailored
materials.
Issues in Tailoring Research
While the general effects of tailoring were discussed, tailoring has variable effects on
different groups and individuals. For example, there is some evidence that individuals
who have an external locus of control are less likely to respond positively to tailored
behavior change messages. When there is empirical evidence that such background
factors serve as important determinants of beliefs, these factors themselves may be
contextual or conditional variables with potential for tailoring. Beyond this, more
research should address the extent to which and under what circumstances different
tailoring tactics elicit each of our proposed mechanisms (attention, etc.) and with what
consequences can and should be empirically examined. This may require creating or
adapting measures to capture these mediating processing constructs as well as creative
laboratory designs to allow experimental isolation/manipulation of each process. For
example, personalization might lead to more positive thoughts but only when

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arguments are strong. In the case of weak arguments, personalization might lead to
more counterargumentation and less desired effects.

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