Journal of Communication ISSN 0021-9916

ORIGINAL ARTICLE

Advancing Tailored Health Communication:

A Persuasion and Message Effects
Perspective
Barbara K. Rimer1 & Matthew W. Kreuter2
1 The School of Public Health at UNC, The University of North Carolina at Chapel Hill NC 27599
2 Health Communication Research Laboratory, School of Public Health, Saint Louis University,
St. Louis, MO 63104

Tailored health communication (THC) is any combination of information and behavior

change strategies intended to reach one specific person based on information unique to
that person, related to the outcome of interest, and derived from an individual assessment.
THCs have been studied as a means to facilitate behavior change by influencing some key
intermediate steps that precede the behavioral outcome. These include the extent to which
people attend to communications, think about them, find them relevant and salient, and
intend to take action. Evidence shows that THCs have achieved modest success in
changing a number of cancer-related behaviors, including smoking, diet, exercise, and
cancer screening. However, it is likely that THCs could be more effective if they were
developed with a greater understanding of message effects and what we refer to as the
behavioral pathway. Instead of using unidimensional approaches to influence behavior
change, a message effects approach would help researchers identify key leverage points for
impact on such intermediate outcomes as persuasion and yielding. Such a strategy also
might be used to determine when THCs are the preferred approach and when generic,
targeted, or combinations of THCs and targeted communications might be appropriate.
Viewing THCs from the perspective of the behavioral pathway might indicate use of
different messages, sources, and formats to influence different people at different points on
the pathway. We provide a brief history of THCs and suggest how integrating a broader
perspective of health behavior and health communication theories could enrich THCs.

doi:10.1111/j.1460-2466.2006.00289.x

What is tailored health communication?

Tailoring is a process for creating individualized communications. It is an assess-
ment-based approach in which data from or about a specific individual and related
to a given health outcome are used to determine the most appropriate information
or strategies to meet that person’s unique needs (Kreuter, Farrell, Olevitch, &

Corresponding author: Matthew W. Kreuter; e-mail: kreuter@slu.edu.

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B. K. Rimer & M. W. Kreuter Tailored Health Communications

Brennan, 1999; Kreuter & Skinner, 2000; Kreuter, Strecher, & Glassman, 1999; Rimer
& Glassman, 1998). To date, researchers have usually inferred these needs based on
an individual’s responses to assessment items measuring behavioral determinants.
Ideally, the concept of ‘‘needs’’ might be expanded to also include specific message
tactics or other elements of communication likely to enhance effectiveness for a given
person. Tailored health communications (THCs) may be produced in any media
and in nearly limitless formats, for example, letters, booklets, and calendars.
Because tailored print materials have been the format studied most extensively to
date, many of the examples here will draw upon this literature. THCs usually
are personalized, but merely being personalized is not sufficient to consider them
THCs.

A brief history of tailored health communication

Through the early to mid-1980s, most printed health information was mass
produced in brochures, pamphlets, and booklets for undifferentiated audiences.
The high cost of printing made it necessary to print many copies of materials to
be cost effective. Thus, developers sought to produce materials and programs that
would meet the needs of many potential users. As behavioral scientists grew
increasingly aware of the heterogeneity within mass audiences and learned more
about methods used in communication and other fields to create persuasive mes-
sages (Prochaska, Redding, & Evers, 2002; Rimer & Glassman, 1998; Slater &
Flora, 1991), they began to develop different versions of materials for distinct
population subgroups. Although principles of audience segmentation had been
well known to communication scholars and widely used in advertising and mar-
keting, including social marketing (Maibach, Rothschild, & Novelli, 2002; Pepper,
2000), their application to creating targeted health education materials was
innovative.
In early examples of this work, audience segmentation based on demographic
and behavioral variables was used to design smoking cessation self-help guides for
blue-collar and minority smokers (Strecher, Rimer, & Monaco, 1989), African
Americans (Robinson, Orleans, James, & Sutton, 1992), older smokers (Rimer
et al., 1994), pregnant women (S. W. Davis, Cummings, Rimer, Sciandra, & Stone,
1992), and women with young children (Keintz, Fleisher, & Rimer, 1994). Such
segmentation generally was based on principles of social marketing and on the
assumption that important differences between groups could be addressed by cre-
ating different versions of health communications. Decisions about what informa-
tion was provided to which groups usually was based on audience research guided
by theories used most frequently in that period (e.g., stages of change [SOC;
Prochaska, 2004; Prochaska et al., 2002] and the Health Belief Model [Janz, Cham-
pion, & Strecher, 2002]). Early stage-based behavior change materials like Freedom
From Smoking For You and Your Family (Strecher et al., 1989) foreshadowed
tailoring by permitting users to select from a self-help smoking cessation guide

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those chapters that applied to their particular stage of readiness to quit. Clear
Horizons, developed by Rimer et al. (1994), used a similar approach and was
significantly more effective than generic smoking cessation materials for smokers
aged 50 and older.
The emergence of tailored health communication was part of a growing market-
ing approach to customize information. Like many scientific advances, the rise of
THC was made possible by the convergence of several innovations that coincided in
time (Rogers, 2003). One was the trend toward customization of health and other
information. Another was the growing use of the Transtheoretical Model that
described ‘‘stages of change’’ in an individual’s readiness to adopt or modify health
behaviors (Prochaska, 2004; Prochaska, DiClemente, Velicer, & Rossi, 1993; Pro-
chaska et al., 2002). Its SOC variable identified discrete population subgroups (those
in precontemplation, contemplation, preparation, action, and maintenance) that
could be targets for change using targeted approaches (focusing on the group),
tailored (individual) approaches, or combinations of these (Rakowski et al., 2003).
Its processes of change specified different ways in which change could be facilitated
for individuals or groups.
Ultimately, different message topics could be introduced and addressed based
on knowing a person’s SOC for a given behavior, along with other relevant
information. Although there are other stage models, none have achieved the level
of dissemination of SOC. The model’s utility for intervention planning and delivery
facilitated its adoption among practitioners and researchers developing prevention
programs and messages (Samuelson, 1997). In most early studies of THC, stage of
readiness was a central tailoring variable (Brug, Campbell, & van Assema, 1999;
Campbell et al., 1994; Prochaska, et al., 1993; Rakowski et al., 2003; Rimer et al.,
2001; Skinner, Strecher, & Hospers, 1994; Strecher, 1999).
Population-wide customization of health information to different individuals
was dependent upon processing large volumes of data quickly. Major improvements
in computing provided health communication researchers the tools to create cus-
tomized interventions. Also, producers had to be able to create and print attractive
documents at affordable cost. As color printers became cheaper, the tools for cus-
tomization became even more accessible.
Computers first were used this way to create health risk appraisals (HRAs),
which calculated an individual’s mortality risk based on his or her risk factor
profile and algorithms derived from national data that weighted the relative
importance of each risk factor to leading causes of mortality (Wagner, Beery,
Schoenbach, & Graham, 1982). In most cases, however, the behavior change rec-
ommendations provided to HRA users had no explicit basis in theories of health
behavior change (Becker & Janz, 1987). There is little evidence to support the
efficacy of HRAs in promoting behavior change (Kreuter & Strecher, 1996).
In summary, THCs arose from the confluence of these innovations as a com-
puter-based, theory-driven approach to customize health information to different
individuals.

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Selecting appropriate tailoring constructs and variables

Program objectives, relevant literature, a theoretical foundation, and audience
research should determine appropriate tailoring variables, just as they should be
the basis for any evidence-based health communication. Although tailored interven-
tions now have been developed for a wide range of health problems, including injury
prevention and immunization, most early tailoring studies addressed outcomes
related to health promotion, prevention, and early detection of cancer (Kreuter
et al., 1999). The topics included cancer prevention behaviors (e.g., diet, smoking,
and exercise), cancer screening (e.g., getting a mammogram or colorectal cancer
screening [CRCS]), and other cancer-related topics such as informed decision mak-
ing about use of prostate and breast and CRCS (e.g., Pignone, Harris, & Kinsinger,
2000; Rimer et al., 2002). Researchers often have selected promising variables or
constructs from different health behavior models, using integrated approaches to
THC construction. This approach to tailoring has been labeled behavioral construct
tailoring (Kreuter et al., 2004). Behavioral construct tailoring also is consistent with
intervention planning models widely used in public health and health education that
identify and address important and changeable determinants of a given behavior
regardless of their theoretical origins (e.g., PRECEDE–PROCEED [Green & Kreuter,
2005]).
Kreuter et al. (2005) conducted a randomized study of 1,227 African American
women from public health centers in St. Louis to compare the effects of cancer
prevention magazines tailored on behavioral constructs only (e.g., self-efficacy, per-
ceived barriers, knowledge, motivational readiness), cultural constructs only (religi-
osity, collectivism, racial pride, and time orientation), or both behavioral and
cultural constructs. Reactions to the magazines (e.g., attention, liking, yielding,
perceived relevance, sharing magazines with others) were highly favorable among
women in all groups, but rates of mammography use and increases in fruit and
vegetable consumption at follow-up were lowest among women whose magazines
were tailored only on cultural variables with no tailoring based on variables from
theories of health behavior change (Kreuter et al., 2005).

Tailoring as a strategy to enhance motivation to process health

information
THCs have been used to enhance the relevance and salience of information. These
are important steps along a hypothesized pathway to behavior change, whereby
greater perceived relevance and salience increase motivation to process information
and enhance message receptivity, information processing, and behavior change (see
Figure 1).
Tailoring could enhance motivation to process health information in at least four
ways: (a) match content to an individual’s information needs and interests, (b) frame
health information in a context that is meaningful to the person, (c) use design
and production elements to capture the individual’s attention, and (d) provide

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Reception Acceptance Yielding Impact

Use messages Encourage Induce

tailored to high reader to think counter-
or low about an issue, arguing
sensation, e.g. by through
seeking to get focusing on exposure to
attention and benefits lost or different
exposure, e.g. gained from message
using vivid taking/not sources
images and taking action in
graphics response to a
compelling
narrative

Figure 1 Hypothetical use of tailored health communications to affect behavior change

pathway.

information in the amount, type, and through channels of delivery preferred by the
individual, thus potentially reducing barriers to exposure of individuals to commu-
nication interventions. Such an approach then could increase attention, lead to
subsequent yielding, and, ultimately, enhance the likelihood of behavior change.
To date, most THC interventions have focused primarily on the first of these
approaches, although there are examples of other levels of tailoring. By providing
content of interest or concern to specific individuals, readers should be motivated
to pay closer attention to the information, process it more carefully, and be more
likely to use it to make decisions and take actions to improve health (Kreuter
et al., 1999). Most but not all THC studies show that THCs indeed lead to these
expected outcomes (e.g., Brug et al., 1999; Campbell et al., 1994; Kreuter & Strecher,
1996; Prochaska et al., 1993; Rimer et al., 2002; Skinner et al., 1994). Still needed are
studies that explicate the pathway that leads from exposure variables to behavior
change. Newer methods of analysis, like structural equation modeling, may aid in
identifying the communication and behavioral impacts of THCs. Moreover, labora-
tory studies could be used to advantage in this regard.
This explanation of tailoring effects—that behavior change occurs through
increasing motivation to process information—is consistent with Petty and
Cacioppo’s Elaboration Likelihood Model (ELM; Petty & Cacioppo, 1981). ELM
asserts that under certain conditions like elevated motivation and ability, people are
active information processors—considering messages carefully, relating them to
other information they have encountered, and comparing them to their own past
experiences (Cacioppo, Harkins, & Petty, 1981; Petty, 2006; Petty, Cacioppo,
Strathman, & Priester, 1994). One condition under which people are motivated
to process information actively is when they perceive the information to be per-
sonally relevant.

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Fazio’s (Fazio & Towles-Schwen, 1999; Fazio, Powell, & Williams, 1989) MODE
model, an integrative dual-process framework of the attitude–behavior relationship,
expands upon ideas introduced in ELM (Petty, Haugtvedt, & Smith, 1995) and is
complementary to theories of behavior change, such as the Theory of Reasoned
Action and the Theory of Planned Behavior (Montano & Kasprzyk, 2002).
MODE is an acronym for motivation and opportunity as determinants of the
process through which attitudes will affect behavior. In short, the model proposes
that when people are motivated and have the opportunity to do so, they will engage
in a more thoughtful, deliberative process of making decisions about their behavior.
When motivation and/or opportunity are lacking, people’s actions will be guided by
whatever existing global attitudes can be spontaneously retrieved from memory.
Attitudes that are based on thoughtful deliberation (and/or personal experience or
repeated expression) are more accessible (Petty et al., 1995). Thus, if tailored mes-
sages enhance motivation and opportunity to process health information and deliver
compelling new ideas (or reinforce existing ones) that are favorable toward a given
health behavior, the resulting attitudes may be more accessible to that person and, in
turn, have greater influence on behavior.
Evidence for this explanation of tailoring effects was provided in a randomized
experiment in which participants received either tailored materials, a standard
American Heart Association (AHA) brochure, or the AHA content formatted
to look like the tailored materials. Analyses showed significantly greater cognitive
activity among those receiving the tailored materials. Specifically, they reported
significantly more positive thoughts about the materials, made more positive per-
sonal connections to the materials, had more positive self-assessment thoughts, and
had more positive thoughts indicating behavioral intentions than those who received
AHA or AHA-formatted materials (Kreuter, Bull, Clark, & Oswald, 1999). Across all
groups, greater processing was significantly associated with intentions to try behav-
ioral recommendations made in the tailored materials. Among those who received
tailored messages, the relationship between processing and behavioral intentions was
consistent with a mediation explanation. However, formal mediation analyses were
not conducted and would be needed to understand the processes underlying tailor-
ing effects.

Using THC to influence the behavior change pathway: Hypothetical

examples
Message development
THCs could be used in new ways to enhance knowledge about how to construct
messages that lead to behavior change by influencing critical steps on the pathway to
behavior change (see Figure 2). Some stage models assume that different messages
are needed for people in different stages of readiness (e.g., precontemplation vs.
maintenance in the SOC formulation). Researchers using this paradigm have created
variations on messages rather than wholly different strategies for communication.

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Precontemplation Contemplation Action Maintenance

Tailored computer
screen pop-ups to Tailored
invoke concern about telephone calls
colon cancer; narratives with on-the-spot
to heighten perceived Tailored print
scheduling
CRCS salience and booklet to overcome
relevance barriers to screening –
e.g. provide tailored pro Tailored health
and con lists and reminders
encourage thinking about
screening

= Intervention
= Behavioral state or outcome

Figure 2 Using tailored health communications along the behavioral pathway to colorectal
cancer screening.

Yet, one could use different approaches to message design for different types of
people in different behavioral readiness states.
Weinstein’s Precaution Adoption Process Model (Weinstein & Sandman, 2002)
proposes that there are distinct phases to taking precautions about one’s health.
Individuals must first be aware of a problem, engaged in thinking about it, deciding
whether or not to take action, taking action, and finally maintaining any change that
was made. Communication objectives would be different for individuals in each
phase, as are the theories or change mechanisms that would inform communication
development for individuals in each phase. If a person is unaware of CRCS, it may be
important to capture his or her attention, perhaps using a compelling narrative or
image to encourage the person to think about CRCS. If he or she is aware of CRCS
but not particularly engaged in the topic, communication strategies would aim to get
the person to think about it and apply it to his or her situation. The person might be
given data about his or her risk and then encouraged to think about how a diagnosis
of colorectal cancer could affect his or her live. This may be particularly effective for
people with high family risk. If he or she was thinking about CRCS but had not yet
decided whether to be screened, theories of persuasion and attitude should apply.
A loss-framed message could highlight the consequences of not being screened,
using individualized information about the person to make the case more salient and
compelling and to facilitate behavior change (Salovey, Schneider, & Bailey, 1999).
Tailored lists of an individual’s reasons for getting screened (pros) and reasons for
not getting screened (cons) might help them evaluate the issues and move toward
action. Such approaches are consistent with the Transtheoretical Model of Change
(Prochaska et al., 2002) in helping people change the balance of pros and cons and
also with ELM in encouraging more effortful processing (Petty et al., 1995). Tailored
telephone calls have been used to help people make informed decisions about

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whether to be screened, offering on-the-spot scheduling to overcome logistic barriers

(N. A. Davis, Lewis, Rimer, Harvey, & Koplan, 1997). Finally, reminders are an
important behavioral strategy to encourage maintenance of behaviors, like cancer
screening (Task Force on Community Preventive Services, 2005).
This potential to integrate health behavior and communication models to design
more effective health communication strategies offers a great opportunity for col-
laboration and leadership among multiple disciplines in research, application, and
theory development. In the section below, we propose additional ways that THCs
could be used to enhance understanding of the pathway to behavior change and
thereby enhance understanding of message effects.
Fishbein and colleagues (Institute of Medicine, 2003) argued that although
behavioral prediction theories can help to identify specific attitudes and beliefs that
may be impediments to behavior change, they do not tell us how to formulate
effective messages to change these attitudes. More refined theories are needed that
disaggregate key steps in the behavior change process, for example, reception, accep-
tance, yielding, and impact, and then permit creation of interventions to address
these points. THCs could be constructed to deliver specific tailored messages to
address each point in the continuum, similar to the way messages have been created
to reflect different SOC (Figure 1).
As described by McGuire (2001), certain elements of a communication might be
designed primarily to capture attention, whereas other elements would influence
important attitudes that are determinants of the behavioral outcome. Applied to
tailoring, this would require specification of what kinds of individual data are needed
to generate each component and how those data would be translated into specific
messages. To date, developing and testing messages in this manner has not been an
explicit strategy for most THC programs, although it is consistent with some
behavior change theories used for tailoring, for example, SOC (Prochaska, 2004;
Prochaska et al., 2002) and Precaution Adoption Model (Weinstein & Sandman,
2002). Such an approach to message development would also be congruent with
theories, such as Goal Directed Behavior (Perugini & Bagozzi, 2001) that focus on
actions required to translate goals into behaviors. Specifying the behavior pathway
could help researchers to identify leverage points for interventions.
Researchers also could test different kinds of messages for different kinds of
people at different points along the behavior pathway as defined by different theo-
ries. Such messages would reflect understanding of the literature and theories appro-
priate for each step. For example, research on messages to influence yielding would
benefit from literature and theories related to attitude change, persuasion, and
attention.
Other approaches might be evaluated for their effectiveness in increasing atten-
tion to tailored communications. Interventions could be tailored on reading level or
learning style. Graphics could be matched to the recipients’ age, race, sex, or other
attributes (Skinner et al., 2002). Some tailored programs have included pictures of
the intended recipient or family members (Kreuter, Caburnay, Chen, & Donlin,

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2004). Even overt claims of relevance (e.g., This information is designed just for you
based on the answers you provided) could be manipulated experimentally, an
approach that has been shown to increase perceived relevance among recipients
(Burnkrant & Unnava, 1989). Skinner et al. (2002) varied graphics and messages
about testing for BRCA 1 and 2 depending on whether women said they wanted a lot
or a little information; art work changed depending on whether women were Black,
White, or Jewish, and there were other kinds of variations as well. It was not possible
to test whether such fine variations resulted in more behavior change. Unfortunately,
even when innovative approaches such as these are used to create THCs, most
research is not powered to assess the impact of particular message design approaches.
Small laboratory-based studies might enable researchers to answer questions without
requiring large sample sizes.
Message source could be varied to determine whether more credible or more
trusted sources exert more impact. In a multicomponent intervention, Campbell
et al. (1999) provided tailored church bulletins to promote fruit and vegetable
consumption to African American churchgoers. Based on random assignment,
some church bulletins used an expert scientific approach to addressing nutrition,
whereas others used a spiritually based approach with a nutrition message from the
church’s pastor. Message trust was significantly higher among those who received
the spiritually based bulletin. Kalichman and Coley (1995) randomly assigned 100
Black women in an urban health clinic in Milwaukee to view one of three videos on
HIV testing. The first had a Black man as the narrator, the second was identical but
used a Black woman as narrator, and the third had the Black woman deliver the
same content but also stressed culturally relevant losses as consequences of not
being tested (e.g., ‘‘.not getting tested puts your family at risk of losing you to the
disease’’ [p. 249]). Participants rated characters in this last video as significantly
more concerned about Black families and the Black community, women like me, and
as being like people I know compared to characters in the other videos. These
findings suggest that it may be productive to tailor the source of health information
to individual characteristics, including not only demographics but also culturally
relevant values and beliefs.
The communication channel through which a tailored intervention is delivered
could be customized based on individuals’ access to health care, their health care
needs, or personal preferences. Whether doing so enhances the effects of tailoring is
an empirical question. Nested substudies could be used to assess the impact of
specific message strategies or use adaptive designs to permit testing discrete hypoth-
eses about particular message strategies. Using ELM as an example, tailored messages
also could be developed to increase time spent thinking about a topic, with the
assumption that more effortful thinking is more likely to lead to behavior change.
Messages could be varied for people who are very resistant to effortful processing.
Studies using a similar design have already suggested that message effectiveness may
be enhanced if tailored to a person’s health locus of control (Holt, Clark, Kreuter, &
Scharff, 2000).

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Tailored messages may be especially useful when emotional arousal facilitates

behavior change. For example, Kruglanski (2002), Lang (2002), and others have
shown that some people are more susceptible to messages that heighten emotional
arousal. Responses to persuasive stimuli may vary by other personality character-
istics, such as trait anxiety and self-monitoring (DeBono & McDermott, 1994;
DeBono & Snyder, 1989). Williams-Piehota, Pizarr, Schneider, Mowad, and Salovey
(2005) found that a minimal intervention that involved brief counseling and a tai-
lored brochure, matched/mismatched to individuals’ monitor blunting styles,
increased self-reported mammography use 6 months after the intervention for
blunters but not monitors. There were corresponding changes in some but not all
the other predictor variables. If personality traits can reliably predict responses to
different types of persuasive messages, it may be possible to measure these variables
and use an individual’s responses to customize how health messages tailored on
other variables are delivered. On a population basis, it might not be feasible to collect
detailed information on variables such as monitor–blunter status. But in a health
plan or other more constrained setting, where patients are expected to provide
certain kinds of personal information, it might be practicable to include personality
scales. The wide range of possible tailoring variables and strategies for customizing
content and delivery of health information raises questions about how much tailor-
ing is required to achieve different communication objectives, and whether the
incremental cost of more tailoring, or even more units of intervention, is worth
the investment. Identifying the optimum dose of tailoring required to induce behav-
ior change or even antecedent changes along the behavior change pathway presents
significant challenges. First, there are at least two dimensions of dose to be consid-
ered: extent of tailoring (i.e., highly tailored vs. minimally tailored) and amount of
exposure (e.g., in minutes or pages, number of tailored materials received, over what
period of time). Second, there currently are no universally accepted models of
tailoring. This includes what is defined as tailoring and whether subsequent com-
munications use the initial data or whether new data are the expected norm for
subsequent THCs. There is some research on this topic, but the results are not yet
published.
Without some agreement on how best to address different outcomes, the com-
parability of studies will remain limited. Different dose models for the same outcome
could emerge simply because the studies started with different assumptions about
the key determinants of change. Moreover, there are important moderating variables
like message and production quality that can be difficult to assess objectively and are
seldom reported in published research. For example, if message quality was low,
a greater dose of tailoring might diminish effects. Few studies of tailoring dose have
been conducted to date, and their results have been mixed. Dijkstra (2005) recently
demonstrated that smoking cessation materials that were minimally tailored using
mostly personal identification and demographic information led to greater self-
reported quitting among college students than did more elaborately tailored materi-
als. Bull, Kreuter, and Scharff (1999) found no effects of minimally tailored materials

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on physical activity in a community sample of adults. Moreover, there has been little
attention to evaluating the quality of messages or of the overall communication
product.
The cost-effectiveness of tailoring (vs. not) and of different doses of tailoring is
not known. Only a few authors have provided any data on cost-effectiveness
(Lipkus, Rimer, Halabi, & Strigo, 2000; Saywell, et al., 2003). Generally speaking,
we would expect that THC programs and materials are more expensive to
develop than nontailored ones, with delivery costs between the two likely more
comparable. Adding dose or complexity to a tailored program usually involves
more assessments, data processing, computer programming, and message develop-
ment, thus increasing costs. With additional assessment points, problems of
participant fatigue and attrition become more important. However, cost-effective-
ness also would be influenced by quantity of units produced, and tailoring effi-
ciency is likely to increase with the number of units produced (Glasgow, Goldstein,
Ockene, & Pronk, 2004). Tailored interventions are highly scalable and may be
most appropriate when there is the potential to reach large numbers of people.
Moreover, as Abrams, Leslie, Mermelstein, Kobus, and Clayton (2003) have argued,
if tailoring permits greater population reach by getting the attention of intended
recipients in a way that generic materials are unlikely to achieve, THCs could be
more cost effective. Quantifying these costs and determining whether they are
justified by superior effectiveness should be a priority for health communication
researchers.

Understanding message effects

Most THC studies have been designed to assess behavioral impact. These studies
provide less information about message effects than they do about overall program
effects. However, an important strength of the THC literature is use of process
measures, such as those developed by Brug et al. (1999). These intermediate out-
comes can provide insights about the behavior change pathway. For example, Rimer
et al. (2002) found that women who received a combined intervention of tailored
print booklet (TP) and tailored telephone counseling (TC) were more likely to have
had mammograms 12 and 24 months later than women in the usual care group or
those who received only tailored print materials. This raised the question of why the
combination of TP 1 TC was more effective than the TP alone. The process items
may have provided some insight into the answer. Women in the TP 1 TC group
were more likely to say that the newsletter helped them ‘‘think about the limits of
mammography.’’ Those who responded that the newsletter helped in this way were
more likely to have had mammograms. Women who received TP alone also were less
likely than those who received TP 1 TC to have read most or all of the material, kept
it, believed that the newsletter contained information especially for them, or said it
helped them think about benefits and overcome barriers. (Findings were similar at 12
and 24 months.) Although reported reactions to the materials from women in both
groups were extremely positive—more than 85% in the highest affirmative category

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on each item—the experience of the booklet seems to have been different for the two
intervention groups and was significantly more favorable for the TP 1 TC group.
These data are not definitive in explaining how the intervention exerted its effect.
However, process items can be useful in understanding how women responded to
different interventions, but it is not sufficient.

Future directions
The first generation of research on THC focused appropriately on the basic question
of whether tailored materials were more effective than nontailored materials. It is
now time to progress to a next generation of tailoring studies to explore how and
under what conditions tailoring works and how its effects can be optimized. Inte-
gration of a persuasion and message effects perspective will help in both types of
inquiry. More attention should be paid to issues, such as the appropriate control
group for THC studies, and to creating standards and metrics so that THC studies
can be compared at the message level.
When developing any health communication, tailored or not, certain operational
tasks must be completed (Kreuter & Wray, 2003). At the simplest level, these tasks
could include choosing credible sources, developing a message strategy, defining the
appropriate sources of data, and determining the settings and/or channels for opti-
mal communication delivery. Although each of these decisions presents an oppor-
tunity to tailor health communications, it should not be assumed that THCs are
always the ideal or even necessary approach to intervention. To date, tailoring has
been used primarily as a message strategy, providing specific content to individuals
based upon information from or about them, typically responding to a theory-driven
assessment of behavioral precursors. There is considerable need and opportunity to
explore a much wider range of tailoring strategies, formats, effects, and mechanisms
for effectiveness. Collaborations between behavioral and communication scientists
may be important in refining understanding of message effects within tailoring
paradigms.
Specifically, this paper identifies multiple intermediary points on the behavioral
pathway and suggests that different tailoring variables and strategies and even dif-
ferent message formats might be better suited for different points along the way. This
assumption should be empirically tested, as should questions about the extent to
which and mechanisms through which different intermediary variables contribute to
the end goal of behavior change, and whether some message strategies and individual
data are more useful than others in influencing different points along the behavioral
pathway. Moreover, to date, most printed health THC strategies have used
researcher-defined data as the basis for developing THCs. Using a combination of
quantitative and qualitative data, we generally decide what interventions people
should receive. Computerized online interventions offer more opportunities for
collaborative, real-time design. Products could range from those that are expert
designed to those that are user designed, with combinations in between. Although

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Tailored Health Communications B. K. Rimer & M. W. Kreuter

some interventions have offered people choices about the amount of information
they could receive on various topics (e.g., Skinner et al., 2002) and similar options,
we are aware of no research that has assessed the efficacy of user-designed versus
expert-designed THCs.
Finally, little is known about the conditions under which tailoring may be most
effective. Kreuter and Wray (2003) concluded that tailoring is not the best or most
practical communication strategy for all situations, but should be considered when
(a) there is a high level of variability in the population of interest on key determi-
nants of a given outcome, (b) there is general awareness and understanding of the
outcome in the population of interest, and (c) there is some mechanism for gath-
ering data from or about the population of interest. These assumptions have not
been tested, however. Methodological advances, such as fractional designs, some-
times referred to as adaptive designs, may permit more efficient testing of tailoring
approaches without requiring many separate studies (Collins, Murphy, & Bierman,
2004).
As with any communication-based intervention for health behavior change,
there are limits to what can be achieved with tailoring. Information alone, even
tailored information, cannot change many important determinants of health and
health-related behaviors. Limited access to health care and other structural barriers
outside an individual’s personal control may be the most important intervention
points for some problems. We might expect tailoring to be less effective when key
determinants of change related to either the behavior or the population of interest
are not amenable to change by information. Indirect evidence from some tailoring
studies supports this point. For example, in a recent study of mammography use
among lower income African American women aged 40 and older, tailoring was
most effective among women who had been screened previously but were currently
behind schedule, but no more effective than usual care among women who never had
mammograms (Kreuter et al., 2005). Perhaps, the women who had never been
screened faced a different set of barriers to mammography than those who previously
had a mammogram.
There are many critical questions to be answered about THCs. We look toward
a productive next generation of research to provide answers. Advances in computer
hardware and software and health informatics, including greater use of electronic
medical records and personal health records, will present new opportunities to
design communication to meet the information and communication needs and
preferences of recipients, using accurate, appropriate data.

Acknowledgments
This research was supported in part by the National Cancer Institute’s (NCI) Center
of Excellence in Cancer Communication Research program (CA-095815-02) to
M.W.K. and National Institutes of Health (NIH) Grant 1 R01 CA105786-01 and
NCI Grant 5-P30-CA16086-28 to B.K.R. The authors thank Linda Kastleman at the

S196 Journal of Communication 56 (2006) S184–S201 ª 2006 International Communication Association

B. K. Rimer & M. W. Kreuter Tailored Health Communications

University of North Carolina and Chris Casey, Danielle Davis, and Keri Jupka at
Saint Louis University for assistance in the preparation of the manuscript.

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