Targeting (international health)

Targeting is a commonly used technique in the areas of international health and public health which focuses on the development of specialized health intervention approaches for a specific group of people. These groups of people may be identified by geography, race/ethnicity, age, and health issues, among others.
Taking into account specific characteristics that the group members share in common, only one version of program materials is used in a targeted health intervention. The intervention materials show features that the targeted population subgroup members prefer. Cultural targeting applied in clinical interventions has demonstrated improvements in health behaviors and knowledge for targeted populations, which supports the potential for this strategy to reduce racial and ethnic disparities in health care.
History
The idea of targeting was adapted from marketing. Target marketing tries to define a subgroup of people with shared characteristics (such as liking of certain product features) as the right group of consumers for a particular product or service. Adopting the same principle, targeted health interventions identify a group of people who are particular vulnerable to certain health risks, intervene to address their health risks and in turn, improve their health.
From early to mid-1980s, most health information was mass-produced for undifferentiated audience in the form of brochures, pamphlets, and booklets. As people are increasingly aware of different characteristics within mass audiences, behavioral scientists began to develop different versions of materials for diverse population subgroups in order for health campaigns to be cost effective while still reaching large number of audiences. Scholars have suggested that compared to generic interventions which do not take into consideration the audience characteristics, targeting strategy can be more effective for health interventions.
Audience factors
Targeting as an intervention strategy is now widely used in the health fields and has been found to help promote behavioral change. The level of audience specificity in targeting can vary significantly, ranging from one single broad factor (e.g. interventions targeting women), to combined factors. For example, Gomez, Tan, Keegan, and Clarke (2007) identified South Asians in the U.S. who were less than age 50 and were unemployed or non-citizens as potential population subgroup for targeted mammogram utilization intervention.
Targeted health interventions have adopted different audience factors, including age (e.g. older smokers), race/ethnicity (e.g. African-Americans), socioeconomic status (e.g. low-income women), professions (e.g. health providers), health status (e.g. pregnant women and women with children, sensation-seeking adolescents).
In international health
Targeting has been widely used in international health interventions and was found to be effective in promoting behavioral change.
Ahmed, Petzold, Kabir, and Tomson (2006) identified the problem in Bangladesh that there was not enough usage of formal health services among the ultra poor population. In order to promote greater use of these health services, Ahmed and colleagues carried out a health intervention in Bangladesh targeting ultra poor households in rural areas in order to change their health-seeking behavior. The intervention provided ultra poor households with money for household activities (e.g. raising livestock, vegetables farming) to increase their income. In addition, it provided 18 months of supports, such as skill training (e.g. vegetable cultivation) and counseling information on health services, to make sure that the targeted people were able to make full use of the money and had the resources to use the health services if they chose to. This targeted intervention was found to be effective that it decreased the amount of self-care and increased the use of professional health care among the targeted population.
In another intervention, Lowndes, Alary, Labbe, et al. (2007) targeted male clients of female sex workers in Benin, West Africa, in order to reduce the male clients' risky sexual behavior and HIV/STI rates. During this peer-education intervention, trained health educators approached male clients at prostitution venues at night, discussed with them HIV and STI transmission risks, educated them about proper condom use, and distributed condoms. Although HIV prevalence remained unchanged, the intervention effectively affected knowledge and there was an increase in the condom use rate among the targeted population.
Ethical considerations
Despite its effectiveness in promoting behavioral change, targeting strategy should be used with caution and with careful considerations of ethics. Kass (2001) suggested that interventions targeting already vulnerable segments of the population may face certain ethical challenges. Potential burden and harm in these health programs may include risks to privacy and confidentiality, risks to liberty and self-determination, and risks to justice. Subgroups who are targeted in interventions take most of the burden from the process (for example, their privacy may be intruded) while the benefits resulted from the health interventions are for the general public (e.g. improvements in mortality). Kass posed the question whether the unequal distribution of burden and benefits is ethical.
Moreover, the evidence of intervention effectiveness may not be strong enough at times. Thus it may not be known for sure whether the benefits the targeted audience may gain from the intervention will outweigh the harms they will be put in. Hence, health experts face another ethical dilemma.
Kass further pointed out that targeting may create stigma that some segments of the population are more vulnerable to certain diseases, which might result in social harms, such as psychological distress and discrimination. For example, although the HIV interventions targeting male clients of female sex workers in Benin contributed to HIV prevention, one possible stigma that it may create is that male clients of female sex workers are high risk population of HIV infection. This stigma may create anxiety and panic among the targeted population. On the other hand, if a subgroup were never targeted in interventions, they may not believe that they are at the risk of diseases. People who were not targeted in HIV interventions, e.g. people with regular sex partners, may perceive themselves as not at the risk of HIV infection and hence continue engaging in risky sexual behaviors.
Given the above discussed ethical dilemma that targeted health interventions may face, Kass suggested that, if health programs and health resources are going to be unequally allocated (e.g. targeting ethnic minority groups), they should be done with caution and be based on strong intervention effectiveness evidences.
Targeting or tailoring? Competing definitions
While Kreuter and Skinner's (2000) definition of targeting "the development of a single intervention approach for a defined population subgroup that takes into account characteristics shared by the subgroups' members" is now widely accepted in international health, targeting was defined in a few different ways.
It is important to understand the concept of tailoring in order to capture the idea of targeting, as interventions using targeting strategy were mislabeled as tailoring in some health interventions. Pasick (1997)defined tailoring as "the adaptation of interventions to best fit the relevant needs and characteristics of a specified target population". Eakin and colleagues described tailoring as "a process of producing a video whose content and characters are adapted for or designed to appeal to a particular target population". Both statements would now be considered as a more appropriate definition of "targeting" according to Kreuter and Skinner (2000). The primary distinction between the two approaches, targeting and tailoring, is the scale at which they are implemented. Targeting is meant to design information for a defined population subgroup while tailoring is to develop interventions for one specific person based on the individual characteristics.
Another competing definition of targeting was developed by Rimal and Adkin (2003). They stated that both targeting and tailoring should follow the audience segmentation process, which is to divide audience into highly homogeneous clusters. They distinguish targeting and tailoring by suggesting that targeting is the selection of communication channel for the health campaign while tailoring is about message design.
Despite the wide acceptance of the Kreuter and Skinner (2000) definition, Rimer (2000 pointed out that, although some "tailored" intervention would now be appropriately labeled as "targeted" intervention, these published projects are out there and the article titles remain as "tailored", which might create confusion. Rimer suggested that precision of language is important in order to avoid confusion. For people who are trying to understand targeting and tailoring, it is important to keep in mind the inconsistent labeling of targeting and tailoring in earlier published articles and to make critical judgments when reading.

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