reportPilot study evaluating the effects of an intervention to enhance culturally appropriate hypertension education among healthcare providers in a primary care setting

Background: To improve hypertension care for ethnic minority patients of African descent in the Netherlands, we developed a provider intervention to facilitate the delivery of culturally appropriate hypertension education. This pilot study evaluates how the intervention affected the attitudes and perceived competence of hypertension care providers with regard to culturally appropriate care. Methods: Preand post-intervention questionnaires were used to measure the attitudes, experienced barriers, and self-reported behaviour of healthcare providers with regard to culturally appropriate cardiovascular and general care at three intervention sites (N = 47) and three control sites (N = 35). Results: Forty-nine participants (60%) completed questionnaires at baseline (T0) and nine months later (T1). At T1, healthcare providers who received the intervention found it more important to consider the patient's culture when delivering care than healthcare providers who did not receive the intervention (p = 0.030). The intervention did not influence experienced barriers and self-reported behaviour with regard to culturally appropriate care delivery. Conclusion: There is preliminary evidence that the intervention can increase the acceptance of a culturally appropriate approach to hypertension care among hypertension educators in routine primary care. Background In Western countries, ethnic minority populations of African descent have higher rates of hypertension and worse hypertension-related health outcomes than Europeans [1-3]. This has also been observed among Afro-Surinamese (hereafter, Surinamese) and Ghanaians living in the Netherlands. A recent study conducted in Amsterdam reported a higher prevalence of hypertension in Surinamese (47%) than in ethnically Dutch people (33%). Treatment rates were the same for both groups, but Surinamese who were treated for hypertension had lower rates of blood pressure control [4], which may explain the excess mortality due to stroke found in this group [5]. Hypertension is also highly prevalent among Ghanaians [6,7]. Poor adherence to antihypertensive medication and therapeutic lifestyle changes is an important modifiable factor contributing to ethnic disparities in blood pressure control [8,9]. There is evidence that patients' health beliefs can be an important barrier to adherence [10-12], and that culture can influence those beliefs [13-17]. This was also found in our own studies of Surinamese, Ghanaian, and ethnically Dutch hypertensive patients living in the Netherlands [18-20]. Hypertension guidelines recommend patient education as a tool for improving adherence [21,22]. There is some evidence that culturally appropriate educational interventions can improve treatment outcomes in ethnic * Correspondence: e.j.beune@amc.uva. nl, j.a. haafkens@amc.uva. nl Department of General Practice/Clinical Methods and Public Health, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, Amsterdam, The Netherlands † Contributed equally Full list of author information is available at the end of the article © 2010 Beune et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Beune et al. Implementation Science 2010, 5:35 http://www.implementationscience. com/content/5/1/35 Page 2 of 10 minority patients [23,24]. However, the literature provides no descriptions of those interventions for hypertensive patients [25,26]. For this reason, we developed an intervention to facilitate the delivery of culturally appropriate hypertension education (CAHE) by primary care providers. In a previous study, we identified two barriers that may prevent healthcare providers from using CAHE: a negative attitude towards culturally appropriate care in general and a lack of the skills needed to implement this type of health education [27]. Thus, we conducted a pilot with the aim of evaluating whether the intervention could remove these barriers. Methods Study design, setting, and participants We used a quasi-experimental design, contrasting intervention and control groups, to evaluate the effects of the intervention (see Figure 1). The study was conducted in six primary care health centres (PCHCs) belonging to the GAZO healthcare consortium in southeast Amsterdam. This area was chosen because it has a relatively high proportion of Surinamese and Ghanaian residents. Three of the selected PCHCs had also participated in a previous study [18-20,27], and they volunteered to pilot the intervention. The three other PCHCs served as control centres. It is estimated that 26% of the 24,094 patients registered in the intervention centres and 26% of the 20,076 patients registered in the control centres are of Surinamese or Ghanaian origin (data are from 2007). Based on data from the SUNSET study [4], we expected that some 47% of the patients of African origin would suffer from hypertension. All six centres used a similar protocol for hypertension care, based on the guidelines of the Dutch College of General Practitioners [21]. According to this protocol, hypertension education for patients with uncomplicated hypertension can be provided by a general practitioner (GP), a nurse practitioner (NP), or a general practice assistant (GP assistant) under the supervision of a GP. The intervention targeted all healthcare providers who provide hypertension education to patients with uncomplicated hypertension (K86). The intervention group consisted of 47 healthcare providers: 7 NPs, 18 GP assistants and 22 GPs. The control group consisted of 35 healthcare providers: 5 NPs, 14 GP assistants and 16 GPs. Intervention The aim of the intervention was to support healthcare providers in using CAHE, specifically for Surinamese and Ghanaian patients. Interventions are more likely to elicit change in healthcare professionals if they use multiple approaches [28,29]. Our intervention consisted of three components: written tools, training, and feedback. Written tools We supplemented the standard hypertension protocol used by the intervention centres with information about six tools to support CAHE: 1. A topic list to explore the patient's ideas, concerns, and expectations regarding hypertension and hypertension treatment. 2. A topic list to explore culturally specific barriers to and facilitators of treatment adherence. The items on the lists were derived from the work of Kleinman [30,31], recent approaches to improve adherence [10,32,33], and our prior study [18-20] (see Table 1). 3. A checklist to facilitate the recognition of specific barriers to hypertension management in Surinamese and Ghanaian patients, based on our prior study [1820]. 4. Information leaflets for Surinamese or Ghanaian patients with answers to frequently asked questions about hypertension. These leaflets were adapted to the language, customs, habits, norms, and dietary cultures of the Surinamese and Ghanaian communities, using information obtained from our previous study [18-20]. Consideration was also given to recommended surface and deep structure elements [34]. The leaflets were pre-tested in two focus groups with Surinamese and Ghanaian hypertensive patients. 5. A referral list, including neighbourhood facilities offering healthier lifestyle support tailored to Surinamese and Ghanaian patients. 6. A list of items used to register the results of hypertension counselling sessions. Information about these tools was made available on paper and also through pop-up screens in the digital hypertension protocol used by the intervention centres. Training and feedback To support the use of these tools, we provided a training course of two half-day sessions to all NPs and GP assistants in the intervention centres. During the first session, information about the prevalence and treatment of hypertension among populations of African origin in Western countries was provided and discussed. There was also discussion of how the tools might be used. During the second session, training was given in culturally sensitive counselling skills through role-playing exercises with Surinamese and Ghanaian hypertensive patients. Educational materials consisted of a course manual and instruction on the use of the new tools. As a second supportive intervention the researcher (EB) organised feedback meetings (lasting 1.5 hours) with the NPs and GP assistants once every two months. NPs and GP assistants could also ask for individual advice. The GPs were invited to an information meeting at their health centre (lasting one hour) at the start of the Beune et al. Implementation Science 2010, 5:35 http://www.implementationscience. com/content/5/1/35 Page 3 of 10 Figure 1 Overview of the implementation and the measurement. Usual Care Assessment of response change (T1-T0): Self-reported attitudes towards culturally appropriate care Experienced barriers towards culturally appropriate health care in general Experienced barriers towards culturally appropriate cardiovascular care and education Self reported actions in delivering culturally appropriate care Intervention Hypertension care providers receive: Written information about six tools to support culturally appropriate HTN education Information meetings (GPs) Training in culturally appropriate HTN education (NPs and GP assistants) Feedback meetings (NPs and GP assistants) 3 Usual Care Sites (N = 35) Response: N = 23 (66%) 3 Intervention Sites (N = 47) Response: N = 45 (96%) T0: Collect baseline data among all GPs, NPs, and GP-assistants (N = 82) on self-reported attitudes, experienced barriers, and self-reported behaviour with regard to culturally appropriate care delivery 3 Usual Care Sites (N = 23) Response: N = 17 (74%) 3 Intervention Sites (N = 45) Response: N = 32 (71%) T1: Collect data among GPs, NPs, and