We described a pilot study of an intervention to assist healthcare providers in delivering CAHE. Inspired by evidence from studies on professional behaviour change [28, 29], the intervention consisted of multiple components: tools for CAHE that complemented an existing digital protocol for hypertension care, training, and feedback possibilities. Moreover, the content of the tools and the supportive interventions were aimed at removing previously observed barriers that may impede CAHE--a negative attitude towards culturally appropriate care and/or insufficient competence to implement it.
The results revealed that healthcare professionals who participated in the intervention considered it more important to address the patient's culture when delivering care than they had before the intervention. The current intervention did not influence experienced barriers and self-reported behaviour with regard to culturally appropriate care delivery.
The absolute value of the observed differences was modest, so the results should be interpreted with care. Nevertheless, they suggest that the intervention has been successful in eliciting attitude change among healthcare providers. In the light of the theories of professional behaviour change , we may conclude that the intervention has specifically contributed to the acceptance of change. This is an important condition for the next stages of change--actual change and maintenance.
Some limitations may have influenced our results. First, only 49% of the participants in the control group responded to both questionnaires, as compared to 68% in the intervention group. An analysis of the response rates reveals that 12 of the 35 participants in the control group (34%) did not return the questionnaire at T0. Of the remaining group, six people (26%) did not return the questionnaire at T1. Possibly, people in the control group were less motivated to fill out the questionnaire than those in the intervention group because they might not have perceived how this could benefit them. More observations in the control group would have increased the chance of finding significant differences on three of the scales. Second, the intervention group consisted of healthcare providers from PCHCs that had taken part in focus groups on delivering culturally appropriate care in our previous study . This may explain the baseline scores of the group on scale four, the self-reported actions in the intervention group, leaving only limited room for improvement. However, a more in-depth understanding of experienced barriers to the application of the tools is needed. Third, we studied PCHCs that belong to the same primary healthcare consortium. Healthcare professionals from these PCHCs meet regularly in joint consortium meetings, thus contamination cannot be ruled out. Randomised study designs may be a better option for evaluating the true effect of an intervention, even in pilot studies. However, it should be acknowledged that randomised designs are not always possible in routine clinical practice because of organisational or ethical impediments. Moreover, even with randomised designs contamination can not always be prevented . Fourth, in order to measure the attitudes, competence, and behaviour of the study population, we adapted an instrument standardised for measuring cultural competence among resident physicians in the USA . A drawback of this instrument is that the questions were not always appropriate for NPs and GP assistants. Moreover, they were rather general and not specifically tailored to the objectives of the intervention. In future studies, other evaluation instruments that are more closely tailored to the specific objectives of the intervention may be considered.
There is an urgent need to improve hypertension education directed at ethnic minority populations of African origin [2, 7, 9]. Interventions to increase the cultural competence of hypertension care providers are a first step towards this end . Multi-component interventions including information, education, and support are most likely to elicit innovations among professionals . Our intervention is the first clearly described multi-component intervention specifically designed to stimulate cultural competence in hypertension educators. Before the clinical significance of interventions in healthcare can be tested successfully, iterative approaches are needed to study any potential barriers to implementation of the intervention . This pilot study provides preliminary evidence that our intervention may positively influence attitudes with regard to the delivery of culturally appropriate hypertension care. Positive attitudes are an important condition for the uptake of new approaches in practice. As a next step our research group will make a qualitative assessment of organisational factors that may have hampered or facilitated the use of the new tools in practice. The results of these studies will then be used in the design of a subsequent study that aims to measure the effect of the intervention on blood pressure control and treatment adherence in patients .