Patient Education and Counseling 82 (2011) 74–80

Provider Perspectives

Barriers and enablers in the implementation of a provider-based intervention tostimulate culturally appropriate hypertension education

Erik J.A.J. Beune a,*, Joke A. Haafkens a, Patrick J.E. Bindels b

a Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlandsb Department of General Practice, Erasmus MC, Rotterdam, The Netherlands

A R T I C L E I N F O

Article history:

Received 26 September 2009

Received in revised form 6 February 2010

Accepted 13 February 2010

Keywords:

Ethnicity

Hypertension

Patient perspective

Sociocultural factors

Patient education

Cultural competence

Provider intervention

Implementation

A B S T R A C T

Objective: To identify barriers and enablers influencing the implementation of an intervention to

stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary

care.

Methods: The intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE,

training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension

educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed

using qualitative content analysis.

Results: Perceived barriers to the implementation of the intervention fell into three main categories:

political context (health care system financing); organizational factors (ongoing organizational changes,

work environment, time constraints and staffing) and care provider-related factors (routines, attitudes,

computer and educational skills, and cultural background). Few barriers were specifically related to the

delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers

consisted of reorganizing practice procedures, team coordination, and providing reminders and

additional instructions to hypertension educators.

Conclusion and practice implications: The adoption of a tool for CAHE by care providers can be

accomplished if barriers are identified and addressed. The majority of these barriers are commonly

associated with the implementation of health care innovations in general and do not indicate resistance

to providing culturally appropriate care.

� 2010 Elsevier Ireland Ltd. All rights reserved.

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1. Introduction

In Western countries, ethnic minority populations of Africandescent are disproportionately affected by hypertension andhypertension-related cardiovascular morbidity and mortality [1–3]. This has also been observed among two major immigrantgroups of African descent in the Netherlands: African-Surinamesefrom the former Dutch colony of Suriname (hereafter, Surinamese)and Ghanaians [4–6]. Insufficient adherence to antihypertensivemedication and lifestyle changes [7–9] is one important explana-tion for the observed ethnic disparities in blood pressure controland negative hypertension outcomes. Enhancing adherence toprescribed antihypertensives and lifestyle changes in ethnicminorities is, therefore, an important challenge for health careproviders [3,6,9–11].

* Corresponding author at: Department of General Practice, Academic Medical

Center, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The

Netherlands. Tel.: +31 20 5663983; fax: +31 20 5669168.

E-mail address: e.j.beune@amc.uva.nl (Erik J.A.J. Beune).

0738-3991/$ – see front matter � 2010 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.pec.2010.02.015

In the Netherlands, general practitioners (GPs) play animportant role in hypertension treatment. European and Dutchhypertension guidelines advise patient education as a means forimproving adherence [12,13]. Patient beliefs have a major impacton adherence and these beliefs may, in turn, affect outcomes [14–16]. Therefore, hypertension guidelines recommend the use ofpatient-centered educational approaches and to explore the beliefsand needs of individual patients in order to find a common groundregarding treatment [12,13]. There is increasing evidence thatpatients’ beliefs about hypertension and treatment may differamong ethnic groups [17–21]. This was also found in studiesamong Surinamese and Ghanaian hypertensive patients living inthe Netherlands [22–24].

Even though there is increasing evidence that culturallyappropriate patient education may positively influence medicationuse and lifestyle changes in ethnic minority patients [25,26], theliterature provides few specific examples or evaluations of the usesof this method in hypertension care [11,27]. For that reason, wedeveloped a provider intervention to facilitate the delivery ofculturally appropriate hypertension education (CAHE) in primarycare.

Box 1. Topic list for eliciting immigrant patients’ explanatory

model of hypertension and hypertension management.

Communication

� Determine how a patient wants to be addressed (formally or

informally).

� Determine the patient’s preferred language for speaking and reading

(Dutch or another language).

� Use this information in your interaction with the patient.

Introduction

� It is often difficult for us (care providers) to give advice about

hypertension and how to manage it if we are not familiar with the

views and experiences of our patients. For that reason I would like

to ask you some questions to learn more about your own views on

hypertension and its treatment.

Ad 1. Elicit personal views on hypertension and its treatment

Understanding

� What do you understand hypertension to mean?

Causes

� What do you think has caused your hypertension? Why did it occur

now/when it did; why to you?

Meaning and symptoms

� What does it mean to you to have hypertension?

� Do you notice any symptoms of your hypertension? How do you

react when you do?

Duration and consequences

� How do you think your hypertension will develop further?

How severe is it?

� What consequences do you think your hypertension may have

for you (physical, psychological, social)?

Treatment

� What types of treatment do you think would be useful?

� What does the prescribed therapeutic measurement(s) mean to you?

Ad 2. Elicit contextual influences on hypertension management

Social

� Do you speak with family/community members about your

hypertension? How do they react?

� Do family/community members help you or make it difficult for you

to manage hypertension? Please explain.

Culture/religion

� Are there any cultural issues/religious issues that may help you

or make it difficult for you to manage hypertension? Please explain.

Migration

� Are there any issues related to your position as an immigrant

that make it difficult to you to manage hypertension? Please explain.

Finance

� Are there any issues related to your financial situation that make it

difficult for you to manage hypertension? Please explain.

Based on Kleinman’s Explanatory Model format [34,35], and our previous

study [22–24].

E.J.A.J. Beune et al. / Patient Education and Counseling 82 (2011) 74–80 75

Implementation researchers have reported extensively aboutcommon factors that may hamper or facilitate the adoption ofinnovations in medical practice. Such factors may be associatedwith political and cultural fit, available resources, the expertiserequired from the users, or how well the intervention fits into anorganization’s current practices [28–30]. Furthermore, the parti-cular characteristics of the intervention itself may influenceimplementation. Thus, before the effect of a provider-basedintervention on patient outcomes can be studied, one importantbut often overlooked question that should be addressed is whetherthey can be applied in practice [31].

For this reason we conducted a pilot study with the aim ofidentifying factors that might hamper or enable the adoption of aculturally appropriate approach to hypertension education in aprimary care setting.

2. Methods

2.1. Setting

The intervention was piloted in three primary care healthcenters (PCHCs) in southeast Amsterdam between September2006 and May 2008. All three PCHCs had participated in a previousstudy [22–24,32] and volunteered to pilot the intervention. It isestimated that 26% of the 24,094 registered at these centers are ofAfrican-Surinamese and Ghanaian origin (data are from 2007). Allthree centers used a similar protocol for hypertension care, basedon the guidelines of the Dutch College of General Practitionersfrom 2006 [12]. In the three centers in question the task ofproviding hypertension education to patients with uncomplicatedhypertension was assigned to nurse practitioners (NPs) andgeneral practice assistants (GP assistants), working under thesupervision of GPs. For GP assistants, hypertension education wastypically a new task that had not been assigned to them in previoushypertension protocols. The intervention was targeted at all healthcare providers who provide hypertension education to patientswith uncomplicated hypertension (K86): 7 NPs, 18 GP assistantsand 22 supervising GPs.

2.2. Intervention

The aim of the intervention was to enhance provider knowledgeof the relationship between sociocultural factors and patient beliefsand behaviors with respect to hypertension management, and toequip providers with the tools and skills to manage these factorsduring patient education. Implementation strategies were devel-oped in cooperation with three GPs and three NP/GP assistants fromparticipating PCHCs. This approach was chosen to ensure that theintervention would fit the patient population and the regularworking methods of the practices, which is considered important forthe acceptance and success of innovations [33].

The intervention consisted of six tools to facilitate a culturallyappropriate approach to hypertension education and counseling,including: (1) a topic list to explore the patient’s ideas, concerns andexpectations regarding hypertension and hypertension treatment(Box 1: Ad. 1); (2) a topic list to explore culturally specific inhibitorsand enablers of adherence to hypertension treatment (Box 1: Ad. 2).The items on these lists were derived from the work of Kleinman[34,35], recent approaches to improving adherence [14,36,37], andour prior study [22–24]; (3) a topic list to facilitate the recognition ofspecific inhibitors to hypertension management in Surinamese andGhanaian patients, based on our prior study [22–24]; (4) a list ofspecific items to register the results of hypertension counselingsessions; (5) information leaflets for Surinamese or Ghanaianpatients with answers to frequently asked questions abouthypertension. Leaflets were adapted to the language, customs,

habits, norms and dietary cultures of the Surinamese and Ghanaiancommunities [22–24], and pre-tested in two focus groups withSurinamese and Ghanaian hypertensive patients; and (6) a referrallist, including neighborhood facilities offering healthier lifestylesupport, tailored to Surinamese and Ghanaian patients. These toolswere supplemented to the standard hypertension protocol used inthe practices. They were made available through pop up screens inthe digital hypertension protocol that could be accessed on theintranet of the practices and also on paper.

To maximize the application of the toolkit and remove potentialbarriers to the adoption of the tools three implementation supportstrategies were used, which were informed by theories regardingthe principles of effective change in medical care [28,29,38]:

- Discussion meetings with GP teams. In order to identify potentialbarriers to the implementation of the new tools in each healthcenter and to reach a consensus about how these barriers couldbe overcome, information meetings (lasting 1 h) with the GPteams were held prior to the intervention. Eighteen GPs attendedfive meetings. Some of the topics upon which consensus was

Table 1Preliminary discussion meetings with GP team.

Themes Identified barrier Activity Result

New national CVRM

guideline for GPs

Lack of consensus in GP team about

key principles: GPs are still adjusting

to new guideline

Facilitate discussion in GP

team about key principles

Consensus about the use of CVRM

guideline and common HTN protocol

Extension of common HTN

protocol with

recommendations for CAHE

None None Consensus that common HTN protocol

would be extended with

recommendations for CAHE

Division of tasks related to

HTN education

Lack of clarity and acceptance about

task delegation from GP to NPs and

GP assistants

Involve target groups:

- discuss tasks and responsibilities

of GPs, NPs and GP assistants in

project

- elicit ideas about barriers

to change

Consensus about task description and

role of GP assistants in

HTN education

No clear demarcation of responsibilities

and concerns about role of GP assistants

in HTN education

Lack of facilities for GP assistants to

provide HTN education

Negotiate prerequisites for

GP assistants

GP assistants own patient file

GP assistants more time for consultation

GP anxiety about losing control

of treatment

Redesign practice GP assistants and GP work in fixed pair to

ensure mutual feedback

Competencies of HTN educators Lack of basic knowledge about HTN

among GP assistants

Training of GP assistants by GPs Increased basic HTN knowledge

HTN, hypertension; CAHE, culturally appropriate hypertension education.

E.J.A.J. Beune et al. / Patient Education and Counseling 82 (2011) 74–8076

reached included: an interpretation of the key principles of therecently introduced CVRM guideline by the Dutch College ofGeneral Practitioners [12]; a translation of this guideline into acommon hypertension protocol to be used in the three PCHCs;the extension of the common hypertension protocol withrecommendations for CAHE; task delegation among GPs, NPsand GP assistants and how GPs could support GP assistants sothat they could perform their task as hypertension educators (e.g.by working in fixed pairs with GPs and by receiving additionaleducation in hypertension management from GPs) (see Table 1).

- Training for counselors. To facilitate the use of the toolkit, wedeveloped a training course of two half-day sessions for all NPsand GP assistants at the intervention centers. The GPs were notinvited because nearly all of them had completed somewhatsimilar training, organized by the PCHCs at an earlier stage.During the first session information about the prevalence andtreatment of hypertension among populations of African origin inWestern countries was provided and discussed. There was alsodiscussion of how the tools could be used. The second sessionconsisted of training in culturally sensitive counseling skills,through role-playing exercises with Surinamese and Ghanaianhypertensive patients. The educational materials providedconsisted of a course manual and instructions for use of thenew tools. All but two of the invited NPs and GP assistantsattended the course (n = 23/25) in April 2006.

- Feedback to counselors. As a second supportive intervention, theprimary researcher (EB) organized a series of collective feedbackmeetings for NPs and GP assistants at their health center tosupport them in implementing the tools described in theprotocol. The meetings took place after the consensus aboutthe implementation of the protocol had been reached with theGPs, counselors had been given training and the protocol hadbeen posted on the intranet of the practices. Meetings were heldonce every two months and lasted 1.5 h. NPs and GP assistantswere also able to request individual advice. After every meetingthe GPs received feedback about the conclusions reached andabout potential obstacles to the implementation of the toolkit.

2.3. Population and data collection

A qualitative research design was used to collect and analyzethe data. Data were collected in three PCHCs from attendees of thefeedback meetings about the implementation of the tools: 16 NPsand GP assistants (hereafter, nurses) attended seven collective

feedback meetings and 7 nurses attended one or two individualcoaching sessions. The period of data collection varied from fourmonths (the shortest period) in one center to six months (thelongest period) in another. This variation can be attributed to thefact that in some centers, due to technical circumstances, postingof the hypertension protocol on the intranet was delayed. Thefeedback meetings were led by a topic guide, with thematic, open-ended questions. In the collective meetings participants wereasked to describe the barriers they perceived to using some or all ofthe protocol and what might support the use of the protocol intheir daily practice. In some of the meetings participants’ videorecordings of consultations with Ghanaian or Surinamese hyper-tensive patients were used to answer these questions. In theindividual consultations participants were invited to discussbarriers they experienced in using the toolkit and what wouldbe needed to overcome these barriers. All collective meetings wereaudio recorded and notes of all individual contacts were made.

2.4. Data analysis

Data consisted of transcripts of the collective discussion meet-ings and written notes and conclusions from individual contacts. Inorder to verify content validity [39], all of the documents were sentback to the participants for member checks. Transcripts and noteswere then imported into Maxqda, a computer program to assistqualitative data analysis [40], and analyzed for thematic content. Inthe first stage of this analysis, all text files were read through in orderto form a general picture of the execution of the implementationprocess. All fragments containing information about experienceswith the use of a culturally appropriate approach to hypertensioneducation were selected. Then, lists of categories and subcategorieswere created, indicating the factors influencing implementation.Next, these categories and subcategories were sorted into twogroups: barriers to the implementation of the toolkit and activitiesthat were suggested or undertaken to remove these barriers(enablers). Finally, the categories and subcategories were mergedinto a matrix that included barriers and related enabling activitiesfor addressing these barriers.

E.B. coded and analyzed the data and established the matrices.J.H. reviewed the matrices to verify the identified categories andsubcategories in the qualitative analysis. Differences in interpreta-tion were resolved by going back to the data and seeking consensusthrough discussion. The plausibility of the results was also checkedby presenting the final matrices and conclusion to a project group.

E.J.A.J. Beune et al. / Patient Education and Counseling 82 (2011) 74–80 77

At the end of the project, the plausibility of the findings wasdiscussed with a panel of experts.

2.5. Ethical considerations

The study protocol was submitted to the Medical EthicalCommittee of the Academic Medical Center of the University ofAmsterdam. The committee established that the study does not fallwithin the realm of the Dutch law on medical research withhumans because it does not include medical interventions orinvasive measures with humans. For that reason, the committeesent a letter stating that the study did not require furtherassessment and approval from the Medical Ethical Committee ofthe Academic Medical Center nor from any other officiallyaccredited medical ethical research committee in the Netherlands(reference number 09171260). In line with the AMC code of goodconduct in medical research [41], provisions were made to assurethe anonymity of the respondents in the collection, analysis andpresentation of the data.

3. Results

Three major categories that describe the barriers health careproviders experienced in adopting a culturally appropriateapproach to hypertension education were identified: (1) nationalpolitical context; (2) organizational factors; and (3) care provider-related factors. Each category included a number of subcategoriesspecifying the barrier. Table 2 summarizes these categories as well

Table 2Identified contextual barriers to and enablers of the implementation of culturally appr

Category Identified barrier

Political context

New national policy for financing

health care system

Less financial support for innovations: loss of

motivation and concerns about reimbursement

Organizational factors

Ongoing organizational

changes

Technical and organizational problems with

the introduction of a new system

for electronic patient registration

Move to other building (one health center)

Environment GP assistant no access to private room

Time constraints High case load GP assistant

GP assistants must provide ad hoc

assistance to GP

No replacement of sick NP or

GP assistants

Staff High turnover of GP assistants

Care provider-specific factors

Capabilities Lack of computer skills and skills

using EMRs

Lack of basic HTN knowledge by

GP assistants

Insufficient skills for patient

education of GP assistants

Routines Relapsing into old routines

Attitudes Resistance to innovations in general

Ambivalence about registering

ethnic background

Cultural background Socially desirable behavior of Surinamese

patients

HTN, hypertension; EMR, electronic medical record.

as the enabling strategies that were undertaken to address theidentified barriers.

3.1. National political context

3.1.1. Barriers

Six months after the start of this project a new policy for thefinancing of the health care system was introduced in theNetherlands. As a result of this policy, health care centers wereno longer given structural funding for quality improvements, andGPs were encouraged to cut costs by increasing their productivity.This has led to an increased workload for both GP assistants andNPs. As a result, some of them were less motivated to participate inquality improvement projects like the present one. Concerns wereraised that quality improvement was no longer reimbursable.

3.1.2. Enablers

To address these concerns we advised the nurses to record thetime they spent on hypertension education as accurately aspossible. This data could serve as baseline information for findingother means of reimbursement.

3.2. Organizational factors

3.2.1. Barriers

At the start of this project the PCHCs were introducing a newsystem for electronic patient registration. The hypertension protocoland culturally sensitive tools could be accessed though this system.

opriate hypertension education.

Strategy Result

Facilitate registration and declaration

of extra time spent on HTN education

Fewer concerns about financial

consequences of the application

of new protocol

Postpone implementation Delay

Postpone implementation Delay

Seek adequate room for patient education Quiet workplace for GP assistant

Stepwise implementation: use new

protocol for newly diagnosed patients first

Prevention of overload of nurses

Arrange clear role for GP assistant in

care process for HTN patient

GP assistant more time to provide

HTN education

None None

Support knowledge transfer about

program for new staff

Study materials available to

new staff

Provide practical tools and

individual coaching

Better access to digital protocol

Increased use of protocol and EMR

Facilitate feedback by GP (continuous

medical education)

Improved HTN knowledge by

GP assistants

Provide video feedback More insight into communication

process

Provide reminders, checklists,

reflections (e.g. video feedback)

Facilitate feedback by GP

More routine to use new protocol

More insight into old routines and

professional attitudes

Acknowledge and discuss reasons

for resistance

Emphasis on the more motivated

participants

Discuss pros/cons of registering ethnicity Increased registration of ethnicity

None None

E.J.A.J. Beune et al. / Patient Education and Counseling 82 (2011) 74–8078

Due to technical and organizational problems it took some timebefore health care providers were able to access the new system inthe practices. This also delayed the availability of the digital tools.

Lack of access to a private room limited GP assistants in theirefforts to provide high quality hypertension education to patients.

Time constraints were also a major obstacle for GP assistantsbecause: (a) their current case load did not allow them to spendextra time on patient education; (b) they support the work of GPsand are not always able to set their own agenda. As a result theywere sometimes asked to provide ad hoc assistance to GPs (e.g.urinalysis, emergencies) while they were engaged in patienteducation; and (c) they often had to replace colleagues who wereill or who had left their job.

The high turnover rate among GP assistant staff also hamperedimplementation.

3.2.2. Enablers

To ensure a suitable environment for patient education,provisions for a quiet workplace for GP assistants were made.

To reduce time-related obstacles for GP assistants, specialarrangements were made with the GPs. For example, GP assistantswere allowed to block out time in their schedule for the provisionof CAHE during which they could not be asked to perform otheractivities.

To support knowledge transfer about the project to newpersonnel, written instruction materials and a take-home CD weremade available for practice at home.

3.3. Care provider-specific factors

3.3.1. Barriers

Some of the observed obstacles to the application of the toolkitwere related to the skills, knowledge, routines, attitudes or culturalbackground of the participating GP assistants and the NPs.

Despite the fact that almost all participants had attended thetraining course on using the new tools, some of them reported theywere not yet capable of using them properly. Several reasons weregiven for this, including a lack of basic computer skills needed foraccessing and using the digital tools and for the registration of theresults of hypertension counseling sessions in the electronic medicalrecord. Some GP assistants felt they were also lacking basic skills inpatient education (e.g. how to use the patients’ explanatory model inpatient education) and basic knowledge of hypertension.

Having to change existing routines was identified as anotherbarrier. The new method of hypertension education required anapproach that was different from the one they were used to,‘‘listening to a patient rather than offering an immediate solution.’’Many GP assistants kept falling back into old routines.

Some barriers were related to the attitudes of care providers.Discussion and analysis of experiences with applying the tools inpatient care was one of the strategies used to enhanceimplementation. Some of the GP assistants were reluctant to dothis, as they were afraid of criticism. Some expressed a negativeattitude towards innovations in general because of the over-whelming number of new guidelines in primary care. In theNetherlands, physicians are not required to register the ethnicbackground of their patients. However, the new protocolrecommended asking about and registering the ethnic backgroundof patients. Some participants thought registration by ethnicitywas not necessary because all patients are the same. Othershesitated to register the ethnic background of their patientsbecause they felt this could contribute to discrimination orstigmatization on the basis of race.

Some GP assistants of Surinamese origin felt that their culturalbackground could serve as an obstacle to communication withSurinamese patients. One of their observations was that Surina-

mese patients tended to give socially desirable answers to nursesfrom their own community in order to avoid gossip.

3.3.2. Enablers

Barriers to the application of the protocol were addressed by theprovision of additional practical tools (e.g. (abbreviated) writteninstructions on how to access the digital protocol for those whowere reluctant to use the digital protocol). Next, to improve theirknowledge of hypertension, GP assistants were offered anopportunity to receive regular feedback from their supervisingGP. Finally, to address the reported communication barriers,nurses were asked to record some of their consultations withGhanaian and Surinamese patients on videotape. Subsequently, inreflective meetings, those communication barriers were discussed.Some Surinamese GP assistants felt that a shared culturalbackground with Surinamese patients could be an enabling factorrather than an obstacle to communication, as it could mean bettermutual understanding of Surinamese customs (e.g. diet, herbalremedies) or a greater readiness on the part of patients to talkabout using these customs in hypertension management.

As Table 2 shows, many of the enabling strategies that wereundertaken succeeded in removing barriers to the adoption of thetools. But some structural barriers related to financial resources,staffing issues and the cultural background of the hypertensioneducator could not be addressed.

4. Discussion and conclusion

4.1. Discussion

We developed a provider-based intervention to enhanceculturally appropriate hypertension education (CAHE) in a primarycare setting. The intervention consisted of a toolkit and aneducational course and discussion and feedback meetings tofacilitate the use of these tools.

In line with previous studies [29], our pilot in three DutchPCHCs shows that the implementation of programs to changehealth care providers’ competence and performance in routineclinical care is a complex and dynamic process, one which does notoccur spontaneously and needs continuous attention. Health careproviders in this study experienced a series of barriers hamperingthe use of new tools for CAHE. These barriers were related to thenational political context, organizational factors and to character-istics of the care providers. A significant finding is that only a fewbarriers were specifically related to problems with applying aculturally adapted approach to hypertension education. One of themost important barriers in this respect was a reluctance to registera patient’s ethnicity. Most barriers were more general, and weresimilar to the problems that have been commonly observed instudies evaluating the implementation of quality improvementtools in routine clinical practice [30,42]. The study also identified anumber of strategies that were useful to address the barriers. Someimportant strategies were: phasing the implementation process;adapting practice procedures (e.g. a clear division of labor, findingsuitable space, allowing for longer appointment times); theprovision of additional instructions and coaching to improve skillsand discussing resistance to change. Yet, some barriers could notbe addressed within the confines of this intervention (e.g. staffshortages).

Our study has some methodological strengths and limitations.Based on evidence based recommendations with regard to theplanning and study of improvements in patient care, weimplemented the intervention using an action-oriented design[43]. An advantage of this approach was that it offered us thepossibility of uncovering barriers to implementation as well asactions that could be relevant to enabling solutions adapted to the

E.J.A.J. Beune et al. / Patient Education and Counseling 82 (2011) 74–80 79

local context. As a consequence of this choice, however, theresearcher had the role of both observer and interventionist. Thismay have influenced the reliability and validity of the researchfindings. However, to ensure content validity we used memberchecks of the collected data. Also, during the analysis data fromdifferent sources (e.g. discussion meetings, video registration,individual consultations) were compared to find similarities anddifferences (triangulation) and preliminary findings and con-clusions were reviewed by and discussed with a secondresearcher and the project committee. In the final stage of thestudy, findings and conclusions were discussed in an expertmeeting to check plausibility. A limitation of our study was thelimited data on the actual delivery of patient education inpractice. Although the video-registrations provide clear insightsinto how education was delivered, only a select group (thosewho volunteered) was willing to record their consultations withpatients. Furthermore, due to the aforementioned technicalproblems and resistance, registration forms from consultationswere not consistently filled out by health care providers. Infuture studies, provisions should be made that allow for a moresystematic registration of data from hypertension educationsessions. Finally, as it was our aim to collect data about thefeasibility of the implementation of the intervention in practice,we did not collect data on how patients experienced the newhypertension education.

Based on implementation theories, in this project we adaptedthe intervention as much as possible to the working methods of thePCHCs involved. We wanted to ensure that all of the health careproviders involved in hypertension care would be able to providethe new hypertension education; however, the results of this studysuggest that some health care providers (NPs and some interestedGP assistants) were better suited for this task than others. Onedrawback for GP assistants was that hypertension education wastypically a new task for them, for which they had not receivedmuch previous education. This implies that adoption of thisintervention may be more successful if it is targeted to a limitednumber of providers with a special interest in, motivation andtalent for CAHE.

4.2. Conclusion

This is one of the first attempts to develop and evaluate theimplementation of an intervention to facilitate CAHE in routineprimary care. Our pilot study shows that health care providers canadopt the toolkit if certain barriers are addressed during theimplementation period. Our study also reveals that many of thebarriers to the implementation are not specific to an interventionthat promotes culturally appropriate education, but are similar tothe type of obstacles that are commonly encountered wheninnovations are introduced in primary care [30,42].

4.3. Practice implications

Most barriers to the implementation of tools for culturallyappropriate care do not indicate a resistance to it; they are notsignificantly different than barriers to the implementation of othertools for quality improvement (e.g. clinical guidelines). Therefore,developers of quality improvement programs should not hesitateto develop innovations to stimulate culturally appropriate care.

The elements of the intervention we developed in this study arewell described (toolkit, course and supportive feedback meetings)and transferable. These elements may be used as baselineinformation or as a prototype for other health care centers orresearchers who want to develop interventions to stimulate aculturally appropriate approach to hypertension education forethnic minority populations.

The implementation of any innovation in health care requiresthe construction of an evidence based implementation plandescribing the potential barriers that may be expected duringimplementation and how they may be addressed [43]. The barriersand enablers identified in this study (Table 2) provide useful datafor constructing an implementation plan for interventions tostimulate culturally appropriate care.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

This study was made possible by Grant No. 48000002 fromZonMw, the Netherlands Organization for Health Research andDevelopment. The authors would like to thank Atie van de BrinkMuinen, Olga Lackamp, Ludwien Meeuwesen and Karien Stronks,who took part in the study’s research group; Raynold Bruessing,Elsbeth ten Kate, Carin Miedema and Lydia Waterval for their helpin preparing the tools for the protocol; co-trainers Lizzy Brewster,Gert van Montfrans and Myra van Zwieten for their contribution tothe teaching course; Janneke Harting and Thomas Ploch for theirhelpful comments on an earlier version of this paper; and, most ofall, the participating care providers for taking part in this study.

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