The goal of this community-based project was to adapt and determine the acceptability of an evidence-based hypertension educational pamphlet tailored to fit the needs of a local Indo-Asian population. Working with members of the target community to identify culturally specific educational needs, language preferences and to test the suitability of the materials allowed us in a five step process, to effectively adapt and translate existing evidence-based English language educational materials. Overall, participants found the educational tools highly acceptable. Participants felt the written and pictorial information was presented in a comprehensible fashion that helped them to better understand hypertension, its complications, treatment and prevention.
Development of these highly acceptable materials can be attributed to the active participation of and the strong partnership with the Indo-Asian community. Ninety-nine percent of the 100 CHAMP follow-up program participants agreed to evaluate and 90% had read the educational materials, suggesting a willingness to learn and play a role in program planning. Further, the target community was pivotal in securing the quality assurance of the materials at all steps of the development and evaluation.
Although self-selected, the 99 respondents had CVD risk factor profiles similar to those of the 248 participants that qualified for the initial CHAMP sessions, and to those reported in the literature . The majority were at high risk for CVD with a high prevalence of uncontrolled risk factors. Despite this, 55/99 or 55% did not report having hypertension or related medication use and less than 10%, reported having experienced any CVD events. This mixed group represents an ideal target group for these educational materials whose objective is to promote improved awareness, increased prevention and management of their modifiable CVD risk factors.
Extensive literature and web-based search revealed that other than resources provided by the Heart and Stroke Foundation (http://www.heartandstroke.ca. Accessed October 12, 2009) dealing broadly with heart disease, stroke and their risk factors, these materials are unique as hypertension-specific educational materials that are appropriately translated for the Indo-Asian community. As such, these materials have the potential to address the awareness, prevention and treatment gap for hypertension in this high risk population.
There are several limitations to this study that need to be addressed by further research. First, initial CHAMP sessions provided an excellent forum to disseminate the adapted and translated Public Hypertension Recommendations. However, at the follow-up sessions, each participant took approximately 25 to 30 minutes to complete the ICA-CHAMP project procedures after which they completed the educational tool evaluation questionnaire. Time and the quantity of information relayed to the participants may have rendered them less attentive to the evaluation procedure. Additionally, the average 8.5 months between receiving and evaluating the materials may have affected recall and be responsible for those that did not provide a response or answered "Not sure why" to the question (Table 1), "Please tell us what part was difficult" or "Do not know what" to the question (Table 1), "What information specifically was missing?"; although participants made no mention of this being a problem.
Secondly, we did not evaluate the literacy skills of our participants prior to their evaluating the educational materials. Careful review of the literature revealed no validated methods of testing literacy levels in Indo-Asians. However, one study  piloted a brief literacy assessment in their British study of South Asians with diabetes. Some of the information collected in this assessment was obtained in our study; such as language preference, and reasons for not reading the materials. However, due to possible sensitivities around admitting the inability to read, this cannot be assumed to represent any form of literacy assessment. To compensate for this, we involved the target community in all steps of the development and evaluation of the materials. Reading grade level is a quantitative determination of reading difficulty and estimates the average grade level a person must have completed to be able to understand the (English) material. The goal for our materials was a grade level of six. There are no data on literacy skills of Indo-Canadians. However, there are data  suggesting that immigrants whose mother tongue is neither English nor French are almost three fold more likely to have low literacy skills (i.e. at the 6th grade level or below). Furthermore, the Fry , and Flesch-Kincaid  are two accepted methods that consider a grade level of six or below as being superior for learners with low health literacy levels [22, 24].
Coupled with the simplified pictures and diagrams, we were able to achieve a high degree of attention (interest in reading the materials) and acceptability in this population that clearly encompassed a broad range of literacy levels.
Thirdly, only three participants evaluated the Dari and none evaluated the Hindi versions, thus not allowing us to form any conclusions on these versions. Future interventions will strive to include more Hindi and Dari speaking participants in order to evaluate these educational materials.
Finally, because the participants in this small study (n = 100) were self-selected and not recruited in an epidemiological fashion, they are unlikely to fully represent the diversity within the Calgary Indo-Asian community itself. This may have lead to a bias favouring the characteristics of the particular groups represented herein, thus limiting the generalisability of study findings beyond this research setting. Additionally, this study design excluded those participants that cannot read. Larger, epidemiologically designed and controlled studies of health information delivery (e.g., audio-forms) need to be undertaken in order to include those who cannot read, those whose language has no written form  and those Indo-Asian sub-cultures not adequately represented herein. On the other hand, 66% of the sample read the English versions, which is consistent with the 2006 census data  indicating that 70% of Calgary's Indo-Asian community speaks English. This suggests that our study population may be somewhat representative of the large proportion of English speaking community members that may benefit from educational materials in English.
There is an abundance of literature guiding the development of health educational materials for low literate and multi-cultural populations. However, the vast majority of this research involves evaluating health educational materials that are written (or illustrations captioned) in English. Furthermore, there is a dearth of literature on health education research in hypertension for Indo-Asians. However, review of the most relevant literature reveals a consistent emphasis on the importance of cultural assessments, involving the target audience and the importance of accounting for low rates of literacy, even in the learner's native language [22, 24, 29, 33].
The importance of involving our target audience in this health education and research was best exemplified in a British study of South Asians with diabetes . The collection of questionnaire data dealing with diabetes self-management was found to be problematic because patients had poor literacy skills and failed to understand the meaning of the questions. The collection of valid data was compromised. To overcome this barrier they recruited individuals with diabetes from the community to participate in focus groups to successfully address and modify the content and mode of delivery of a self management questionnaire. In a similar fashion, Kai and Hedges  successfully used training and facilitation of resident community members to conduct semi-structured interviews within their own communities to inform the development of a service delivery model aimed at addressing a disparate ethnic health need.
Our five step iterative approach to the development and evaluation of the materials mirrored, in part that of Makosky and Daley . For the cross-cultural adaptation of materials for Native Americans, they also used a modified SAM, in addition to two independent readability assessments along with target community input to successfully tailor and evaluate educational materials on smoking cessation in English. Specifically, they also found the SAM assessment inadequate for determining cultural appropriateness, suggesting that current validated tools may not be fully relevant or valid for non- English speaking people and used a learner verification method to modify their original untailored educational tools. Content experts undertook rigourous scientific review of their untailored materials while ours were originally developed by content experts. And finally, they had 2 independent individuals specially trained in the use of SAM review the materials, while we used a focus group format with a 12 member key informant team that was asked to review and comment on the materials guided by the factors outlined in the 17 point checklist and SAM tools.
We hired certified and experienced translators that unfortunately provided a very literal translation of the materials. This difficulty was addressed in our study by the process of back translation. This challenge was minimized in other studies [33, 37, 38] by the use of bilingual community members (with help from content experts) for the concurrent translation and adaptation of the original English source materials. Conceptual and cross-cultural equivalence of the materials was achieved in fewer steps and the process obviated the need for formal assessment of the original versus the adapted English versions.
The goal of this project was to tailor and evaluate the acceptability of the adapted and translated versions of an existing English version educational pamphlet. We did not formally evaluate the superiority of the adapted against the original English version. The adapted English version was designed following the recommendations of the 12 member key informant team. They had carefully reviewed the original version following the 17 point checklist of attributes and the SAM protocols along with making suggestions aimed at rendering it more culturally appropriate. Further, along with the readability assessment, and the informal assessment by the 56 English reading community members, the adapted version was considered at least equivalent to the original. Paradoxically, 90% of the individuals who originally stated that the original was no more difficult to understand than the adapted version stated that the pictures in the adapted version helped them to better understand the written information. This finding suggests at minimum, that the adapted version was equivalent or even superior to the original version. However, the question arises as to whether the original version even required adaptation for the English reading target audience. Further testing (below) will help to address this question.
All participants who read the translated versions of the pamphlet (Group 2) appreciated receiving the information in their language of preference and, like those in Group 1, found that the pictures helped to increase their understanding of the information. Further probing revealed that it was the additional pictures in the adapted version that assisted with a better understanding. This finding is supported by 2 review articles [39, 40] showing that adding pictures to written (and spoken) health information can significantly improve patient attention (interest and acceptability), recall, comprehension and behaviours. They also present evidence suggesting that if pictures are appropriately simplified, they can be particularly helpful to those with low literacy skills.
Given the high level of acceptability of these materials, we believe the materials (original, versus adapted, and translated versions) are ready for formal randomized controlled testing among English and non-English literate ethnic community members to determine whether the adapted version is superior to the original version and to determine the effect upon change in hypertension knowledge and health decision-making of each version.
Implications for further research and dissemination
A recent survey in Canada  suggested that immigrants whose mother tongue is neither English nor French are almost three fold more likely to have below basic (6th grade level or below) literacy skills. Since the majority of patient health information is written at a 10th grade or higher , a clear comprehension gap exists for much of the population. Tailoring health information to address lower health literacy skills can significantly increase acceptability, comprehension, recall and of particular importance, health behaviours [22, 39, 40] such as medication adherence.
The principles and methods of cross-cultural adaptation and translation of educational materials used in this study follow published guidelines [37, 41] and have been validated in numerous other settings; for example, materials for smoking cessation in Native Americans , for obtaining informed consent in Indo-Asians  and for quality of life measures for Hispanic American patients . The high level of acceptability of the materials within the target audience suggest that this process may be useful to other researchers who wish to develop targeted multicultural public educational materials for multiple purposes, within a broad range of multiethnic communities internationally.
It is imperative to involve the target community in identifying the key health issues as well as in the creation and review processes for health education materials [21, 23, 24]. In collaboration with the target community, we were able to modify the standardized/validated processes for creating and evaluating English language and translated materials to suit our target community. Scientific accuracy, reducing the complexity and achieving a 6th grade readability level, simplifying the pictures and finally, ensuring cultural appropriateness of the educational materials are fundamental to improving health literacy and patient engagement. If individuals do not have the capacity to obtain, process and understand basic health information, they will not be able to make appropriate health decisions.