Table 1 Cultural competence strategies informing program development

1. Defining research questions: Cultural knowledge

• Does the question reflect an authentic awareness of the culture?

• Our previous work in this population and pilot studies have established evidence on the current health problems prevalent in this population

• Has previous research related to the population been critically acknowledged?

• Follow up studies will be conducted to establish the extent of the problem

• How does the question relate to current health care problems?

• African Review Panel ensured that the methodology is culturally appropriate

• Is there an indication of knowledge of appropriate ways of developing and maintaining trust?

• Is the guiding methodology consistent with culture?

2. Cultural sensitivity

• What mechanisms are used to enhance cultural appropriateness?

• A cultural competence framework and community-partnered participatory approach was applied

• Do the participants define the health issue as a priority problem?

• African Review Panel and African bilingual workers were integral in advising about cultural appropriateness

• Is there evidence of a flexible process throughout data collection?

• Our previous research indicated this to be a priority problem for this sub-population

3. Collaboration

• Was the problem developed with the target population?

• Community consultation and collaboration occurred throughout the process – from the pilot studies to the development of the final HMFI program (refer to main text)

• At what level were the participants involved?

• The level of participation varied depending on the phase of the project – for instance, the ANGELO workshop was community driven, the pilot interviews were conducted by community members, and the community were consulted at numerous stages of the HMFI program development

• Were participants involved in the development and implementation of methodology?

4. Forming partnerships

• Did the researchers work through gatekeepers to establish peer educators (community workers who are of the same cultural background as participants matched to the culture, language, gender, age and life stage of the research participants)?

• Formation of partnerships with community gatekeepers was essential in collecting pilot data – often the person collecting the data was required to seek permission from the President (gatekeeper) of the community before commencing work within the community group. The same will be vital in implementing the program.

5. Identifying data sources and target populations

• Do the researchers recognize their own cultural framework and its influence on the research approach?

• African review Panel and African bilingual workers ensured that a culturally congruent approach was maintained

6. Appointing staff

• Did the researchers ensure involvement of peers, not just community gatekeepers?

• The African Review Panel and African bilingual workers are both composed of a range of people – some are community gatekeepers, some are community-nominated, and some are involved for other reasons e.g. they have work experience or a personal interest

7. Recruitment of sample

• Do the researchers recognize diversity within cultural groups?

• The African Review Panel and African bilingual workers are key in assisting the researchers in understanding the cultural diversities within the African communities

• Recognize potential power imbalances in working and consultation?

• To minimize power-balance effects, participant recruitment utilized a strategy where communities elected one of their own for training in recruiting families to the study and conducting the interviews.

• Recognize differences in defining language and cultural identity?

8. Data collection

• Is the methodology responsive to cultural and migration considerations (e.g. family groups rather than individual interviews, use of professional interpreters rather than family members)

• The methodology was culturally appropriate due to input from the African Review Panel

• Were data collected by local community organizations or community members?

• Data for the pilot studies were collected by community elected members who received training in data collection methods (e.g. interview techniques, ethical considerations)

9. Analysis/evaluation

• Were peer educators involved in the analysis and interpretation of the data?

• Two community forums were held to present and discuss the results of the pilot studies and discuss the plans for the program

• Was there feedback from the participants to confirm the results?

• Feedback was also sought from the African Review Panel into the content of the program

10. Reporting/disseminating findings

• Was there an opportunity for the community to discuss findings and generate solutions?

• In addition to the community forums and African Review Panel meetings (see box above), the ANGELO process (on which one of the pilot studies was based) [25] allowed the community to generate their own solutions, which fed back into the HMFI program plan