Healthcare Professionals

The Chronic Diseases Initiative for Africa (CDIA) is a network of researchers, which promotes collaboration across universities, government departments and research organisations in the development and evaluation of interventions aimed at preventing and controlling chronic diseases of lifestyle. These include: cardiovascular disease, cancer, diabetes and hypertension. Its members include leading scientists from the universities of: Cape Town; Stellenbosch; Western Cape and Harvard, and the Medical Research Council. The CDIA also works in close partnership with the Heart and Stroke Foundation; the Cancer Association of South Africa and the Department of Health.

This manual forms part of a resource package for health care providers, called  ‘i CHANGE 4 HEALTH’, which includes educational/motivational materials for distribution to patients, on the topics of smoking, diet, physical activity and alcohol use.

The package has been designed to assist health care providers in South Africa to integrate brief behavioural change counselling into routine practice to prevent and control NCDs and to promote health and well-being. It aims to enhance the practitioner’s knowledge and skills to enable them to effectively motivate and assist patients make healthier lifestyle choices. The protocol and tools can be easily incorporated into usual clinical care and do not necessarily require any prohibitive or significant, additional investment of time and resources.

The package is applicable to both the private and public sector health service settings, although special attention has been given to tailor the education materials to the needs of patients or clients of lower socio-economic status, as this sector of South African society, generally, has less access to appropriate information on NCDs.

Rationale

The burden of mortality and morbidity from chronic diseases of lifestyle or non-communicable diseases (NCDs) in South Africa is predicted to increase substantially over the next few decades. The leading causes of NCD related deaths in South Africa are, as in the rest of the world, cardiovascular disease; cancers; chronic respiratory disease and Type 2 diabetes (Bradshaw et al., 2011).

NCDs are associated with four particular behaviours – an unhealthy diet, physical inactivity, tobacco use and the harmful use of alcohol. These behaviours lead to overweight and obesity, high levels of blood glucose and cholesterol and raised blood pressure, which are the main risk factors for NCDs. Improving health behaviour is an important means of addressing health disparities in SA, because those who are economically and socially disadvantaged, disproportionally bear the burden of NCD risk (Mayosi et al., 2009).

NCDs are significant contributors to a growing public health burden in South Africa, which threatens social and economic development, as well as the sustainability of the health system. Yet, effective interventions which support healthier lifestyles can alleviate, and even prevent the problem (Renehan & Howell, 2005). Such interventions involve measures at a macro level which create enabling environments for healthy lifestyles through policy and legislation, and interventions at an individual level which promote behaviour change.  It is here, that health care providers have a vital role to play in encouraging and supporting their patients or clients to make and maintain healthier lifestyle choices.

Major reviews of the research on lifestyle interventions show that brief behaviour change counselling by health care providers can be effective in changing NCD risk behaviours and improving self-management among patients with existing chronic conditions (Whitlock, 2002; Artinian, 2010).

The South African government’s recent national strategic plan to control the NCD epidemic (Department of National Health, 2012) places a strong emphasis on the need to improve the detection, early intervention and management of NCD lifestyle related risk factors, particularly at the level of primary health care. This includes a focus on strengthening the capacity of health service staff to provide brief counselling on the main lifestyle risk factors for NCDs.

References:

Artinian N, Fletcher G, Mozaffarian D, Kris-Etherton, Van Horn L et al. (2010). Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation (122): 406-441.
Bradshaw D, Steyn K, Levitt N, Nojilana B (2011). Non–communicable diseases – a race against time. Chronic disease Initiative for Africa, Department of Medicine, University of Cape Town.
Department of Health, Republic of South Africa (2012). Draft Strategic Plan for Non-Communicable Diseases, 2012-2016.
Mayiso BM, Flisher AJ, Lalloo UG, Sitas F, Tollman et al (2009). The burden of non-communicable diseases in South Africa. Lancet 374 (9693): 934-47.
Renehan AG and Howell A (2005). Preventing cancer, cardiovascular disease and diabetes. Lancet; 365 (9469): 1449-51.
Whitlock E., Orleans CT., Pender N., Allan J (2002). Evaluating primary care behavioural counselling interventions: An evidence-based approach. A Review. American Journal of Preventive Medicine 22 (4): 267-284.

This manual provides:

Information on the burden of NCDs in South Africa, the main risk factors and the potential for prevention. A clear rationale for why behaviour change counselling for NCD risk factors should be considered a vital element of primary care practice
The evidence base for brief behaviour change counselling (BBCC) interventions and a description of current best practice methods and approaches Adapted best practice guidelines which offer a simple framework for counselling patients about smoking cessation, a healthy diet, physical activity, alcohol use and overweight/obesity
Tools to assist the practitioner in broaching the subject of behavioural risks and jointly negotiating health goals. Suggestions for how to integrate BBCC into routine primary care, acknowledging the typical constraints of time and resources.A directory of other available resources, which may be useful for improving practice in this area

Who could benefit from using this manual

This manual is intended for use by a variety of health care providers, including medical doctors, nurses, dieticians, nutritionists, health promoters and biokineticists. The intervention proposed in this manual is relevant to any consultation where lifestyle change needs to be addressed in order to prevent NCDs or more effectively control an existing chronic condition. Whilst it is aimed chiefly at primary care providers, it is also appropriate for health professionals in the specialist fields of diabetes, hypertension, cardiovascular disease and cancer, as well as for various allied health professionals.
This manual may also be helpful to the cadres of health promoters and nurses employed by civil society organisations, such as the Cancer Association and the Heart and Stroke Foundation.

It can also be used as a resource in the training of lay counsellors or community health workers, but in this situation, it needs significant adaptation and simplification.

How to use this manual

This manual is designed for flexibility. The intervention can be used opportunistically or in a planned way, by one practitioner or by a health care team. How you use the manual depends on to what extent you wish to or can incorporate such prevention strategies into your clinical practice. You may simply browse through the manual for new ideas or to familiarise yourself with current, best practice approaches in order to enhance what you are currently doing. Alternatively, you may choose to closely follow the proposed framework for intervention and make full use of the support materials which accompany this manual (also hosted on this website).

This manual can be a helpful resource in the training of health care providers in counselling and communication skills, either in-service, as part of continuing professional development, or in an academic context. It can also be used to develop and plan the roles of various staff within a particular practice to establish a consistent approach for improved NCD risk factor assessment and management.

If you are interested in receiving expert training in this area and earning CPD points (8 points, level 1), the Division of Family Medicine and Primary Care at the University of Stellenbosch, at times, offers an accredited short course in Brief Behavioural Change Counselling (BBCC), which is based on this approach.

For enquires in this regard, please contact Professor Bob Mash: rm@sun.ac.za or Dr Zelra Malan: zmalan@sun.ac.za You can also earn 3 CPD points in level 2 through self-instruction, if you read this manual thoroughly, complete and submit the MCQ questionnaire and achieve a pass rate of 70%. The questionnaire can be downloaded and submitted online at: WEBSITE address

Acknowledgements:

• The research for the development of this resource package was funded by: The Cancer Association of South Africa; the University of Stellenbosch, United Health and the Medtronics Foundation.
• The production and printing of the guide and the other materials in the resource package, as well as the training of a number of health care providers around the country has been sponsored by PharmaDynamics.
• Expert working groups were convened to develop the 5A protocols for each NCD risk factor and the content of the patient educational materials. The valuable input of the following individuals is gratefully acknowledged: Professor Krisela Steyn, Professor Dinky Levitt, Professor Vicki Lambert, Ms Clare Bartels, Dr Catherine Draper, Dr Kolbe-Alexander, Ms Erika Ketterer, Ms Lucy Gericke, Ms Jessica Bacon, Ms Victoria Clarke, Dr Anniza DeVilliers, Ms Deborah Jonathan, Ms Unita Van Vuuren, Dr Zaino Petersen, Ms Svenja Wolfromm and Ms Thandie Chuma.
• We would also like to acknowledge the vital contribution of individuals from various communities who participated in a series of focus groups to pre-test the education materials, as well as those who generously shared their personal stories for publication in the materials. Their contribution is very much appreciated.
• This manual and the training module were tested with groups of family medicine registrars, dieticians, biokineticists and nurses during the course of 2012 at the University of Stellenbosch. We gratefully acknowledge their valuable feedback in developing these practice support materials.