People who smoke and drink too much, don’t exercise and eat unhealthily are likely to suffer from non-communicable diseases such as heart disease and diabetes. They are also likely to die early. More than most, they need counselling on how to change their behaviour. This is important because it can ensure that scarce resources in the public health sector are used more cost-effectively.
But, in South Africa, counselling about non-communicable diseases and the underlying risk factors has, until recently, been particularly inadequate. Primary care providers are ill equipped to provide more than ad hoc advise on how to adopt a healthy lifestyle.
More than 38 million people die across the world from non-communicable diseases every year. Four groups of diseases are responsible for 82% of these deaths: cardiovascular diseases, cancers, respiratory diseases and diabetes.
According to the World Health Organisation 40% of deaths in the developed and developing world occur in people who are younger than 70. Of these, 82% are in lower- and middle-income countries.
In South Africa, non-communicable diseases are among the top ten leading causes of death. These have been on the increase, driven by risky lifestyle choices. Smoking, drinking excessively, a lack of physical inactivity and an unhealthy diet all contribute to high levels of morbidity and death from these diseases.
Although these can be changed, progress towards prevention has not kept pace with the rising burden of disease.
The effect of non-communicable diseases is felt by the individual as well as their families, communities and the over-burdened health system.
Research has shown that interventions that target people as part of a family unit and a community is more effective. For example, two 40-year-old men – one married and the other single – but both suffering from diabetes need a counselling approach that takes into account their lifestyles.
Doctors and nurses lack the know-how
In South Africa, patients are most likely to be counselled by public sector nurses or primary care doctors. Recent studies that assessed healthcare providers’ capacity to deliver behaviour change counselling show this service is inadequate in both the public and private sectors.
None of the nurses included in the study and only one-fifth of the doctors had excellent knowledge of the key issues around non-communicable disease risk factors.
Public sector nurses accept the role of providing counselling and about one-fifth believe they are knowledgeable. But they may have an inflated perception of their knowledge on how to modify a patient’s lifestyle for non-communicable diseases.
Primary care doctors also accept that they must deliver brief counselling and feel it is important. But they doubt their ability to effectively assist patients to change risky behaviours.
Aside from insufficient training, several other factors contribute to their lack of confidence to deliver counselling.
Many have faced several barriers which have discouraged them. These include:
a lack of patient education materials;
time and language constraints;
poor continuity of care and record-keeping;
conflicting lifestyle messages; and
an unsupportive organisational culture.
There is a need to revise the approach to training doctors to ensure skills can be learnt and transferred to the clinical setting.
Putting the patient at the centre
Current training for primary care providers in the Western Cape is not sufficient to achieve competence in clinical practice. Training is limited by time constraints and is not integrated into the curriculum. There is a focus on theory rather than modelling and practice as well as a lack of assessment.
To improve the current training programs, I designed, developed and implemented a best practice training program along with training materials and resources. The program, piloted in the Western Cape, targeted primary care doctors and nurses.
The training programme is based on a conceptual model that combines the 5 A’s: ask, alert, assess, assist and arrange. The training is based on a guiding style derived from motivational interviewing, which differs from the traditional directing style of counselling. This guiding style has been widely used internationally.
The program is designed to target all four risk factors associated with non-communicable diseases.
Traditionally, primary care doctors have been the expert advice giver. They try to convince the patient why, what and how they should change. But in the guiding style, the argument for change is evoked from the patient. Primary care providers are trained to expertly guide the shared decision making process.
This moves the counselling approach from provider-centred to patient-centered.
The program changed primary care doctors’ approach and skills to deliver patient centred counselling, at least in the short term. And it helped them develop the approach of the guiding style, which they were able to retain in clinical practice.
Training is not enough
Although training enabled primary care doctors to deliver better behaviour change counselling effectively, and increased their confidence, delivering it in a clinical environment remains challenging. Training alone is not enough to ensure that better behaviour change counselling is implemented.
There are still several barriers. These include:
lack of managerial support; and
poor continuity of care.
To incorporate better behaviour change counselling into everyday care, a whole systems approach is needed. This requires training primary care doctors to change their counselling behaviour, but also requires change at other levels.
For example, the current organisational culture is not congruent with the patient-centred guiding style of better behaviour change counselling. Asking primary care doctors to embody values of trust, respect and openness in an environment where they are experiencing manipulation, blame and control, is unrealistic.
Incorporating better behaviour change counselling into everyday care does not only require training, but also a change in the underlying supportive culture in primary care settings.