23. Jun 2015

In South Africa, changing habits to improve health

Gwendolyn Carleton
Agents for Change is teaching people how to live healthier lives – and the government is taking note.
Agents for Change graduates in Ventersdorp celebrating completion of the programme.
In South Africa, developing diabetes is easy. Eating habits have changed, with processed and convenience foods consumed like never before. Extra pounds are viewed, by many, as a sign of health and beauty. Obesity is on the rise. 
Yet in South Africa, managing diabetes can be very difficult. Misconceptions that diabetes is contagious, a death sentence or the result of witchcraft are still common. Some people don’t take prescribed medications, preferring traditional remedies, and many resist changing their lifestyles. The estimated diabetes prevalence in South Africa is now above 8%, yet the country’s health system, geared to treating infectious diseases such as HIV and tuberculosis, is struggling to keep up.
WDF supports a programme working to change this. A programme for healthcare workers in rural areas called Agents for Change, it teaches the importance of lifestyle change when living with a chronic disease. Participants attend two intensive 2-day workshops, six months apart, in each designated region, where they learn about self-management of diabetes, the importance of peer support, and how to help themselves, their colleagues and their patients motivate themselves to change their habits for the better. 
Buyelwa Majikela Dlangamandla, a diabetes educator who is a member of Diabetes Education Consultative Section (DECS) of the International Diabetes Federation, trains the healthcare workers in diabetes management and behavioural change. Many need to lose weight themselves – and by the end of their training, many have (by the end of WDF11-590, 63% of healthcare workers who needed to lose weight had done so, and 80% had increased personal exercise.) 
Collaborative and respectful
Once they complete their training, they are ready to begin teaching others in their communities.
“At the beginning of each course, we give participants a tape measure,” says Noy Pullen, Diabetes South Africa project manager for Agents for Change, who manages the course. “The ideal in Europe is 80cm for a lady’s waist – in Africa, that’s often the size of a lady’s thighs! So we focus on what you are doing about your health, not on the numbers. We use a buddy system to help them keep the promises they’ve made.”
The approach is collaborative and respectful, she adds. “We ask them, what do you want to do these two days? Then we work in the clinical information around their questions and concerns.” 
Agents has trained more than 1,500 healthcare workers and reached more than 100,000 South Africans since 2008.  The programme does not work for everyone, Noy says – yet after six months, a majority of participants have lost weight, decreased their waist circumference, and are exercising more. 
“On the final day of the course, we give them a skipping rope, which they absolutely love,” Noy says. “You see these huge ladies: they participants of all ages, shapes and sizes scream with joy, run outside and start skipping.”
Making a smarter system
The World Diabetes Foundation began supporting Agents for Change in 2008. In June 2015, Martin Wolf Andersen and Susanne Olejas attended Agents for Change seminars in Western Cape and North West Province during a field visit.
“South Africa has a chronic deficit of doctors, so it is often nurses at primary level clinics and community caregivers who meet patients. They have limited training, and so much responsibility – TB, HIV, non-communicable diseases. Agents is providing tools and structure for behavioural change, an important part of everything they do,” Martin Wolf Andersen says.
The programme coincides with a push in South Africa to re-engineer primary healthcare. In 2011, the South African National Department of Health unveiled the human resources in health (HRH) and revitalisation plan. During their visit, the WDF representatives met with government officials to exchange ideas.
“Budget allocations now are mainly for AIDS and TB, but leaders are seeing priorities in NCDs,” Phumzile Xaba, from the South African Ministry of Health, explained during one meeting. Other government representatives noted the need to support nurses – the backbone of South Africa’s health system – and to ‘make the system smart’, so it can manage the many burdens placed upon it.
“I’ve rarely seen a country where the Ministry is so engaged,” Susanne Olejas says. “We will be working with the government – we want to support and stimulate their strategy for re-engineering primary care in South Africa and look at how we best can support the capacity building of doctors in parallel.”
“Diabetes is a complex disease that should not be managed by nurses alone,” she adds. 
“So once the primary care plan is in place, the next step will be to build the secondary care level – and with it, specialised diabetes care. We hope to be a partner at this level, as well.”
For more information, see:
Agents for Change: champions in the fight against diabetes in South Africa (Diabetes Voice, June 2009 | Volume 54 | Issue 2)