New countrywide training initiative to combat lifestyle diseases

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Ichange4healthA new approach to patient care has been launched, developed at Stellenbosch University and spearheaded by Pharma Dynamics. The training initiative, aimed at reducing chronic lifestyle diseases, is being introduced in medical school curricula and to practising doctors as continuing professional education, writes Karen MacGregor for MedicalBrief.

The resource, Brief Behavioural Change Counselling or BBCC, offers training on how to quickly and effectively advise patients about lifestyle adjustments that can help to reduce the epidemic of chronic lifestyle diseases which cause close to 40% of deaths in South Africa.

Already hundreds of health professionals have been trained in the course intended for medical doctors, nurses, dieticians, nutritionists, health promoters, biokineticists and health professionals in specialist fields of diabetes, hypertension, cardiovascular disease and cancer.

From this year, BBCC will be included in the undergraduate and postgraduate curricula of family medicine departments in all medical schools. Efforts to reach practicing doctors are being stepped up. Similar programmes have been rolled out in Australia, Canada and the United States – but this is a first for Africa.

The BBCC resource guide was funded by Pharma Dynamics as part of its umbrella wellness campaign, iChange4Health. It was researched and developed by the Chronic Disease Initiative for Africa, Stellenbosch University and the Cancer Association of South Africa.

Erik Roos, CEO of Pharma Dynamics, says doctors will now be trained to tackle the root cause of an illness from the outset, rather than just dealing with symptoms.

“Doctors will be armed with the necessary knowledge and skills to better evaluate a patient’s overall health status, based on diet, level of physical activity, smoking, alcohol intake and other risk factors – even if a patient looks healthy, a thorough assessment will be done, followed by recommendations. It is high time that more emphasis is placed on prevention.”

The research

The training flowed from research conducted by Dr Zelra Malan, postgraduate programme coordinator in the Division of Family Medicine and Primary Care at Stellenbosch University, for her PhD.

“As a doctor I was never trained to speak to patients about losing weight or stopping smoking or abusing alcohol. There was no structured approach in any programmes. I saw a need,” she told MedicalBrief.

Drawing on the expertise of colleagues, evidence from international and other bodies and interviews about existing preventative care training with students, doctors and academics, Malan helped to develop an eight-hour training programme that was offered to doctors and nurses – including the use of actors who posed as, for instance, smokers.

According to Malan, since the start of the pilot at the university in 2014 more than 600 undergraduate medical students and about 40 doctors specialising in family medicine have been trained in Brief Behavioural Change Counselling.

The trainees were monitored during and immediately after the training, and then again six weeks later when actors were sent anonymously into clinics with recorders to ascertain what trainees did in actual clinical practice.

The research uncovered statistically significant differences between treatment by doctors before, during and after training, indicating that it was effective. Then Stellenbosch trained one person from each of the eight family medicine department in universities across the country – training the trainers. They went back and are launching training at their universities.

Today the course has been implemented for undergraduate medical students from fourth year on, and has been incorporated into postgraduate training programmes – all doctors training as family physicians are being reached.

The training

The training comprises one-on-one, active, integrated workshops that include exercises – such as practicing reflective listening, to help doctors to move from a directive to a guiding style. A manual was written as an aid for healthcare practitioners, and it is used in training, along with info booklets for patients,

Educational and motivational materials for patients – on the topics of smoking, diet, physical activity and alcohol use – can be made available to practitioners on request.

“The training is built around what is called the ‘five As’, which has internationally been incorporated into primary care,” Malan says. These are five steps that give the doctor a structured approach to patients who need counselling.

The ‘five As’ are: Ask about risky behavior; then Alert the patient to the health risk and behavior linked to the health risk; then Assess the patient’s readiness to change; then Assist the patient by giving out leaflets or helping with a plan; and lastly Arrange a follow-up.

“What happened before was that the ‘five A’s’ could happen but the doctor used to be very directive – you should do this, you must do that. So the approach was very doctor-centred – the doctor came over traditionally as the expert and the patient was usually diminished or given a fright or a lot of information,” explained Malan.

“With the new approach doctors use the five As but in what we call a guiding style that is both doctor- and patient-centred with shared decision-making. The doctor acts more as a guide than an expert, realising that patients are experts in their lives and if something needs to change, the change will come from the patient. It is more about building up motivation.”

Malan and colleagues have published qualitative and quantitative feedback from the training (see academic articles below), including monitoring over time. “We interviewed people after the training to see how they experienced it and how it was making a difference,” she said. Also, whether previous difficulties doctors had in speaking to people had been alleviated.

Targeting practicing doctors

There is a drive underway to raise awareness of the Brief Behavioural Change Counselling among practicing doctors. BBCC is offered as a registered short course by Stellenbosch University, two to three times a year.

Malan says there has been training for doctors working with Medicross, which offers primary healthcare services through family medical and dental centres across South Africa, and for doctors and nurses working at Koeberg.

“With the Department of Health in the Western Cape we are busy with a chronic care programme in which we identify medical officers from clinics and clinical nurse practitioners, and hold one-day training for them.” This, she argues, “is a great vote of confidence from government”.

There has also been training of registrars in Botswana, and the Department of Health in Namibia approached Malan to do training there.


Asked about challenges, Malan said there were numerous barriers to effective counselling.

“The biggest barrier is time. Doctors are overwhelmed with a lot of patients, and speaking to somebody about something as sensitive as this takes time and you can open up this can of worms.”

Language is also a barrier. As part of the Pharma Dynamics package, four patient information leaflets have been developed but they are only in English. They are now being translated into isiXhosa and Afrikaans, to help overcome this barrier. The patient leaflets, said Malan, are quality material and are available on the website.

The training and its approach are themselves helping to overcome some barriers, says Malan.

Previously, doctors were often frustrated because they weren’t seeing results from the way they were counselling. With the new counselling, responsibility is shifted away from the doctor. “If the doctor does this intervention and the patient is not ready to change, it is fine. This lessens the frustration of the doctor.”

Also encouraging is that doctors know their intervention can be brief.

Further, Pharma’s Roos points out: “There is a considerable body of research that strongly supports the benefits of lifestyle change as a means of decreasing the risk of chronic diseases of lifestyle. Even modest changes in behaviour can substantially reduce morbidity and mortality. The objective is to ensure that every consultation counts, especially when it comes to helping people adjust their lifestyles.”

More information on the Brief Behavioural Change Counselling Programme:


A situational analysis of training for behaviour change counselling for primary care providers, South Africa

Authors: Zelra Malan, Bob Mash and Katherine Evere -Murphy


Background: Non-communicable diseases and associated risk factors (smoking, alcohol abuse, physical inactivity and unhealthy diet) are a major contributor to primary care morbidity and the burden of disease. The need for healthcare-provider training in evidence-based lifestyle interventions has been acknowledged by the National Department of Health. However, local studies suggest that counselling on lifestyle modi cation from healthcare providers is inadequate and this may, in part, be attributable to a lack of training.

Aim: This study aimed to assess the current training courses for primary healthcare providers in the Western Cape.

Setting: Stellenbosch University and University of Cape Town.

Methods: Qualitative interviews were conducted with six key informants (trainers of primary care nurses and registrars in family medicine) and two focus groups (nine nurses and eight doctors) from both Stellenbosch University and the University of Cape Town.

Results: Trainers lack con dence in the effectiveness of behaviour change counselling and in current approaches to training. Current training is limited by time constraints and is not integrated throughout the curriculum – there is a focus on theory rather than modelling and practice, as well as a lack of both formative and summative assessment. Implementation of training is limited by a lack of patient education materials, poor continuity of care and record keeping, con icting lifestyle messages and an unsupportive organisational culture.

Conclusion: Revising the approach to current training is necessary in order to improve primary care providers’ behaviour change counselling skills. Primary care facilities need to create a more conducive environment that is supportive of behaviour change counselling.


Development of a training programme for primary care providers to counsel patients with risky lifestyle behaviours in South Africa

Authors: Zelra Malan, Bob Mash and Katherine Evere -Murphy


Background: We are facing a global epidemic of non-communicable disease (NCDs), which has been linked with four risky lifestyle behaviours. It is recommended that primary care providers (PCPs) provide individual brief behaviour change counselling (BBCC) as part of everyday primary care, however currently training is required to build capacity. Local training programmes are not suf cient to achieve competence.

Aim: This study aimed to redesign the current training for PCPs in South Africa, around a new model for BBCC that would offer a standardised approach to addressing patients’ risky lifestyle behaviours.

Setting: The study population included clinical nurse practitioners and primary care doctors in the Western Cape Province.

Methods: The analyse, design, develop, implement and evaluate (ADDIE) model provided a systematic approach to the analysis of learning needs, the design and development of the training programme, its implementation and initial evaluation.

Results: This study designed a new training programme for PCPs in BBCC, which was based on a conceptual model that combined the 5As (ask, alert, assess, assist and arrange) with a guiding style derived from motivational interviewing. The programme was developed as an eight-hour training programme that combined theory, modelling and simulated practice with feedback, for either clinical nurse practitioners or primary care doctors.

Conclusion: This was the rst attempt at developing and implementing a best practice BBCC training programme in our context, targeting a variety of PCPs, and addressing different risk factors.


Evaluation of a training programme for primary care providers to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa

Authors: Zelra Malan, Bob Mash and Katherine Everett-Murphy


Objective: To evaluate the effect on clinical practice of training primary care providers (PCPs) in an approach to brief behaviour change counselling (BBCC), integrating the 5As (ask, alert, assess, assist, arrange) with a guiding style derived from motivational interviewing in the South African context. BBCC was focused on the four risky behaviours (unhealthy eating, tobacco smoking, physical inactivity, harmful alcohol use) for non-communicable diseases.

Methods: It was a before-and-after design, recording BBCC skills at baseline, directly after training and 6-weeks later. We evaluated each recording for adherence to the guiding style and delivery of the 5As using the Motivational Interviewing Treatment Integrity 3.1.1. tool, and a tool based on the 5As training design. Results: 123 recordings were collected from 41 PCPs. Results showed a significant improvement in adoption of the guiding style (e.g. global score at baseline 2.0 (2.0–2.6) and in clinical practice 3.0 (2.7–3.3) p < 0.001) and completion of the 5A steps (e.g. assist score at baseline 1.26 (1.12–1.4) and in clinical practice 1.75 (1.61–1.89) p < 0.001).

Conclusion: Training PCPs in this approach to BBCC is effective at changing their clinical practice in the short term.

Practice implications: The training programme should be integrated into the curricula of PCPs, and used in continuing professional development.


Qualitative evaluation of primary care providers experiences of a training programme to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa

Authors: Zelra Malan1, Robert Mash and Katherine Everett-Murphy


Background: The global epidemic of non-communicable disease (NCDs) has been linked with four modifiable risky lifestyle behaviours, namely smoking, unhealthy diet, physical inactivity and alcohol abuse. Primary care providers (PCPs) can play an important role in changing patient’s risky behaviours. It is recommended that PCPs provide individual brief behaviour change counselling (BBCC) as part of everyday primary care. This study is part of a larger project that re-designed the current training for PCPs in South Africa, to offer a standardized approach to BBCC based on the 5 As and a guiding style. This article reports on a qualitative sub-study, which explored whether the training intervention changed PCPs perception of their confidence in their ability to offer BBCC, whether they believed that the new approach could overcome the barriers to implementation in clinical practice and be sustained, and their recommendations on future training and integration of BBCC into curricula and clinical practice.

Methods: This was a qualitative study that used verbal feedback from participants at the beginning and end of the training course, and twelve individual in-depth interviews with participants once they had returned to their clinical practice.

Results: Although PCP’s confidence in their ability to counselling improved, and some thought that time constraints could be overcome, they still reported that understaffing, lack of support from within the facility and poor continuity of care were barriers to counselling. However, the current organisational culture was not congruent with the patient-centred guiding style of BBCC. Training should be incorporated into undergraduate curricula of PCPs for both nurses and doctors, to ensure that counselling skills are embedded from the start. Existing PCPs should be offered training as part of continued professional development programmes.

Conclusions: This study showed that although training changed PCPs perception of their ability to offer BBCC, and increased their confidence to overcome certain barriers to implementation, significant barriers remained. It is clear that to incorporate BBCC into everyday care, not only training, but also a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels.

Academic article links

A situational analysis of training for behaviour change counselling for primary care providers, South Africa

Development of a training programme for primary care providers to counsel pa ents with risky lifestyle behaviours in South Africa

Evaluation of a training programme for primary care providers to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa

Qualitative evaluation of primary care providers experiences of a training programme to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa


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