Empowering and educating patients — a new approach to managing diabetes
For many years, the focus of our health system has been on HIV, TB and maternal and child health, and the resources needed to treat diabetes and other non-communicable diseases have been limited. Now, however, diabetes has become a major public health issue.
Diabetes is the leading killer of women in South Africa and the second leading cause of death for all people in the country. One in four people over the age of 45 has diabetes and one in two have pre-diabetes or diabetes. In Cape Town alone, the public sector health services are treating more than 100,000 people with diabetes.
World Diabetes Day is on 14 November and this year the focus is on “the need for better access to quality diabetes education for health professionals and people living with diabetes”. The theme is “Education to protect tomorrow”. But why is education so important?
Diabetes is usually a lifelong disease that a person needs to understand and self-manage. It is not just a question of taking medication, but of changing one’s behaviour to feel well and reduce the risk of complications. In fact, education is not really enough; people need to be empowered and motivated. It is not just knowing about diabetes, but embodying a healthier lifestyle.
Most people living with diabetes have type-2 diabetes, with underlying overweight and obesity, an unhealthy diet and a lack of physical activity. Diabetes leads to further problems with the heart and blood vessels and complications such as heart attacks, kidney failure and strokes.
These problems are more likely in those who smoke tobacco, drink too much alcohol, and have high blood pressure and high cholesterol. Therefore, key behaviours to focus on are healthy eating, physical activity, tobacco smoking and alcohol use.
Most people with diabetes are treated in public sector primary care facilities by nurse practitioners or doctors. Unfortunately, three-quarters of people with diabetes are not well controlled and a third are very poorly controlled. A failure to educate and empower patients to self-manage diabetes and change their behaviour is a key factor behind these poor results. So, why are we so poor at empowering our patients?
Public sector primary care facilities are often overwhelmed with large numbers of people with chronic diseases and a long queue of patients to get through by the end of the day. Clinicians talk of “not disrupting service delivery”, and by this they mean not doing anything that would delay processing people as fast as possible. The focus is more on prescribing medication than on educating or empowering people, which takes time.
Mechanistic and impersonal care
Patients complain that their care is mechanistic, rushed and impersonal. One strategy to try to improve this is referred to as “differentiated models of care”. This means trying to look after the more stable patients in the community so that facilities have more time to help the unstable patients.
Another problem is that many health professionals have been poorly prepared to tackle lifestyle modification and empower their patients. In general, health professionals spend little time understanding the perspective of their patients and their circumstances. They tend to instruct, order, warn, blame and judge their patients, more than guiding and understanding them.
Often their expert knowledge of lifestyle modification is lacking. Health professionals, therefore, may lack the knowledge and skills to help patients make difficult decisions about changing their behaviour.
Stellenbosch University’s Division of Family Medicine and Primary Care has developed several initiatives to try to tackle the problems with patient empowerment. First, a new model of brief behaviour change counselling has been developed. This model provides health professionals with a structured approach to discussing behaviour change and helps them to adopt a more guiding style. The structure is based on the 5As (ask, alert, assess, assist and arrange).
The guiding style of communication emphasises that the interaction should be collaborative, empathic, respectful, evocative and yet focused. The approach is brief and can be completed within five to 10 minutes. Health professionals can learn this new approach in six to eight hours using either face-to-face or online education. Nevertheless, some clinicians feel that even this adds too much time to the consultation if you are going to get through the queue.
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Another approach is to engage groups of people with diabetes outside the consultation. This group empowerment and training (Great) of healthcare workers for diabetes is being implemented in five provinces of South Africa.
In this cost-effective approach, people with newly diagnosed or poorly controlled diabetes meet four times in a group of 10-15 people with a trained facilitator who could be a health promoter, a nurse, a dietician, or any health professional that is available and appropriate. The four sessions focus on understanding diabetes, lifestyle change, taking medication and avoiding complications. Facilitators use a guiding style that encourages interaction and activities in the group.
This approach has been positively received by patients. Implementation is ongoing, but hindered by a lack of space for groups to meet, a need for support from the whole healthcare team, and the need to embed the organisation of this into appointment systems and patient flow.
A further innovation was prompted by the Covid-19 pandemic and involved digital solutions. Most people with type-2 diabetes, even those living in poorer communities, have access to a smartphone.
During the pandemic, a WhatsApp chatbot was developed to provide education to people with diabetes via short voice notes and graphics. The content of Great for diabetes was redesigned for the chatbot. People could automatically receive 16 voice messages over a period of a month. The total programme was only 90MB of data at a cost of less than R20. These voice messages were then available for repeated listening or to pass on to other people.
The chatbot does not require any consultation time and speaks directly to people with diabetes. In fact, it may even save time in the consultation, as clinicians can just explain how to access the chatbot. The pilot in the Western Cape reached more than 8,000 people in multiple languages and the feedback was very positive. Unfortunately, in 2022 the chatbot was discontinued, because of issues with policy and procurement, and the need for ongoing funding.
The combination of brief behaviour change counselling, group empowerment and digital solutions should meet the needs for education and empowerment of people with diabetes in the public sector. World Diabetes Day would be a good time for policy- and decision-makers to commit to the implementation of such a package. DM
Prof Bob Mash is a family physician and the executive head of family and emergency medicine at Stellenbosch University. He is the president of the South African Academy of Family Physicians, the professional body for family physicians.