Sweet Life is South Africa’s diabetes community: a space to share information and advice about living well with diabetes, both here on the website and on Diabetic South Africans. But we’re also involved in diabetes education research – a big focus for 2020. Each month, we’ll be sharing the research we’ve done into diabetes education in public clinics, in the hopes that it helps someone else looking for answers to diabetic questions! This is the January report, be sure to scroll to the bottom of the page for the other months.
Background to the diabetes education project:
Sweet Life is currently working with the National Dept of Health and we recently formed the Diabetes Alliance (www.diabetesalliance.org.za) which is an alliance of all the diabetes organisations, associations and companies in South Africa. One of the priorities for NDoH and the Diabetes Alliance in 2020 is to work on diabetes educational materials in public clinics.
Our original plan was a targeted project in the Western Cape, working with Prof Joel Dave and distributing information to the Western Cape public diabetes clinics in various formats, including print (posters and leaflets) and WhatsApp. Working with a behavioural scientist, we planned to figure out which format is most effective, what messaging works best, what language the information should be in, how to illustrate it and what information people actually want (rather than giving them what we think they want).
Prof Dave pointed out that in order for the research to be usable, it needs to be conducted by an academic team, and perhaps such research has already been done.
To find out what research has been done in diabetes communication in public clinics in South Africa, and connect with those who have done the research to get further information. To identify other areas of research (like HIV) that could be applicable.
Relevant diabetes education research:
- Perceptions of patients regarding diabetes-related health communication strategies in the Free State, South Africa
- Development of a health dialogue model for patients with diabetes: A complex intervention in a low-/middle income country
- Health Dialogue: a concept analysis
- Quality of care delivered to type 2 diabetes mellitus patients in public and private sector facilities in Johannesburg, South Africa
- Current policies and practices for the provision of diabetes care and self-management support programmes for older South Africans
- A pilot investigation into the readability of Sesotho health information pamphlets
- Development of a Sesotho health literacy test in a South African context
- Implementation of diabetes group education (DLECA) in South Africa, WDF17-1534
- An Observational Checklist of Health Dialogue Elements (OCHDE): Development and evidence of reliability (PDF)
- Diabetes-related knowledge, attitude and practices (KAP) of adult patients with type 2 diabetes in the Free State, South Africa
- Knowledge, attitude and practices [KAP] of healthcare workers in the Free State, South Africa regarding type 2 diabetes mellitus
- Communication strategies to accomplish effective health dialogue in adults with chronic diseases in low- and middle-income countries: An integrative review.
- Mobile health devices used to support a compliant lifestyle in patients with chronic diseases: a systematic review
HIV focus that could be relevant to diabetes education:
- Effective interpersonal health communication for linkage to care following HIV diagnosis in South Africa.
- Development of a national campaign addressing South African men’s fears about HIV counselling and testing and antiretroviral treatment.
- Assessing the Print Communication and Technology Attributes of an Academic Medical Center
- Health Communication and the HIV Continuum of Care
- Design and evaluation of a drama-based intervention to promote voluntary counseling and HIV testing in a South African community
Notes from research:
A health dialogue model
- A health dialogue model focuses on the interaction between healthcare provider (HCP) and patient, rather than the top-down approach usually seen in health education. “Our culturally sensitive health dialogue model has the potential to improve adherence to treatment, leading to greater satisfaction and consequently improved health outcomes.” Dr Marianne Reid, University of the Free State
Health dialogue seems to make much more sense for diabetes because the condition requires the patient to be involved in their own health – it’s not just about taking medication, there need to be lifestyle changes.The more engaged the patient is, the better the outcomes.
- Key messages identified for patients with diabetes:
- Diabetes can be controlled and complications prevented
- Eat small regular meals
- Walk fast for at least 30 mins most days
- Take medication as prescribed
- Lose weight as prescribed
- Patients with diabetes can enjoy normal lives
This research was done in the Free State. Would these messages apply nationwide? People can only remember 3 things at a time, so ideally we want to choose 3 to focus on this year.
- In order for printed pamphlets to be successful, they should be tailor made to address all patients, and especially those of low literacy. These pamphlets should be on an accessible level (ideally at a readability level 7 or lower – Grade 7 education or lower – to accommodate possible low schooling levels).
The question is also whether printed material is the best vehicle for information. Patients are bombarded with posters and pamphlets at local clinics, and most of them sit in the waiting room on their phones. Wouldn’t sharing information through mobile phones be more useful?
- Health literacy (HL): Four essential competencies of HL include accessing, understanding, appraising and applying health-related information. Each competency is linked to related skill dimensions. Access to health care depends on patients’ ability to find health-related information and navigate health systems. Understanding health information is influenced by patient’s literacy, numeracy and comprehension skills. It is only possible for patients to appraise health information if they are able to critically evaluate health-related decisions. In order to apply these decisions, patients need skills enabling them to communicate on health subjects, apply health information to changing environments, take responsibility for their own health care decisions and express confidence in accomplishing personal and community health. Patients navigate the mentioned competencies and related skill dimensions within three domains, those of health care, disease prevention and health promotion.
Health literacy is a complicated topic and can’t easily be equated to reading literacy, as it’s not just about being able to read the words, but internalise and understand them.
- The healthcare provider should use a multi-strategy approach, for example, one-on-one communication augmented by brochures or mobile messages to reinforce the message.
We can’t expect HCPs to communicate all the relevant knowledge about diabetes, diet, medication adherence, physical activity and lifestyle changes in the short space of time they have to share with the patient.
- Storytelling as a method to convey diabetes information: This communication medium holds potential for breaking through communication barriers and since it carries cultural significance; it is trusted and influential amongst indigenous groups.
Storytelling and health education
Perhaps there’s a chance to collaborate with Gcina Mhlophe (South Africa’s favourite storyteller) and create stories in English, Xhosa and Zulu (her three languages) that share the essence of the diabetes messaging we want to spread. But how could these be distributed in the clinics? Audio? Video?
- Developed an intervention based on the Xhosa tradition of intsomi, in which storytelling is used as an educational tool. Traditionally, intsomi stories often include a mixture of historical and mythical characters, and focus on topics including personal relationships, rites of passage, and marriage.
- Specific topics for these sketches were identified through local community consultations. A diverse team, including the educators, medical personnel, and the dramatist, compiled the sketches together to ensure local appropriateness and accuracy of the content.
- Community artists and dance groups, public health care services and health workers, community radio stations and community members; researchers can design folk media diabetes awareness street campaigns, that can be performed in various health care services during the month of November
I love this idea but I’m not sure how feasible it is right now… perhaps something for the future?
Awareness of community norms
- Social and community network norms (eg, views on manhood, culture, HIV stigma, perceptions of treatments, and other belief systems) influence men’s health-seeking behavior in a number of ways, including how men make decisions about whether or not to seek help, where, and from whom. For example, where masculinity is framed as being strong and not needing help, and where cultural beliefs associate weakness with illness, men are less likely to seek help at health facilities.
I think this is so important to remember: that many people (particularly men because of the diabetes and impotence connection) may be reluctant to get treatment.
- The men interviewed stated a preference for advertisements that are humorous because these facilitate interpersonal discussions.
A superb example of a humorous HIV ad: Negative or positive, you’re still the same person
How can we bring this kind of creativity to diabetes?
Further clarity from Dr Marianne Reid:
How widely used is the term health dialogue?
In SA and Africa and USA, the words we use are health education, health counselling, health promotion. They all have a top-down approach: “I’ve told you what to do – why haven’t you done it?” It’s important for people with diabetes to be equal partners in their own treatment. It’s about the patient taking responsibility.
The biggest obstacle with health dialogue is the healthcare provider. They don’t want to get off their pedestal. It’s safe if I can say: I know what to do, these are the facts. It’s a totally different ball game to say: I have certain expertise and knowledge, but you as the patient have different skills that you bring to the table. It’s a mind switch. The biggest challenge is honestly the healthcare worker themselves.
What (if any) training in communication skills is currently done in public clinics?
Training overall in primary health care clinics is a serious problem. That’s exactly where I was involved. People do not get regular in-service training. Something like communication skills are non-existent. Completed a study in the Free State with nurses on when last did you get diabetic training – the answer was 20 years ago. I don’t think it differs much in the rest of the country. The basics are often neglected. I want to say that there’s lots of excuses – the whole system is overburdened. Burnt out healthcare professionals, can’t take it all on.
Has anyone in SA assessed the current diabetes educational material, as was done in this US research project? I know it was done for the Sesotho health pamphlets, but has it been done for the English ones?
Not that I’m aware of. Why we went for Sesotho is that it’s the predominant language in the Free State health sector. The results were Grade 4 to 7 in Sesotho, in English the health literacy would probably be even lower. If you talk about health literacy, it’s not equal to literacy. If you pass Grade 7 in SA, health literacy is probably two grades below that. So we really have a problem there. I worked with a communications scientist when we looked at the readability level and you’ll see we had to call it a pilot because there wasn’t enough material in Sesotho.
In what context do you see the Sesotho Health Literacy Test being used?
We wrote it with the public health sector in mind – using the material they use. It’s only 10 questions, so it takes 10 mins. Content wise, I suspect because the clinics and the profile of people are similar, one can expect that it would translate nationally, but that would have to be tested. There are many health literacy tests available in the world, but they are not usable in SA. It’s also on the side of the patient to come in and take responsibility for their own condition. To be told that they have permission to ask your doctor questions. You should never leave a doctor’s office without understanding what’s going on with your health.
Do you think the 6 key messages identified for patients with diabetes (from the KAP surveys) are nationally relevant?
We did this in the Free State public sector. I can’t say it will be the same nationally, but I suspect it will be very similar. We got the same messages from various studies – patients, HCP and community members who don’t have diabetes but support those who do.
Because of all the detail people with diabetes have been bombarded with, they come out with funny things like red apples over green apples. We actually didn’t differentiate between newly diagnosed or not since we got these messages from community members.
Has there been much research done into mobile health device education?
I’m busy with a lecturer at Ulster University in Ireland, doing a scoping review of mobile reviews within Type 2 diabetic patients. Bulk SMSs could play a role. But how do you make it interpersonal, specific, part of a health dialogue? You could tailor it depending on where they are in their diabetes journey. Funding is an issue. Most of the public health clinics in the Free State are blocked for not phoning out cell phones because of the cost. Maybe MTN or Vodacom could get involved?
Met with Katusha de Villiers from the Bertha Centre for Social Innovation at the UCT Graduate School of Business. She suggested looking for similar diabetes education projects in other parts of Africa and Asia, and looking at what other chronic disease associations are doing.
She also pointed out the importance of focusing on the process rather than just on outcomes: we are now at the stage where we’re asking National DoH for meetings, we’re setting the agenda, we’re sending out the invitations. When they ask for the meetings, set the agenda and send out the invitations we need to recognise that as a big step forward. Sometimes focusing only on outcomes can be demoralising: we need to recognise the steps along the way.
Next steps: February diabetes education
- Research mhealth and diabetes – see which apps are available and how they could help.
- Meet with Prof Zandile Mchiza , from the School of Public Health at the University of the Western Cape to discuss overlap with her work.
- Meet with Prof Priscilla Reddy from the HSRC to discuss their diabetes projects for the year.
- Meet with Prof Bob Mash from the University of Stellenbosch to discuss GREAT (GRoup Empowerment And Training) for diabetes.
- Meet with Prof Dinky Levitt from CDIA (Chronic Diseases Initiative for Africa) at UCT.
The 2020 Diabetes Education Project by Sweet Life is supported by Pick n Pay and BD.