People who engage in smoking, excessive drinking, lack exercise, and eat unhealthily are likely to experience non-communicable diseases like heart disease and diabetes and may face early mortality. These individuals significantly benefit from counseling aimed at encouraging changes in their lifestyle. This is vital as it can help optimize the limited resources in the public health sector. However, in South Africa, there has been a notable deficiency in counseling regarding non-communicable diseases and their risk factors until recently. Primary care providers have been found unprepared to offer more than sporadic advice on living healthily.
Globally, over 38 million people die each year from non-communicable diseases. Four major disease categories account for 82 percent of these deaths: cardiovascular diseases, cancers, respiratory diseases, and diabetes. The World Health Organization states that 40 percent of deaths in both developed and developing countries occur in people under 70, with 82 percent of these occurring in low and middle-income countries. In South Africa, non-communicable diseases rank among the top ten leading causes of death, with an upward trend driven by risky lifestyle choices such as smoking, excessive drinking, inactivity, and poor diet contributing to high morbidity and mortality rates from these diseases. Although change is possible, preventive measures have lagged behind the increasing disease burden. Non-communicable diseases affect not only individuals but also their families, communities, and strain the health system.
Research indicates that interventions targeting individuals within their family unit and community are more effective. For instance, two 40-year-old men—one married and the other single—both with diabetes would require counseling that considers their different lifestyles. In South Africa, public sector nurses or primary care doctors typically provide counseling. Recent studies evaluating the capacity of healthcare providers to conduct behavior change counseling reveal inadequacies in this service in both public and private sectors. None of the nurses in the study and only one-fifth of the doctors had comprehensive knowledge of key issues surrounding non-communicable disease risk factors. Public sector nurses agree to provide counseling, with about one-fifth believing they are knowledgeable, though they may overestimate their understanding of how to guide patients in modifying lifestyles for non-communicable diseases. Primary care doctors acknowledge they should provide brief counseling and consider it crucial, yet they are uncertain about their ability to effectively help patients change risky behaviors.
Besides inadequate training, various factors undermine their confidence in delivering counseling, such as a lack of patient education materials, time and language barriers, inconsistent care and record maintenance, conflicting health messages, and an unsupportive organizational culture. Training for doctors needs revising to ensure skills are teachable and applicable in clinical settings. Current training for primary care providers in the Western Cape is insufficient for achieving competence in clinical practice, constrained by time and not integrated into the curriculum, with an emphasis on theory over practice and evaluation. To enhance training programs, I designed, developed, and implemented a best practice training program with resources focused on primary care doctors and nurses in the Western Cape.
The program uses a conceptual model combining the 5 A’s: ask, alert, assess, assist, and arrange, incorporating a guiding style from motivational interviewing rather than traditional directive counseling. This guiding style is widely adopted internationally and aims to address all four risk factors related to non-communicable diseases. Traditionally, primary care doctors have been tasked with providing expert advice, persuading the patient on why, what, and how to change. In the guiding style, however, the case for change emerges from the patient, with providers trained to expertly guide shared decision-making. This shifts the counselling approach from being provider-centered to patient-centered. The program enabled primary care doctors to deliver patient-centered counseling, at least short-term, and adopt the guiding style, sustaining it in clinical practice. Despite improved counseling proficiency and confidence, implementing effective behavior change counseling in a clinical setting remains challenging.
Training alone isn’t sufficient to ensure better behavior change counseling is applied. Several obstacles persist, including staffing shortages, lack of managerial support, and poor care continuity. A comprehensive systems approach is needed to integrate improved behavior change counseling into daily care, necessitating not only training for primary care doctors but also changes at other levels. For instance, the existing organizational culture doesn’t align with the patient-centered guiding style essential for better behavior change counseling. Expecting doctors to demonstrate trust, respect, and openness is unrealistic in environments where they face manipulation, blame, and control.