The Zinakekele Project puts action into words and provides a great blueprint for tackling NCDs throughout South Africa.
When we see an iceberg, the portion which is visible above of the water is only a small piece of the much larger whole. This symbol is easily applied to the emergence of non-communicable diseases (NCDs), or chronic diseases linked to lifestyle, which are rising rapidly in both rural and urban South Africa. While the growth is alarming, current levels are only the tip of a much larger underlying problem — South Africans’ unhealthy lifestyles.
The solution for tackling the NCD iceberg requires a strong preventative focus, which includes education, health screening, and appropriate behaviour change. A great example of a solution in action is the Zinakekele Project, the result of an innovative partnership between the KwaZulu-Natal department of health, Metropolitan Health and Kheth’Impilo to tackle NCDs in the largely rural Amajuba District of KwaZulu-Natal, the location of a National Health Pilot site.
Ironic paradox
NCDs are chronic medical conditions or diseases that are non-infectious. Most of the major NCDs are preceded by unhealthy behaviour or lifestyles that give rise to the devel- opment of risk factors for metabolic diseases. The NCD statistics are alarming. According to the World Health Organisation (WHO) 2014 country profile, it’s estimated NCDs account for 43% of total deaths in South Africa.
The four main NCDs responsible are cardiovascular diseases such as hypertension and stroke, cancers, chronic respiratory diseases and diabetes.
The ironic paradox is that success in managing high levels of infectious diseases, like HIV and TB, will contribute to the rise of NCDs, as South Africans enjoying improved longevity now face a greater risk of developing a chronic disease during their lifetimes.
Rural South Africa at risk
We often think that living in the countryside away from the temptations of urban fast food outlets and the stresses of city life offers a healthier lifestyle but rural South Africans are also at significant risk when it comes to NCDs.
Unfortunately the rural and remote areas of South Africa are least equipped to deal with rising NCD levels. Home to 43.6% of the population, these areas are served by only 12% of the doctors and 19% of nurses in the country.
Awareness levels around healthy lifestyle behaviour also appear lower in the remote, poorly resourced rural areas. According to the 2013 SA National Health and Nutrition Survey, individuals from rural formal settings reported a significantly lower rate (34.7%) of trying to quit smoking as compared to those from urban formal (49.9%) and urban informal (56.9%) settings.
Preventative interventions
NCDs have some key features that need to be considered in formulating solutions. One such feature is that there is typically a long latent period between the initial exposure and the ultimate disease. During this long period, behavioural risk factors can be identified which offer early signals that a NCD may emerge in the absence of appropri- ate behaviour changes.
These behavioural risk factors consist of two main groups. Primary risk factors which are very early risk factors that can be spotted before the disease develops. These primary risk factors may then be followed by a phase where one has signs and symptoms of the impending NCD. Most people will see the symptoms or signs, but will not seek health care and these are only picked on questioning the person or on screening, such as increased blood pressure; or symptoms of diabetes as well as increased blood sugar (or glucose), with overweight and obesity.
Secondary risk is where the person has been diagnosed with the NCD but they have not developed complications, such as stroke from hypertension or kidney damage from diabetes.
Preventative care and treatment interventions are key to address and manage both primary and secondary risk factors. Primary prevention interventions may include diet modification and addressing inactivity or tobacco use to prevent diseases from developing. Secondary prevention means that someone who already has high blood pres- sure receives appropriate treatment, as well as support to adhere to medication so as to prevent the development of more advanced disease.
Think global, act local
Given the magnitude of the NCD iceberg, strategies at a global and local level are being rapidly adopted. In South Africa, the department of health has developed a strategic plan for the prevention and control of NCDs. This plan has ambitious goals that align closely to the global targets set by the WHO.
To enhance the efficacy of the department of health’s strategy for tackling NCDs, it’s essential that provinces develop and implement local NCD strategies that align to the national strategy. One province taking proactive action in this regard is the KZN department of health, where strong political will, visionary leadership and a multi- sectoral approach is creating an enabling environment for solutions that tackle NCD prevalence and directly support the national strategic plan.
One pillar of the KwaZulu-Natal health strategy for tackling NCDs is establishing key, focused external partnerships. One innovative project, although only operating for a short period, is already showing indications of making a solid contribution to long-term NCD prevention and management in the province.
The Zinakekele Project
Project Zinakekele focuses on integrated NCD prevention and support in the largely rural Amajuba District. It is the result of a powerful partnership that sees Metropolitan Health, the KwaZulu-Natal health department and a public benefit organisation Kheth’Impilo joining hands to support the province’s quest to prevent and manage NCDs.
Addressing the primary prevention of NCDs, as well as the secondary prevention of morbidity and mortality associated with NCDs, the project strives to:
• Reduce common health risk factors through essential public health action;
• Promote healthier lifestyles and disease management by increasing awareness and understanding of common NCD risk factors; and
• Strengthen implementation of the programme at all levels, through integration with clinic programmes.
Following the launch of the project in November 2014, the first phase of Project Zinakekele focused on three key activities:
• Supporting the health facility and selected schools in the Amajuba District to determine the baseline levels of risk factors associated with NCDs;
• The provision of health screening, prevention and promotion services in the schools and community; and
• Initiating a “Health Screening Jamboree”. The project launch event was used as a platform for this initiative.
Activities, results, insights
A total of 758 pupils were screened at Phendukani High School and Mandlamasha Combined schools. Pupils were screened for blood pressure, blood glucose, body mass index, blood cholesterol and mid-upper arm circumference (MUAC), a measurement of nutritional status.
Nutritionists provided learners with healthy eating and balanced nutrition information. The pupils were also educated on the benefits of regular exercise and taught various aerobic exercises. A total of 65 adults were screened at the launch, 55 women and 10 men.
Screening results for pupils indicated that a total of 288, or 38% between grades eight and 10, had profiles that put them at risk of developing NCDs in the future. The 34 pupils with elevated blood pressure levels were made aware of their risk and were linked to the local clinic for further investigation and follow-up. The second phase of the project will investigate family links for the elevated blood pressure by providing screening for the pupils’ households.
The 77 pupils with high blood glucose have also been linked to the clinic and a home follow-up of these pupils to screen their families will also be conducted.
School health nutritionists provided support for healthy eating choices to the 89 pupils identified as overweight or obese. An interesting observation was that the majority (85%) of these pupils were in grade 12, while pupils in grades eight and nine had a lower prevalence of obesity. While further investigation is required, if correct, this presents an intervention opportunity in grades eight and nine to enable pupils and their families to reduce the risk of being overweight in pupils approaching grade 12.
The figures from the adult screening were most concerning and represent the NCD danger the pupils face in the absence of preventative interventions to change behaviour. Results indicated that one in five adult females had diabetes and one in three had hypertension. Furthermore, 9% had high cholesterol, 16% were overweight and 42% were obese, with 63% of this group showing high risk for cardiovascular diseases based on waist circumference measurements.
One can assume that if pupils with behavioural risk factors outside the normal range are not supported and enabled to change current behaviour, they will end up with NCDs as adults. Now, however, through this project, healthcare workers and pupils have an opportunity to work on changing behaviours and reducing their risk for developing NCDs during adulthood. The baseline screening also paves the way for motivating far larger scale screening across all pupils – an essential intervention for driving the behaviour changes necessary for the prevention of NCDs.
Make ubuntu a working reality through the power of partnerships
While many glibly talk about the need for working together to address the problems facing South Africa’s healthcare, it’s often just talk, but the Zinakekele Project puts action to these words, with inspiring results for all involved.
Although the scale has been limited at this point, the investment in creating awareness through health screening and enabling behaviour change among these young people and their families will deliver returns for many years to come. The Zinakekele model can be easily scaled up and provides a great blue- print for tackling NCDs in rural KZN and, indeed, the rest of the country. It is a great example of making ubuntu a working reality through partnerships that enable more South Africans to enjoy the benefits of healthier lives, including those in poorly resourced rural areas.