Agents for Change – Exploring the intangibles of primary healthcare

Noy Pullen informs us about the birth of Agents For Change, all that the project has achieved and what they aim to achieve with effective communication in the field of health.

Agents for Change is an unusual project. Its efficient and sound methodological approach is proving successful in dealing with root causes to changing lifestyles that are highly difficult to deal with. The courses seemingly also prove to be effective as a supplement to the current ongoing training healthcare staff.Extract from a report by Hanne Strandgaard, World Diabetes Foundation project manager, after a field visit to the ‘Agents for Change Project’ in South Africa.

 The current debate around communication in the field of health

A conversation is currently developing online through an international communication network initiative. Here are some of the provoking questions posed by the participants, all of whom work in the field of health empowerment

  • The health community seems not to be able to learn lessons, tagging communication onto the end of any intervention. When will we ever learn to interweave communication strategy (not just politicians and experts telling people what to do) but engaging people in difficult situations to hear their solutions?
  • If you had R500 a month to live on how would you juggle it? I always maintain that poorer people are often much cleverer with their money than the middle classes. They need to be.
  • It’s the same with finding solutions that will work locally. Buckets of money go to big PR firms and advertising firms who make clever slogans and nicely animated ads, basically sending the messages that the experts think best.
  • For almost a year, governments all over the world have been struggling to control spread of the COVID-19 pandemic. Literally hundreds of billions of dollars have been spent on appliances, supplies, hospital equipment and space to accommodate COVID patients. But what has been spent on social research to find out why people don’t follow these guidelines? Does anyone finance controlled experiments to validate communication interventions? I believe if a fraction of what is spent on treatment of diseases was spent on social, psychological and communication research, and findings were used, the pandemic stats would be different today. But who is listening?
  • Let us look at health issues and how they are communicated. Most of the information is too clinical and not accessible. Statistics shared are causing panic instead of encouraging behaviour change. The way healthcare facilities have been operating is creating stigma and discrimination, especially for people with limited information.
  • Knowledge paternalism, or to put it more bluntly, god complexes are a major causal problem with its failure to listen to lived experiences of patients. Motivational interviewing seems to work, in part at least, by dialogue and listening.
  • Brazilian educator, Paulo Freire, compares the conventional or ‘banking’ concept of education (in which students/patients receive, file and store the knowledge from the ‘experts’) with that of the people’s own lived experiences. These lived experiences are, for Freire, the primary source of knowledge which can be translated and used to overcome learning barriers.

The birth of Agents for Change

Such questions and dilemmas faced Noy Pullen as early as 1996 in her capacity as journalist and communication liaison at Diabetes South Africa head office. Passionate telephonic discussions with Trudy Bodenstein, a progressive pharmacist and diabetes activist, led to the conception of Agents for Change. Trudy and Noy would spend two days with health providers, exploring existing barriers to reaching the diabetes community, as well as ways to improve communication about diabetes management, nutrition and lifestyle.

The first courses were run in Kwa-Zulu Natal for the Department of Health, sponsored by the South African Sugar Association. When Noy moved to Cape Town, Trudy started a family, so Noy and Buyelwa Majikela Dlangamandla, diabetes nurse specialist, met and employing their diverse strengths, created the present model.

The present model

Agents for Change metamorphosed into a three-tiered project. The health providers attend a two-day module and are asked to set their own health goals, also indicating how they propose to enhance interaction with patients and colleagues. After three months, the same participants meet again and share what they experienced.

This second module is called Empowering the Patients. Here the health providers who attended the first module are invited to share their successes and challenges over the past three months. These are converted into living case studies. Diverse counselling skills are introduced to address these issues.

A multi-disciplinary group attends so that the whole team is involved. Depending on the needs and availability in each region, doctors, psychologists, physiotherapists, food scientists and dietitians, health promoters, paramedics, matrons, sisters, home-based carers and other community workers are invited. In this way, everyone is considered.

Impact over the years

Agents for Change in its present form has offered more than 200 modules (with each participant attending both modules). There is an average of 30 participants on each module. This affects the lives of their colleagues to whom in-service training is offered 3000 x 10 = 30 000. These health providers probably influenced at least 200 patients each.

Agents for Change has influenced the lives more than seven million considering families, churches and friends. WDF project manager, Hanne Strandgaard, wrote in her field report there was evidence from participants whom she met during her site visits, that Agents for Change still influenced  individuals more than five years after the course had been completed. People stay in touch.

Who is invited?

Participants are selected by the Department of Health or NGOs focusing attention on outlying regions around the country. The Department of Health or the NGO provides the venue and the participants’ travel.

Last words from one group of participants

‘Aha! Moments’ from the Agents for Change project

  • The right way of eating, the right portions at the right time can prevent diabetes or improve management.
  • It begins with me. I can assess my own risk factors for getting diabetes and can reverse this process. I must first help myself before I start helping my patients.
  • We enjoyed the way you served the food, the leafy salads and the lemon and cucumber water to drink.
  • Watching my own weight is important. I enjoyed the healthy eating demonstration and promise I will help others do the same.
  • I learnt a lot. The main thing is giving hope. Based on Tim’s story (one of the true stories in the diabetes manual – My Diabetes Toolkit) you can live a long time with diabetes.
  • Tim’s story helped me know how to live a balanced lifestyle. Being active after eating and not lying down. Because of Tim’s story I now know the symptoms.
  • Because we learnt that diabetes is a killer of our people. I am happy to learn how to help people.
  • My grandmother has diabetes. I have learnt a lot of tools I can apply in the home.
  • My mother-in-law has diabetes. I will help her plan her groceries so that she eats less fried food.
  • The main message I picked up about diabetes is that one does not have to die from diabetes. I always thought it was a killer disease.
  • We do not have clinics where we live, only mobile clinics. It’s why we help the elderly. It’s us who work with the youth in the community. We have been empowered to do so.
  • I have learnt about the co-morbidities with diabetes like hypertension and glaucoma and can now start an awareness campaign to prevent and /or manage diabetes.
  • I have learnt that stress makes diabetes worse. It made me realise that I give my dad stress. I am going to stop doing that.

Below are comments from the participants of what they aim to achieve before the nest module:

  • I want to lose 5kg before the next module.
  • I want to change my cooking habits.
  • Less fatty food and polony and more of what we ate here on the course.
  • Use less oil. Boil and steam my food.
  • Cut down on my alcohol. One glass of wine once a week.
  • Start with two push-ups and increase.
  • Reduce my sugar by half. Do daily vowel exercises.
  • Reduce sugar and do stretching exercises.
  • The vowel exercise helps with my heart palpitations. I will continue with them.
  • My grandchildren loved the vowel exercise. It also helps my asthma
  • Change to low-GI bread at home.
  • I am going back to soccer.

Impact of Agents For Change

The below is an extract from World Diabetes Foundation field trip report:

  • Improved clinical knowledge of diabetes and impact of lifestyle and nutrition on health.
  • More effective collaboration between HCP, healthcare workers and patient.
  • Increased number of food gardens among participants and communities.
  • More effective patient interaction groups.
  • More effective hands-on use of the distribution of Diabetes Focus and other Agents for Change tools to motivate and sustain these groups.

How is Agents For Change funded?

The Agents for Change project has been supported by the World Diabetes Foundation, various trusts, banks as well as pharmaceutical companies. Funding from these communities enables this work to continue. Participants who wish to attend can contact us. Details below.

Many experts who have been involved with this initiative have been impressed by the relatively low-cost per project. A course for 30 people for two days’ costs in the region of R42 000. This includes travel costs and accommodation for both course presenters, as well as healthy eating presentations during the courses.

The course material consists of practical tools, such as monofilaments, tape measures for waist circumference, recipe guides for healthy colourful food, food gardens manuals, a counselling manual called Discovering Hope, and a colourful comprehensive Q&A style, user-friendly diabetes manual, called The Diabetes Toolkit.

All materials are developed or sourced by the presenters. Fun physical activities are shared. Attendees also receive a Hand Jive portion guide and the Five pointed star guide, addressing physical, rhythmical, community, individuality and spiritual health.


Please contact Noy Pullen if you would like more information: [email protected] or 072 258 7132.

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