The purpose of Mamelani’s Community-Based Health Education Program is to ensure that community members have access to essential health information so that they are informed and equipped to take action with regard to health challenges they face. Mamelani believes that every human being has the right and responsibility to have a basic understanding of how their body works and what steps can be taken to stay healthy. This information should not be limited to certain groups, but should be accessible to all people.

• Wellness workshops
• Consultations
• Mother and Child Wellness Program
• Imifuno for ALL – Healthy cooking demonstrations

Although South Africa is considered a middle-income country in terms of its economy, it has health outcomes that are worse than those in many lower income countries. The South African health system is marked with inequity.

Aside from other illnesses, the HIV pandemic places an extra burden on our already over-stretched health system. Statistics show that roughly 5.4 million people are living with HIV in South Africa. In the Western Cape, 29.1 % of mothers testing for HIV at antenatal clinics test HIV positive – that’s almost 1 in 3 pregnant mothers (Department of Health 2006). Health education and psychosocial support are services that are neglected as a result of the strain on the health care system.

Health challenges faced by communities are compounded by high levels of food insecurity, lack of access to clean water and sanitation, lack of access to adequate housing, lack of education and mixed messaging around prevention and treatment for illnesses including HIV, accompanied by stigma and social inequality, limited access to treatment and care and lack of information about prevention and how to cope with illness. Low-income communities are therefore faced with the double burden of illness and poverty. Since most of these communities receive care from overcrowded clinics and emergency rooms, they often are not adequately informed on how to take care of their health and prevent illness. Poverty-related illnesses such as infectious diseases, maternal death and malnutrition are widespread, and there is a growing burden of non-communicable diseases such as Diabetes and related heart conditions. The number of people living with HIV/AIDS in South Africa remains highest in the world. South Africa is one of only 12 countries where child mortality has increased, rather than declined, since the Millennium Development Goals baseline was set in 1990.

Mamelani runs community-based health education workshops that share essential health information so that participants are able to make informed decisions that enable them to prevent and manage particular illnesses. The topics covered in the workshops include:

• Understanding how the body and the immune system works
• Understanding prevention, symptoms and treatment for common illnesses (HIV/AIDS, TB, Diabetes, High Blood Pressure, Arthritis and Cancer)
• Understanding how different illnesses affect the body
• Low-cost ways of maintaining a healthy body
• Information regarding access and adherence to treatment regimens and the correct use of prescribed medication
• Healthy eating and healthy lifestyle

The workshops are taught in isiXhosa and are facilitated once a week over seven weeks. Workshops are run 3 times a week from community-based settings. The workshops are attended mainly by unemployed women from HIV and TB support groups, home-based care groups, church groups and community action groups. Roughly 500 women are trained through this program annually.

Workshop content focuses on broad health issues and not just HIV. Given the high rate of HIV infection in South Africa, components of the workshop are focused on HIV information, including prevention, care and treatment for HIV/AIDS. However, there are many other health challenges faced by communities that also require increased awareness, such as, TB, Diabetes and High Blood Pressure. Diet plays a large role in the prevention and management of many chronic illnesses, which is why the workshops promote healthy eating and balanced nutrition. In particular, with regard to HIV, evidence shows that Anti-retrovirals are key to the effective treatment of HIV/AIDS. However, emphasis must also be placed on the role of a balanced nutritious diet in maintaining a healthy immune system that is able to fight opportunistic infections and prolong the period of time until ARV treatment is required. Healthy eating is also vital while on ARV treatment for increased adherence to treatment regimes. Given the history of AIDS Denialism in South Africa it is important to clarify that Mamelani promotes healthy eating as a component of HIV care, and in no way as a replacement for treatment or a cure for HIV.

Health education is an on-going need. Mamelani aims to provide accurate and relevant information through the workshops. A safe space is created where participants are encouraged to continually return with questions and openly share their knowledge and experiences. The structure and nature of facilitation is critical in building trust with people. Mamelani facilitators do not keep a distance as authoritative experts, but encourage everyone to participate equally in the learning process.

One participant expressed her level of comfort in the workshop in the following way: "You always feel free to ask anything when you attend the workshop, about your health and even about the fears you have and about the community." This climate of respect is necessary in order for participants to feel comfortable to discuss sensitive personal and health related issues.

The majority of workshops are attended by HIV and TB support groups. The workshops are particularly useful to members of these groups whose health is compromised. The content of the workshops is focused on practical tips to promote health, including healthy eating, early treatment of common ailments and opportunistic infections, correct use of medication and effective stress management. Mamelani returns to the groups after 3 months to revise information that was shared in the first workshop, share updated information, and assess what support Mamelani can offer, such as linking groups with other resources in their area.

Workshops are also offered to home-based carers. For these groups, a stronger focus is placed on how to explain the information to their patients and on making more informed decisions with regard to caring for them.

"I have learnt a lot through the workshops, especially how to prevent different illnesses. I have learnt that staying healthy does not need to be expensive. The information that I learnt about has really helped me with my clients." - A home-based carer from Phaphamani Sizwe

"The workshop was very useful to me, especially the information about HIIV and AIDS, because even as a home-based carer, I did not have all this knowledge." - A participant from LACAP (Langa Community AIDS Project)

Workshops are also offered to community action groups and church groups. The members attending these groups have a vested interest in improving their community and show an eagerness to share the information with the wider community.

"Thank you Mamelani for the information about nutrition. We are cooking for the children that we care for and now we know what we can cook for them that is full of nutrients." - Member of the Ikhaya Labantu Community Group

"This information can be used like a weapon, to protect our communities. Especially in the rural areas – they are in desperate need of this information. When I go home, I will share this information with my family. I will be helpful to them now" – participant from Dunoon Community Group

"I see all these conditions in my community, but I don’t know what to do about them. Now I understand what I can do. Lack of Knowledge destroys people’s lives. The more you know, the more you can take action" – participant from Dunoon Community Group

In the last cycle we trained two male only HIV support groups. One of the groups expressed that they will be sharing the information with other men in the community. They also said, "All that we have learnt from Mamelani has helped us on day-to-day life. We put our hands together and hope that Mamelani could educate other organisations in our communities. We really benefited from them. Mamelani has made a change to our lives, we will never forget them."

In 2009, Mamelani worked with support groups, home-based care organisations and community action groups. We have run workshops for 22 groups in total.

This is what some of the workshop participants had to say:

"From the first day I have gained a lot because of the way the facilitator is doing her work. She explains things clearly."

"Since we started the workshop, I feel alive, in a good mood, healthy and strong and my spirit is high. The facilitator has enlightened our minds and reminded us of what we know. Now I am clear about what is happening in my body."

"I learnt about the things we must eat and what we must not eat. I learnt about treatment and so much knowledge that I want to share with those around me."

"I learnt a lot because now I am well informed about different things that can help a person to stay healthy. I learnt about the practical steps I can take to stay healthy like the importance of exercising"

"The workshops are like a revival – reminding us of the things we know, but have forgotten. At school, you study to get knowledge to pass. Now we need to study and gain knowledge to LIVE"

"As young people we are expected to care for our elders, but we don’t understand the conditions they have. Now we understand and can help them and be patient with them. And we can even prevent the same thing from happening to us"

Disproportionate numbers of people affected by chronic illnesses in South Africa come from impoverished backgrounds, and staying healthy and preventing illness is further challenged by the fact that many live in crowded, unhygienic living environments and often come from socially marginalized communities. To negotiate and cope with the multiple impacts of illness and poverty, such as stigma, isolation and loss of employment, Mamelani provides psychosocial support and care so that participants can focus on taking steps to improve their health.

A consultation service provides individual support to participants from the workshops. Support takes the form of one-on-one counselling, serving as patient advocates (assisting participants in accessing treatment and encouraging medication adherence) and referrals to other NGOs for specialised services.

Consultations offer a safe space where necessary information can be shared, and a trusting relationship can be developed. This relationship often empowers the individuals to make the necessary changes in their lives. Facilitators also share information with family members so that they can support the client. We encourage clients to make gradual changes to their lifestyle that will reduce their stress and improve the body’s ability to stay healthy. Mamelani also plays a role in advocating for clients rights when they fall through the gaps of the clinic system.

Mamelani believes strongly in developing meaningful partnerships. We work closely with other NGOs and community-based organizations. Over time, we strive to build a strong network of inter-organizational referral and support structures throughout the Western Cape.

While some clients come from the support groups, many come from community-based organizations. These consultations often provide the first real opportunity to reveal their status and express the difficulties that they face at home. Many have been isolated by their families and do not attend support groups because they fear further stigmatisation.

"I came to see the facilitator because I did not know how to disclose my status to my partner. After seeing the facilitator, I found a way to disclose to him and his family. Now I am getting the support that I need."

We support roughly 60 clients per year.

Studies show that low birth weight, malnutrition, acute respiratory infections, diarrhoea and HIV/AIDS are the biggest killers of small children in South Africa. Most of these conditions are preventable, or at the very least treatable and many can be closely linked to incorrect infant feeding.

Current policy dictates that ideally an HIV positive mother should exclusively formula feed (as this poses no risk of HIV transmission) if she meets the criteria for safe exclusive formula feeding. Sadly, given the socio-economic conditions in many of these communities, as well as the stigma now associated with formula feeding, exclusive formula feeding is often not a suitable option. If a mother does not fit the criteria for safe formula feeding (AFFASS), increasing the likelihood of the mother mix feeding (proven to have the highest risk of HIV transmission), the mother is encouraged to exclusively breastfeed. Further, incorrect formula feeding can have a negative nutritional impact on a child.

The Mother and Child Wellness Program promotes safe infant feeding, particularly amongst HIV positive mothers. The aim of the program is to empower mothers to make informed choices regarding feeding to prevent HIV transmission and maximise child nutrition. The program promotes safe infant feeding by addressing the complex challenges faced by mothers, particularly those who are HIV positive, in selecting the feeding method that maximises nutrition and minimises the risk of transmitting HIV to their unborn child.

The focus our program is on ensuring that if the mother does choose to exclusively breastfeed, safe practices are used to prevent transmission. Similarly, if the mother chooses to formula feed, correct information and messages around knowing how to prepare formula correctly is shared to prevent incorrect feeding practices. Emphasis is placed on the eradication of mixed feeding by HIV positive mothers, as the risk of infection is highest when babies are mix fed. Breastfeeding mothers on HAART have a lower chance of transmitting HIV to their child, thus it is recommended by new guidelines that mothers who are on HAART should exclusively breastfeed until 3 months.

The program was piloted in early 2008 at KTC Maternal Outreach Unit (M.O.U) and Mowbray Maternity Hospital. Initially, the facilitators visited the clinics on a weekly basis offering support to mothers who had recently found out their HIV status or who were visiting the clinic as part of the National Prevention of Mother to Child Transmission of HIV (PMTCT) Program. While information sharing at clinic level is key, ongoing support needs to take place at community level. The program is now focused on sharing information from community-based settings.

The topics covered include:

• Advantages and disadvantages of exclusive breastfeeding
• Advantages and disadvantages exclusive formula feeding
• Staying healthy while pregnant
• Dealing with common childhood illnesses (including diarrhoea, fevers, teaching mothers how to assess if a child is dehydrated, how to prevent dehydration and how to make the rehydration formula for children to avoid dehydration).

The program is offered to HIV positive mothers as well as women from the broader community. The program is not only offered to pregnant mothers, but to all women who are interested in the information, in the hope of popularising the information to ensure that the wider community has this knowledge and is able to support mothers once they return to the community, as this is the time when feeding choice is most challenged. Culturally, mothers, aunts and grandmothers support young mothers during the babies’ first few months, and for this reason, it is vital that they have access to this essential information.

An estimated 200 women were reached through the Mother and Child Wellness Program, with 40 women benefiting from 6-week safe infant feeding workshops, which were initiated in the last quarter of 2009.

From our experience of running the workshops, it has become evident that a combination of overconsumption of particular foods, as well as cooking techniques employed, can be obstacles to improving health. For this reason Mamelani has developed a booklet that shares information on how to cook low cost healthy meals, maximizing flavour and nutrition, while minimising energy use. The book covers topics such as understanding basic nutrition, cooking methods, filtering water, sprouting beans and basic hygiene. The book shares over 50 vegetarian recipes that are low-cost and utilise locally available, affordable ingredients to make healthy meals. The book has considered what local communities are already eating, and adjusting these traditional recipes to maximise health. In some cases, beans have been used to encourage a reduction in meat consumption, without the loss of necessary protein. Emphasis has been placed on not overcooking vegetables, to retain vitamin levels and taste.

Mamelani uses the Imifuno for ALL! cookbook as the basis for a series of healthy cooking demonstrations that are being offered as a follow up session after the workshops. The demonstrations aim to show participants how to prepare affordable healthy meals.

The cooking demonstrations are offered to the groups that have attended the workshops. These demonstrations are usually done in the same venues where the training is held. Other groups have also requested the cooking demonstrations. The demonstrations can be adjusted to the group’s needs. Demonstrations are charged at a rate of R50 per person, for a minimum of 10 people per demo.

The workshop is for anyone who wants to learn about low-cost healthy cooking.

Between March 2009 and February 2010 a total of 650 community members were reached through the Community-Based Health Education Program, with 90% of them being women. Roughly 400 people received 6 weeks of health education training, followed by healthy cooking demonstrations and ongoing support. An estimated 50 individuals accessed one-on-one counselling and referrals. An estimated 200 women were reached through the Mother and Child Wellness Program, with 40 women benefiting from 6-week health education training workshops. (Workshops were initiated in the last quarter of 2009.) If the information and support gained by each participant extends to 3-4 family members, the Program has impacted over 2500 people in the last year.