Abstract
D.Litt. et Phil.
Health and social issues have a reciprocal relation and this is evident in the South African
context. Poverty that includes poor living conditions, unemployment and the consequent
low income results in disease and malnutrition. A vicious circle exists between poverty
and disease. The HIV/Aids pandemic results in people being in need of care, not being
able to work nor provide for their next of kin, children being orphaned and taking over
the parental role, without emotional and material means. Chronic diseases, for example
tuberculosis, hypertension, diabetes and chronic psychiatric disease assume enormous
proportions and influence the person-and-environment interaction, which is the social
work focus. Health and social issues can therefore not be seen as separate entities.
Social workers should then form an integral part of health care services.
The social work service rendering in the Health Sector should be effective, efficient and
appropriate. Effective, efficient and appropriate health care social work services will
encompass people-centred, developmental, preventative, promotative primary health care
approaches with emphasis on participation, partnership and self-determination. An
effective and appropriate service will rely on home-based and community-based
strategies.
Health care social work is however fragmented and social workers in the Health Sector
practice within different governmental and non-governmental organizations. Health care
social work in the Gauteng Health Department where the researcher did the research, is
largely curative, rehabilitative, hospital-based, individual-based and relies on institutional
care. It is therefore ineffective, inefficient and inappropriate.
A shift towards an effective, efficient and appropriate health care social work service is
essential especially when the reciprocal relationship between health and social issues in
South Africa are taken into account. The researcher decided therefore to develop a
community-based model for health care social work with emphasis on a people-centred
and developmental approach emphasizing participation, partnership and self-
determination of the people. This model will be utilized on a primary health care level
within a community health centre and community context where the health care social
worker will form part of a multi-disciplinary health care team. The main goal of this
study is the development of a community-based model for health care social work.
The objectives to attain the main goal of describing a community-based model for health
care social workers were:
♦ To explore and describe the thoughts and experiences regarding the perceived needs
with reference to the general health of the following patients:
Patients who attend provincial community health centres to address their health
needs;
Patients who are representative of the diversity of all South African citizens and
therefore include White, Black, Coloured and Indian population groups;
Patients who qualify in terms of their income to utilize Governmental health
services and who do not belong to medical schemes;
Patients from formal, well organized and structured communities with different
community resources, as well as patients from informal settlements without
structured community services;
Patients of different age and gender groups; and
Patients with acute and chronic, including life threatening medical conditions.
♦ To describe the needs of patients after interviews were conducted and data had been
analyzed;
♦ To explore and describe the needs that health care social workers can address and the
intervention strategies that they can utilize in doing so;
♦ To explore and describe the priority needs that a health care social worker could
address and the intervention strategies they could utilize in doing it, in the opinion of
the following multi-disciplinary health care team members:
Medical doctors;
Nursing staff;
Allied health professionals (physiotherapists or their assistants, occupational
therapists or their assistants, speech therapists, dieticians, pharmacists and
community based rehabilitation workers);
♦ To describe specific needs and services which health care social work exclusively or
most effectively can address according to ranking on a scale;
♦ To develop a community-based model for health care social work according to the
needs that a health care social worker can address and which will result in an
effective and appropriate health care social work service;
♦ To evaluate the tentative model; and
♦ To revise the intervention and describe guidelines to operationalize the model.
The research design utilized to attain these objectives was based on a research model that
the researcher developed. The researcher developed the research model by utilizing The
Intervention Design and Development model (Rothman & Thomas, 1994) qualitative
research for interviews with patients, observations and field notes, data analysis and
literature control. Quantitative research designs were included in the model and consisted
of the Delphi technique and Lickert scale. Levels of theory generation were also
included in the model and the researcher developed level of theory generation for the
research based on the levels of theory generation of Dickoff et al. (1968) and Chinn and
Kramer (1995). The research model that the researcher developed for developing a
community-based model for health care social work encompasses certain phases and
research activities, as well as theory generation and reasoning strategies. The reasoning
strategies included analysis induction, synthesis, derivation and deduction.
The first phase of the research was the problem analysis and project-planning phase of
the research. The researcher carried into effect the following research activities. The
researcher determined the feasibility of the research project; gained entry to and
cooperation from setting and identified and involved role-players in the research. The
identification and involvement of the role-players encompassed the sampling and the
pilot study.
The second phase of the research was the information gathering, analysis and
synthesis phase of the research. This phase included research activities, as well as levels
of theory generation.
The research activities that were followed during this phase started with the conducting
of semi-structured interviews with twenty-two patients and observations and the keeping
of field notes. Ethical issues were addressed during this phase and formed part of the
interviewing and observation process. Data analysis of interviews, with an independent
coder, and literature control to affirm the findings of data analysis followed as part of the
research activities.
The researcher then utilized the Delphi technique with nine experts in health care social
work. The aim of this was to establish the patient’s needs, established during data
analysis, that a health care social worker could address and the intervention strategies that
they could utilize. These needs and intervention strategies were established by
questionnaires and a group session was held to reach consensus of data.
The above-mentioned data established from health care social work experts were then
compiled into a Lickert scale for twenty-five multi-disciplinary health care team
members. The aim of the scale was to establish the needs that health care social work
could address exclusively of most effectively, as well as the intervention strategies that
they could utilize in the opinion of the multi-disciplinary health care team members.
A final literature control completes the research activities of the information gathering,
analysis and synthesis phase in order to establish if literature exist that verifying the
results of the data obtained and if these could assist in the development of a communitybased
model for health care social work.
The levels of theory generation followed in the information gathering, analysis and
synthesis phase of the research consist of the following:
The first level of theory generation consisted of factor isolating theory. The researcher
utilized concept analysis. Concepts were firstly identified and the researcher identified
the concept health. The concept health is a central concept in all the policy documents
and theory that were utilized in the problem analysis of the research. The concept health
was also central in the data analysis and literature control of the interviews with patients.
The concept health was then defined and refined by utilizing dictionaries and thesauruses,
as well as utilizing sources of evidence namely, a model and contrary case, evidence of
people and professional literature. The researcher then classified the concept health and
the related concepts.
The second level of theory generation, factor relating and structuring followed during
the information gathering, analysis and synthesis phase of the research. The researcher
related factors and associated them through statements that indicate interrelationships.
The third level of theory generation consisted of the situation relating level followed by
predicting relationships between concepts utilizing if-then statements.
The third phase of the research was the design and early development phase. The
researcher utilized the fourth level of theory generation that consisted of the situation
producing level of theory generation to conduct the research activity of the creating and
describing of the theoretical model for community-based health care social work.
The last phase of the research consisted of the theory testing and evaluation phase of the
research. The research activities that were followed encompass the planning of
evaluation, selection of evaluation methods and then the evaluation process. The
evaluation process was done with a panel of nine experts utilizing a specific
questionnaire in the form of a Lickert scale. The panel consisted of academic staff from
the Universities of the Witwatersrand, Pretoria and Randse Afrikaanse University from
social work and nursing as well as multi-disciplinary health care team members from
community health centres and social workers from different practice settings. The
second part of the evaluation process was done during doctoral seminars where peer
evaluation was done by health care social workers, medical doctors, nursing staff and
allied health workers from different levels of service rendering including the Gauteng
Health Department’ Head Office, community-based centres and different levels of
hospitals. Participants from private hospitals also attended the doctoral seminars. The
researcher then utilized the evaluation results to identify design problems and to revise
the community-based model for health care social work. The final level of theory
generation was then done in the theory testing and evaluation phase of the research to
operationalize the model by describing guidelines for operationalization.
The methods of trustworthiness that were followed during the research included the four
criteria of Lincoln and Guba (1985) of credibility, transferability, dependability and
conformability.
The researcher finalized the research by indicating the conclusions from the research,
specifying the limitations of the research and providing recommendations for social work
practice, education and research.
The research document might be marked by repetition of content, but this was necessary
because chapter six, the model, as well as chapter eight, the guidelines for
operationalizing the model, form the basis for health care social work practice at
community health centres. These chapters could then be extracted from the research
document as a tool for implementation.
Prof. J.B.S. Nel
Prof. A. Nolte