| Summary: | 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
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