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PART II- SOCIAL DETERMINANTS OF HEALTH

2.1-Social determinants of health and health inequalities

2.2-Psychosocial consequences of health and ill health
2.3-Selected theories of health behaviour

2.1. Social determinants of health and health inequalities

-Determinants of health include not just an individual’s particular characteristics and behaviors
but also their economic, physical and social environment.

-Social Determinants of Health (SDH) include economic, social, political and environmental
factors across the life course of individuals (IFSW, 2008). Behavioral factors are also part of this.

-Different determinants have a differential influence on different groups of people and this can
contribute to health inequalities.

-As described below, knowing the social determinants of health provides a comprehensive
perspective. The Ottawa Charter for Health Promotion (WHO, 1984) set out nine prerequisites
for good health

1-Peace 4-Food 7-Sustainable resources

2-Shelter 5-Income 8-Social justice

3-Education 6-A stable ecosystem 9-Equity

-Unfortunately, most investment in health still reflects and reinforces the biomedical worldview.
However important individual genetic susceptibilities to disease may be, population health has
been influenced much more by the rapidly changing social conditions in which people live
(WHO, 2003)

-Scholars called Dahlgren and Whitehead (1991) designed a model that shows determinants of
health. The model has a form of rainbow. The following list shows the hierarchy of the issues
from inside out

1-Age, sex and constitutional factors (physical condition)

2-Individual lifestyles factors

3-Social and community networks

4- Living and working Conditions: and in a clockwise manner from below:

-Agriculture and food production -Water and Sanitation

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-Education -Health Care Service

-Work environment -Housing

-Unemployment

5-General socio-economic, cultural and environmental conditions

-This model is a resemblance of the system’s theory.

-System theory states that a system is composed of interdependent and interrelated parts, with
change in one part producing changes in others (Von Bertalanffy, 1968)

Social and Behavioral factors in Illness

-The following discussion presents the major social and behavioral factors in illness.

-The social factors include: Socio-economic Status (SES), Sex and gender, Race, Social Support
and Life Style

Socio-economic Status (SES)

-It is evident that the lower the SES, the higher will be the disease and death rates

-There would be higher susceptibility to infections

-Communities with low SES experience higher Maternal Mortality Rate (MMR), Infant
Mortality Rate (IMR), Low Birth Weight (LBW) babies

-Medical care accessed by low SES groups is more likely to be of poorer quality (e.g. issues of
affordability, etc)

Sex and Gender (i.e. one is biological and the other one is social)

-Women are biologically stronger that men; males have higher death rates than females at every
stage of life including unborn fetuses

-Men traditionally have less healthy habits, like smoking, drinking, ‘chewing tchat’. We can
explore how gender affects the condition of men and women in Ethiopia.

-There are risky work conditions both for men and women that would affect their health
condition e.g. war, mining and other similar activities for men. If you compare Cobble Stone
production for men and women, it would be harder in terms of health for the women.
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Race (or culture)

-Some tribes in India and African Americans have considerably higher death rates and more
threatening disease conditions. One major reason is their low SES. Research shows that even
when SES is controlled, some racial differences persist. This could be because of genetic factors
and hence require more biological explanation.

-We can compare the different ethnic groups in Ethiopia in association with their cultural
practices or what we call Harmful Traditional Practices (HTP)

Social support

- Social support mediates/ moderates impact of stressful life events on negative health outcomes.
It relives the stress that leads to health problems

-African Americans have a suicide rate half that of white Americans. This is associated with
going to church and connecting to people. How this can be contextualized to our situation,
Ethiopia.

-The presence and absence of social security programs is also an important factor in health
promotion

-In short, social support adds on to our own resources and makes us feel stronger

Life style

-Our life style determines our health conditions in many ways.

-Use and abuse of alcohol, tobacco, drugs, tchat etc affects the health condition badly

-Unemployment and occupational stress are linked to hypertension and heart disease

-Change over to more comfortable life style is detrimental (damaging) too. For example, in a
modern life especially in highly urbanized settings we walk less, use elevators, household
gadgets (tools), aerated drinks (such as soda drinks which have more gas and more sugar),
carcinogenic (causing cancer) harmful fertilizers in fruits, vegetables, dairy, sea food and meat
products

-Use of junk food which provides only ‘empty calories’ and no nutrition; hence, it is useless or
has only little value

Behavioral causes of illness

The following points indicate some of the health concerns associated to behaviors

-Superstition and socio-cultural beliefs with respect to health

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-Poor environmental and personal hygiene

-Faulty dietary habits, lack of knowledge with respect to ‘balanced diet’

-Gender and age biases in intra family food distribution

-Indifference (lack of attention) to health as a worthy personal goal; slow health seeking behavior

Environment and Health

Definition of Environment in the Health context

-“All that which is external to the human host, it can be divided into physical, biological, social,
cultural; any or all of which can influence health status in populations.”

-The definition is based on the notion that a person’s health is basically determined by genetics
and environment.

-From parents come the ‘genes’. Genes generally do not change. In case the gene changes it is
called ‘mutation’ and is dangerous for health, could lead to cancer.

Food for thought: health environment in Ethiopia

-What are the major causes of death in our country?

-Which of the causes of death are related to environment or which are not genetic?

-What trends do you see over the next 30 to 40 years?

-What are the basic requirements for a healthy environment?

We need the following basic requirements to be fulfilled in order to have a healthy life: clean air,
safe & sufficient water, adequate & safe food, safe, peaceful environment.

Clean air

-Air pollution is caused by household energy sources, industrial effluents (liquid wastes),
gaseous emissions, tobacco smoking, heating and cooling systems

-Air pollution causes respiratory infections, lung diseases, eye problems, an increased risk to
cancer

-Dust from construction sites has been also a problem for the respiratory organs and the eye.

Safe & sufficient water

-As per WHO, 80 % of all sickness in some developing countries is attributed to lack of safe
water and inappropriate disposal of excreta, garbage etc
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-Contaminated water causes cholera, typhoid, skin diseases etc

-Insect vectors breeding in water cause malaria, filarial, dengue

-We need to get adequate water daily for drinking and for sanitation. How much liters of water?

Adequate & safe food

-Humans need 1, 000 to 1, 500 calories per day to stay alive (not to stay healthy)

-Without adequate food humans can develop deficiency diseases (Kwashakoor, Marasmus),
suffer premature death

-Food production not keeping pace with population growth in Africa and former Soviet Union
countries. This issue has been a concern for long worldwide.

-Poor food distribution and utilization are other important issues at many places. We can observe
that people get starved while food is available because there is distribution problem.

Safe, peaceful environment

-Low income, uncertain employment, inadequate housing, lack of sanitation, shelters made of
combustible (burning easily) materials

-Overcrowding and poor hygiene spreads TB, respiratory diseases, meningitis, intestinal
parasites

- Garbage disposal problems are common in many places. The WHO estimated that 30-50 % of
the wastes are left unattended

-Drug abuse, family break-up, war, civil disturbances/violence are other health hazards

- There is also inappropriate disposal of excreta

Environmental health

-As social workers we need to bring about or work for environmental health.

-Environmental health comprises those human aspects of health, including quality of life, that
are determined by physical, biological, socioeconomic and psychosocial factors in the
environment

-It also refers to the theory and practice of assessing, correcting, controlling and preventing those
factors/ health hazards. We as social workers should involve in these activities.

Environmental health hazards

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-There are several types of environmental health hazards. The following points capture some of
them.

-Physical and chemical agents- these agents can exist in the environment in to two ways. First,
as independent of any human activity, like naturally occurring ultra violet rays; and second are
added to the environment by humans like industrial wastes, fossil fuel combustion, biomedical
wastes, radio-active wastes

-Biological pathogens like female anopheles causing malaria, and other vectors of filarial,
dengue fever. Reservoirs that host these vectors represent the physical environment e.g. swampy
areas

-Socioeconomic factors control how resources are used. There are issues of social injustice and
inequality. We can take for instance poverty as the greatest risk factor to health. How much trust,
co-operation and social cohesion exists in a community to promote health? There are also
vulnerable groups in society in the health context; e.g. people in the street, older adults etc.

-Agricultural practices- this is about whether safe, adequate and affordable food is available?
How much investment is made to improve health of populations? Some chemicals used for
agricultural production is harmful; e.g. chemicals in floriculture and horticulture.

Household environment and diseases

-We see the following at households in relation to health status: crowding, poor sanitation, poor
water supply, poor hygiene and sanitation, indoor air pollution, unclean toilet/rest rooms

-The following are the most common diseases that we seen in unhealthy households:
Tuberculosis, diarrhea, cholera, dysentery (infection of the bowel), cataract, Trachoma, Intestinal
worms, Respiratory infections including chronic lung disease and respiratory cancers.

Health Inequalities
*sociological viewpoints on health inequalities

*Impacts of inequalities

*Gender and health: Gender and age disparities on health services

*Inequalities among geographical disparities

Question- What do you observe regarding health and health inequalities? (Reflect in pair)
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Sociological viewpoints on health inequalities

-Poor health is the consequence of wider health and social inequalities. For instance, the
relationship between poor health and poverty is well known.

-The primary determinants of health are economic, physical and social environments within
which individuals live. These determinants bring inequalities in health among different groups.

-The roots of ill health are income, education, employment, material environment and life style.

-Economically or socially disadvantaged groups consistently experience relatively poorer health

status. They are always in vicious circles in which they get trapped.

-The WHO established the Commission on the Social Determinants of Health which boldly
asserted that social justice is a matter of life and death (CSDH, 2008: Preface) and that global
health inequalities were immoral as well as economically inefficient. As a result of such
inequalities, new area of tourism such as health tourism emerged.

-There are different issues or factors that affect health. These include class, gender, ethnicity etc.
According to the social model of health, poor health is socially patterned by class, gender and
ethnicity. Other than these, health is also directly and indirectly conditioned and affected by
power, economics and status.

-People with poor health can face several social protection including stigma due to their physical
illness or mental distress. This will further the unequal treatment. Social workers involve in
health matters in a variety of ways either by providing very practical support or tackling
prejudice and discrimination.

-There are different health inequality outcomes. E.g. differences in life expectancy, mortality
rates of males and females (boys and girls)

-Healthcare services may not be uniformly available to all sections of the population.

-there are geographical variations in the availability of services according to local priorities

-the priority normally given to acute care cases may mean cutbacks in services for people
with chronic conditions, particularly older people and those with long-term mental illness.

-personal responsibility for health is emphasized in prevention strategies covering issues

such as smoking, obesity and sexual health. This would imply that there would be no or less
services at public health institutions.
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-There are causes of distressing inequalities in health (CSDH, 2008, p. 1)

1-Unequal distribution of power, income, goods, and services, globally and nationally

2-The unfairness among people in terms of access to services

3-Unequal distribution of health is the result of a combination of poor social policies and
programs, unfair economic arrangements, and bad politics

Class and health inequality

-WHO reports show the impact of class on health. It is clear that one’s class position has a
considerable bearing on one’s length and quality of life.

-The differences in morbidity and early mortality between social classes are highly significant

-There are also differences between men and women within the same class. This is true in a
global scale.

-There are social, political and economic processes that create the fragmentation of society and
the poor health of many people.

-Ideology is also central factor to health promotion. For example, neo-liberalism (a political
ideology that promotes a highly capitalist free market) is criticized for creating small but highly
wealthy social elite, while running down important resources such as housing, education and
health care for the wider, but especially poorer, sections of the population. (The ideology
advocates a very minimal role of governments).

Ethnicity and health inequality

-The health of people from various ethnic minority groups on a variety of measures tend to be
poor.

-Ethnic minorities in the west show less good health, experience long-standing illness, and show
some form of disability than others

-In the earlier days explanations have been given why there is inequality among ethnic groups
from genetic and cultural point of view

-These theories of genetic or cultural causality imply that there is something ‘wrong’ or
‘deficient’ in

1-the actual biological make-up of ethnic minority groups or

2-their culture that predisposes people from ethnic groups to greater ill-health; through these
explanations, there were intensions of promoting racist thinking and ethnocentric views
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-In a society where there is deep-rooted racism, people experience different levels of health
services. Do we have a sort of racism in Ethiopia?

-The racism is not only verbal or physical abuse, there is also institutional racism. These have
negative effect on health. Sometimes institutions systematically discriminate others and favor
few.

-The racism itself leads people to anxiety, stress and worry which creates another situation of
ill-health.

Gender and health inequality

-There are health inequalities between men and women

-Contemporary discourses of masculinities and femininities condition and shape the healh of
men and women. For example, dominant masculine discourses in the UK require men to be fit,
healthy and not to admit to weakness in public and to health professionals. Hence, men may not
discuss or admit health problems.

-Think of the cultural factors or media sources or other explanations that may put young men or
women under pressure to conform to certain aspects of hegemonic masculinity/femininity?
Which of these affects health behavior?

*Think of the following points and compare the two sexes. Do you see any inequality?

PRE BIRTH & EARLY CHILDHOOD

 Practice of infanticide in some regions within countries.Example: one child policy of

China in the past, some cultures where male are given priority to survive (India), etc

 Harmful traditional practices adversely affect physical & mental health (in Ethiopia)

 Girls receiving lesser food and medical attention than boys

 Birth of boys celebrated while that of the girls not celebrated ...impacts mother’s social
status & mental health

ADOLESCENCE

 Boys under social pressure & their own hormones engage into unsafe sexual practices at
risk of STIs, HIV

 Early marriage for girls, early child bearing – fistula, anemia, STIs, HIV, discontinuation
of education leads to further disempowerment
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 Social pressure forces girls to accept marriages with partners they don’t like, may be also
older men

AFTER MARRIAGE

 Women’s low status limits their life and reproductive health choices

 No say in regulating fertility including no. of children, spacing, limiting family

 Women cannot negotiate condom use, prevent STIs, HIV. Married men can have
multiple sex partners & bring diseases

 Low access to health care. Only reproductive roles of women cared for

VIOLENCE AGAINST WOMEN – A HEALTH ISSUE

 Domestic abuse is socially sanctioned (endorsed) in some places. Leads to physical,

mental, sexual health consequences

 Coerced sex leads to unwanted pregnancies, gynecological problems (think of “marital

rape”)

 Violence in pregnancy causes abortion, still births, low birth weights;

 Murder by intimate partners or serious physical and emotional hazards

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2.2-Psychosocial consequences of health and ill health

Health related psychosocial problems of clients (excerpted from Cowles, 2003)

The following are common problems for social workers when working with patients and families
coming to medical services or treatments.

1-Barriers to admission to the service or facility

-This could be psychological barriers e.g. fear

-Financial barrier e.g. lack of health insurance or pocket money

-Informational barrier e.g. lack of information; misinformation

2-Problems of adjustment to the service or facility

-Patients or family may not be comfortable and satisfied with the health service or the setting

-These things have several implications. Think of possible examples to understand this problem?

3-Problems of adjustment to the diagnosis, prognosis or health care (treatment) plan

-There are many issues involved here

-major life changes in the patient and the family members; e.g. change of work as a result
of the health problem

-Emotional reactions (self-image, sexual relationships, dependency, fear)

-For example, think of paralysis or a patient with permanent and severe kidney damage

4-Lack of information to make informed decisions and to feel in control (take control)

-The social workers can play an important role by providing appropriate information to patients
and their families to assist them I making informed decision about matters that concern them.

5-Lack of resources to meet needs

-There are resources vital for patients’ health care needs and social workers can provide or
facilitate their obtainment. These fall in the following categories

a) Medical aid and appliances- these include several tools and equipments e.g. glasses

b) Support services- e.g. housekeeping, transportation, day care etc

c) Income supports- related to money generations

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d) Environmental adaptations- e.g. ramps, elevators, low-level sound

e) Interpersonal support- human relationship; social interaction

6) Barriers to discharge from the service or facility

-They are similar to admission barriers; psychological, financial, informational, related to family
care, transportation or other resource needs

-Patients may develop dependency on the services of the hospital

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2.3-Selected theories of health behaviour

Some of the theories in healthcare social work

I-Health Belief Model

(The following discussion is excerpted from the book chapter of Nancy K. Janz; Victoria L.
Champion & Victor J. Strecher in Glanz et al)

Introduction

This is one of the most widely used conceptual frameworks in health behavior. The
Health Belief Model (HBM) explains change and maintenance of health-related behaviors. It
also serves as a guiding framework for health behavior interventions. HBM was developed in the
1950s in the US by a group of social psychologists in public health service. The HBM was
developed to see the responses of people in the US to the Free program that tried to screen
tuberculosis among eligible adults in the 1950s and 1960s. The program was interested to look at
the factors that facilitated or inhibited positive responses. The point is that the people have to do
X-rays- and their readiness for the test has to be understood. In short the Health Belief Model
was originally developed to explain why people failed to participate in health screening for
tuberculosis despite accommodations such as mobile vans that came into the neighborhoods.

The theory underlines that human behavior stems from rational, logical thought
processes. People make health choices largely based on consideration of the costs and benefits of
various actions. The HBM is a value-expectancy theory which falls under cognitive theory.
Under cognitive theory, behavior is a function of the subjective value of an outcome and the
subjective probability, or expectation, that a particular action will achieve that outcome.

Value-expectancy in health related behaviors is as follows. The desire to avoid illness or

to get well (this is an example of value). The belief that a specific health action available to a
person would prevent (or ameliorate) illness (this is an example of expectation). In this
expectation issue; we can further see the following. First, individual’s estimate of personal
susceptibility to and severity of an illness; the second is, the likelihood of being able to reduce
that threat through personal action.
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In general, it now is believed that people will take action to prevent, to screen for, or to
control ill-health conditions.

1-If they regard themselves as susceptible to the condition

2-If they believe it would have potentially serious consequences

3-If they believe that a course of action available to them would be beneficial in reducing either
their susceptibility to or severity of the condition and

4-If they believe that the anticipated barriers to (or costs of) taking the action are out weighted by
its benefits

The model posits two major components of health behavior: threat and outcome expectations.

Components of the HBM

Empirical evidences support that the Health Belief Model (HBM) predicts health
outcomes. This means each component predicts health outcomes. The HBM has the following
six components: 1) Perceived Susceptibility 2) Perceived Severity 3) Perceived Benefits
4) Perceived Barriers 5) Cues to Action 6) Self-Efficacy

1-Percieved Susceptibility- This refers to one’s subjective perception of the risk of contracting
problem of a health condition. In medically established illness, it includes acceptance of the
diagnosis, personal estimates of re-susceptibility, and susceptibility to illness in general.

2-Perceived Severity- This refers to feelings concerning the seriousness of contracting an illness
and its consequences. It also includes feelings concerning the seriousness of leaving it (the
illness) untreated. These feelings include the following: evaluation of both medical and clinical
consequences (for example, death, disability, and pain), and also evaluation of possible social
consequences (such as effects of the conditions on work, family life, and social relations). The
combination of susceptibility and severity has been labeled the perceived threat.

3-Perecevied Benefits- This refers to the beliefs regarding the effectiveness of the various
available actions for reducing the disease threat. Hence, there would be perceived benefits of
taking the health actions. Other factors include non health-related benefits (for example, quitting
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smoking to save money; getting a mammogram to please family members). Thus, an individual
exhibiting an optimal level of beliefs in susceptibility and severity would not be expected to
accept any recommended health action unless that action also was perceived as potentially
efficacious. This means action has to be perceived as efficacious.

4-Percieved Barriers- It is obvious that the recommended behavior may not be acted because of
perceived barriers. Among others, perceived barriers can also be the potential negative aspects of
a particular health action. This refers to various things. The first is analyzing and weighing the
action’s expected effectiveness against perception that it may be expensive. There should be an
acceptable cost, as cost is one of the barriers.Second, it may be dangerous (having negative side
effects or iatrogenic outcomes). Third, it may be unpleasant (painful, difficult, upsetting). Or it
may be inconvenient. Furthermore, it may be time-consuming etc. Perceived benefits and
perceived barriers/cost collectively are named outcome expectations.

5) Cues to Action - This concept is about cues that trigger action. Cues instigate actions. We see
cues as trigger mechanism. These cues could be bodily events or environmental events, such as
media publicity. The cues are strategies to activate one’s “readiness”. These cues are potential
factors to make people ready for perceived susceptibility and perceived benefits.

6) Self-efficacy- Self-efficacy is defined as “the conviction that one can successfully execute the
behavior required to produce the outcomes”. It requires a good deal of confidence that one can,
in fact, alter for example lifestyles, life-long habits, etc. before successful change is possible. For
behavior change to succeed the following must be fulfilled. As indicated earlier people must be
threatened by their current behavioral patterns (perceived susceptibility and severity). In
addition, people must believe that change of a specific kind will result in a valued outcome at
acceptable cost. Furthermore, they also must feel themselves competent (self-efficacious) to
overcome perceived barriers to taking actions. Self-efficacy in short means one’s confidence in
one’s ability to take action.

Other variables- In addition to the above components, there are other variables that have
contributions in affecting the health behaviors. Diverse demographic, socio-psychological, and
structural variables may affect the individual’s perceptions and thus indirectly influence health-
related behavior. Specifically, socio-demographic factors, particularly educational attainment,
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are believed to have an indirect effect on behavior by influencing the perception of susceptibility,
severity, benefits, and barriers.

Using the HBM to Address Public Health Concerns

The HBM continued to be a major organizing framework for explaining and predicting
acceptance of health and medical care recommendations. The HBM has been used extensively to
determine relationships between constructs and behaviors of public concerns as well as to inform
interventions. For instance, tailoring messages for breast cancer screening using the HBM
constructs of susceptibility, benefits, and barriers has been found to increase mammography
adherence (regular check-up for breast cancer).

Empirical evidence supports the Health Belief Model’s ability to predict health outcomes.
Becker and colleagues (1977; Maiman, Becker, Kirscht, Haefner, & Drachman, 1977) were able
to explain 39% of the variance in dietary adherence using the Health Belief Model’s components
in multiple regression analysis. Components of the Health Belief Model, such as perceived
susceptibility, were measured in the group’s dietary adherence, the model’s components were
important to understanding the dietary adherence.

The HBM suggests that for individuals who exhibit high-risk behaviors, perceived
susceptibility is necessary before commitment to changing these risky behaviors can occur. For
example, perceived susceptibility to HIV/AIDS was associated with behavior changes, including
increased condom use, fewer sex partners, and a decreased number of sexual encounters. If
perceived HIV/AIDS threat is high, and perceived benefits outweigh perceived barriers, the
HBM predicts that a cue to action could prompt an individual to adopt AIDS preventive
behaviors. The cue is thought to stimulate the belief-action link.

The HBM constructs/models can be used as measurements in research. Prior to engaging

in instrumental development, researchers should search for instruments (e.g. survey tools) that
have previously been developed and have established validity and reliability. Only when these
cannot be found should scale development be undertaken. This means development of new
assessment tool.
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In conclusion, the Health Belief Model should be taken as a model or a combination of

constructs. It is not a collection of equally weighted variables operating simultaneously. In order
to influence health-related behaviors, one has to use the health belief variables including self
efficacy. It has to be noted that the beliefs and behaviors of each of the individuals is a crucial
point to bring improved health.

It is reasonable to assume that a theory such as the HBM is applicable to different

cultures. It also is important to realize that constructs may have to be adopted to make them more
relevant to the target culture. The dimensions of the HBM can be useful in understanding health
behaviors in multicultural settings. The cultural beliefs of the target population have to be
considered as the same time.

II- Stages of Change

The “stage” construct provides a temporal (time) dimension of change. The Transtheoretical
Model (TTM) construes (interprets) change as a process-involving progress through a series of
six stages discussed briefly below. The stages model can be applied in a range of health and
mental health behaviors.

1-Precontemplation: This is the stage in which people do not intend to take action in the
foreseeable future. At this stage people may be uninformed or under-informed about the
consequences of their behavior. On the other hand, they may have tried a number of times and
become demoralized about their abilities to change. At this stage people tend to avoid reading,
talking, or thinking, about their high-risk behaviors. Generally, there is no motivation or
readiness to think about change.

2-Contemplation: This is a stage where people intend to change. This is a period of

ambivalence (feeling two conflicting emotions at the same time). This is because there is
awareness of the pros and the cons of changing. As a result of this, the process here can take long
period of time. There is less immediate action and there is a tendency of behavioral
procrastination.
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3-Preparation: This is the stage in which people intend to take action in the immediate future.
People at this stage develop a plan of action, such as joining a health education class, consulting
a counselor, talking to their physician, buying a self-help book etc.

4-Action: This is a stage where people made clear and overt modifications in their life styles
within the past six months. In short the action is observable. Of course, there should be criteria to
consider the actions as sufficient.

5-Maintenance: This is a stage in which people strive to prevent relapse (or staying sober). This
is a time where the actions are maintained for long. At this stage people develop the confidence
not to be tempted by relapse.

6- Termination: This is a stage where the individuals develop the total self-efficacy and do not
succumb (fail) to temptation. In whatever condition they are in, those who reached at stage will
not turn back to their old unhealthy habit. This is an ideal stage where there will be zero
temptation and total self-efficacy. For example, physical exercise, consistent use of condom,
weight control etc.

III- Processes of Change

Processes of change are the covert and overt activities that people use to progress
through the stages. We use these processes of change for intervention programs. The following
ten processes are crucial.

1-Conciousness raising: This involves increased awareness about the causes, consequences, and
cures for a particular problem behavior. This change process involves several interventions. The
following interventions are common: increase awareness; providing/ receiving feedback,
confrontations, interpretation, bibliotheraphy (collection of therapy) and media campaigns.

2-Dramatic relief: This move people emotionally to make change because they have seen
others’ experiences. There is noticeable thing for the change. This initially produces increased
emotional experiences followed by reduced affect if appropriate action is taken. Interventions
include psychodrama, role playing, grieving, personal testimonies, and media campaigns. These
are examples of techniques that can move people emotionally.
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3-Self-reevalation: Combines both cognitive and affective assessment of one’s self-image with
and without a particular unhealthy habit. Interventions include value clarification, healthy role
models, and imagery. These are techniques that can move people evaluatively.

4-Environmemtal reevaluation: This combines both affective and cognitive assessments of

how the presence or absence of a personal habit effects one’s social environment, such as the
effect on others of smoking. It is obvious that one can serve as positive or negative role model
for others; and understanding this is part of environmental reevaluation. Empathy training,
documentaries, and family interventions can lead to such reassessments.

5-Self-liberation: This is a belief that one can change. It also includes the commitment and
recommitment to act on that belief. This also includes enhancing the willpower (the ability to
control one’s thoughts and actions in order to achieve what one wants to do). Some of the
measures to enhance willpower include: New Year’s resolutions, public testimonies and multiple
choices.

6-Helping relationships: This is about building social supports. This combines caring, trust,
openness, and acceptance as well as support for healthy behavior change. Measures such as
rapport building, a therapeutic alliance, counselor calls, and buddy systems (making new
friendship) can be sources of social support.

7-Counterconditioning: This requires the learning of healthier behaviors that can substitute for
problem behaviors. Relaxation, assertion, desensitization, nicotine replacement, and positive
self-statements are strategies and measures for safer substitutes.

8-Contingency management: This is about knowing the consequences of taking steps in a

particular direction. This involves both punishments and rewards. Reinforcement measures will
be taken increasingly to increase the probability of repeating healthier responses.

9-Stimulus control: This is about removing the cues (triggers or signals) for unhealthy habits
and adding prompts for healthier alternatives. Avoidance, environmental reengineering, and self-
help groups can provide stimuli that support change and reduce risks for relapse.

10-Social liberation: This comes through an increase in social opportunities or alternatives,

especially for people who are relatively deprived or oppressed. To increase these opportunities
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especially related to health promotion, we do advocacy, empowerment procedures and take

appropriate policy measures. These can help people to make change.

IV-The biopsychosocial approach in health care delivery system

The biopsychosocial approach considers three overlapping aspects of the patient’s

functioning. The biopsychosocial approach enables social workers to assess each of these
domains to gain a full understanding of the patient. The “bio” refers to the biological and
medical aspects of the patient’s health and well-being. This model states the importance of
recognizing the physical state of human beings in (bio), among others. These include possible
genetic predisposition and neurotransmitter imbalance. Genetic factors can be causes of death or
can determine life span. There are diseases like diabetes, schizophrenia run in families.The
“psycho” refers to the patient’s self-worth, self-esteem, and emotional resources as they relate to
the medical condition. The emotional or psychological aspects are in the psycho. These include
one’s psychological make-up, irrational beliefs, frustration, chemical imbalance-mood (affective)
disorder.

The “social” refers to the social environment that surrounds and influences the patient.
The social involves the socio-cultural, socio-political, socio-economic conditions. The socio-
cultural includes social and cultural norms, cultural differences, cultural change and cultural
ritual. The socio-political includes political fraternity or conflict of society. It also includes
policies and laws governing life aspects e.g. taxation, labour issues, environmental issues etc.
Socio-economic includes income, education and occupation.

There is another dimension called the spiritual in the model. Hence the bio-psychosocial
and spiritual model is one of the strength based perspectives in social work practice. It includes
bio, psycho, social and spiritual components. The spiritual is about finding the meaning of lives.
For example, feeling empty inside or missing something or search for more-high meaning (such
as extreme happiness). As indicated earlier this approach provides a holistic view because it
seeks to encompass the whole picture of the individual and places the individual in a context that
informs social work intervention.

The following indicates the Health Related Consequences on the dimensions:

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1-Physical effects- these include chronic headaches, chest pains, heart trouble, blood pressures,
stomach ulcer, appetite loss, disturbed sleep patterns, skin irritation

2-Psychological consequences- ways of thinking, feeling and behaving downs, inability to think
clearly and denial of reality, agitated (arguable) state, can’t handle feelings, mood swings

3-Social consequences- relationships damaged, isolation (secrecy), self (obsessed),

communication difficulties

4-Spiritual consequences- feels helpless and hopeless, despair, dishonesty with self and others,
self-worth diminished, dominated by fear-trapped not free

Cyclic Relationships of the Factors

The above four components are interdependent to one another. A life change event (more
of social) can produce emotional distress. For example, we can take divorce or separation or loss
of jobs. Emotional distress causes physiological changes which make a person vulnerable to
disease. The physical health problem can erode self confidence, limits physical activity and can
affect social/family roles, in turn cause emotional distress, impaired immune system function.
Hence, when an individual is sick all dimensions of the person will be affected. It is in short the
whole person.

This model implies that the “whole person” should be assessed for effective diagnosis
and treatment. Mental and physical health are related due to cyclic association. Various forms of
mental illnesses have rates of physical illness far in excess of expected frequency in the general
population. We can ask the following questions in practicing in the health care setting

1-Did patients have people in their immediate environment that could care for them?

2-What supports existed and what needed to be enhanced?

3-Were there community resources that could be brought to patients to help them recover?