Chapter 6

Handbook of Health Social Work, 2nd Edition

THE USE OF THEORY IN SOCIAL WORK

PRACTICE AND RESEARCH

Kerlinger (1986) defines theory as “a set of interrelated constructs, definitions, and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena” (p.9).

He defines constructs as concepts that have been “deliberately and consciously invented for a special scientific purpose” (p.27).

DEFINE THEORY IN GENERAL AND THEORIES OF HEALTH BEHAVIOR IN

PARTICULAR.

Theories of health behavior have the potential to order the panoply of constructs with which health social workers are faced and provide a conceptual framework that assists in understanding why people behave as they do in terms of their health

These theories provide direction for the helping process and structure for research.

THEORIES OF HEALTH BEHAVIOR

Orienting theories are cognitive, behavioral group, or family systems.

Social work interventions are based on orienting theories, most of which come from the field of psychology.

Orienting theories and theories of health behavior are related, but they differ in two ways

DISTINGUISH THEORIES OF HEALTH BEHAVIOR FROM ORIENTING THEORIES

Orienting theories are narrower than theories of health behavior because they focus on the origin and treatment of human problems rather than full constellation of human behavior.

Theories of health behavior are germane to all behaviors, not just those that are problematic

Theories of health behavior restrict themselves to health, Orienting theories are concerned with many areas, including health, marriage, education and employment

DISTINGUISH THEORIES OF HEALTH BEHAVIOR FROM ORIENTING THEORIES

Theories and skills are natural partners in social work practice, as the time allotted to assess and treat client problems decreases, tools that facilitate assessment and the development of effective treatment approaches increase in value.

Relying on theories to help construct interventions increase the likelihood that they will be successful.

THEORIES OF HEALTH BEHAVIOR TO ADVANCE SOCIAL WORK PRACTICE IN

HEALTH CARE

The Health Belief Model (Hochbaum, 1958; Rosenstock, 1960,1966,1974) 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 model posits two major components of health behavior: threat and outcome expectations.

THE HEALTH BELIEF MODEL

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 HEALTH BELIEF MODEL

I. Perceived Threat A. Perceived susceptibility B. Perceived severity

Outcome Expectations A. Perceived benefits B. Perceived costs

Expectations of Self-Efficacy

MAJOR ELEMENTS OF THE HEALTH BELIEF MODEL

The Theory of Reasoned Action (Fishbein, 1967; Fishbein & Ajzen, 1975) extends the Health Belief Model to include the influences of significant others in the environment on individual health behavior.

The theory assumes that behavior is immediately determined by behavioral intention.

THE THEORY OF REASONED ACTION

Behavioral intention is, in turn, determined by a person’s attitude toward the behavior and the influence of significant others in the environment, or social norm.

Attitude towards the behavior consists of two things: (a) an individual’s belief that if a behavior is performed, a given outcome will accrue, and (b) how important the individual considers the outcome to be.

THE THEORY OF REASONED ACTION

The Theory of Reasoned Action has been applied to many health behaviors and conditions, including substance abuse (Beck,1981), weight loss (Sejwacz, Ajzen, & Fishbein, 1980), and hypertension (Norman, Marconi, Schezel, Schechter, & Stolley, 1985).

The Theory of Reasoned Action has been widely used in studies of health behavior of adolescents, often in the area of contraception decision making (Albarracin, Johnson, Fishbein, & Muellerleile, 2001)

THE THEORY OF REASONED ACTION

Ajzen and Madden (1986; Ajzen, 1991) extended the Theory of Reasoned Action to include perceived control over behavior.

The idea was that intention alone could not predict behavior if the behavior was one over which the individual did not have complete control.

Perceived behavioral control is assumed to reflect past problems encountered in behavioral performance, such as a person being unsuccessful in losing weight , and thus has demonstrated poor control, it is less likely that he will be able to execute it no matter how strong his intentions.

THE THEORY OF PLANNED BEHAVIOR

A meta-analysis of 96 studies found that the Theory of Planned Behavior predicted condom use less accurately that did the Theory of Reasoned Action (Albarracin et al., 2001).

A meta-analysis of 185 studies using the Theory of Planned Behavior prior to the end of 1997 found the theory to account on average for 27% of the variance in health behavior (Armitage & Conner, 2001).

THE THEORY OF PLANNED BEHAVIOR

The Social Action Theory (Ewalt, 1991) represents a marriage of psychological and public health models and principles. The prevailing model in public health is a three-way interaction between host, agent, and environment.

Social Action Theory encourages a social-contextual analysis of personal change by suggesting pathways by which social and other environmental factors influence cognitive processes.

THE SOCIAL ACTION THEORY

The Social Action Model contains three dimensions: Influences on Health Behavior

Personal level (health habits, personal projects, action states, motivation).

Social level (social and biological contexts, social interdependence, social interaction processes, action linkages).

Societal level (organizational structures at the level of government; economic, educational, and healthcare systems; laws; policies).

THE SOCIAL ACTION THEORY

Social Action Theory holds that social ties strongly influence the success of attempts to alter behavioral routines, such as lowering dietary fat, increasing physical activity, or engaging in less risky sexual practices.

Social Action Theory is fairly new and applications have been fewer. McCree (1997) found high relationship closeness, favorable attitudes toward condom use, high self-esteem, and a secure attachment style to best predict condom use among a sample of African-American women.

THE SOCIAL ACTION THEORY

The Behavioral Model of Health Services Use was developed in the 1960’s and has gone through three phases since that time (Andersen, 1968,1995) and fairly recently underwent another major revision-the Behavioral Model for Vulnerable Populations (Gelberg, Andersen, & Leake, 2000).

The original model (Andersen, 1968) divided determinants of health service use into three groups

BEHAVIORAL MODEL OF HEALTH SERVICES USE

Three groups of the Behavioral Model of Health Services Use.Predisposing- variables such as demographic factors and

health beliefs and attitudes that influenced an individual’s use of health service

Enabling- factors included insurance coverage, social support, and family income.

Need- included perceived and objectively determined health problems.

BEHAVIORAL MODEL OF HEALTH SERVICES USE

The model’s second phase in the 1970’s (see, e.g., Aday & Andersen, 1974) saw predisposing, enabling, and need variables subsumed under the category of population characteristics and the addition of a category of variables and the healthcare system.

Phase three, in the 1980’s and 1990’s, brought the addition of the external environment to an expanded category of determinants of health behavior (see Figure 6.3).

BEHAVIORAL MODEL OF HEALTH SERVICES USE

Empirical support for the Behavioral Model of Health Services Use has been strong.

Andersen and Aday (1978) used the model to understand levels of health services use of a probability sample of 7,787 non-institutionalized persons in the U.S.

BEHAVIORAL MODEL OF HEALTH SERVICES USE

They were able to explain 22% of the variance in physician visits using (a) age, race, and education of the head of household as predisposing variable.

(b) family income, physician visit insurance, number of physicians per 1,000 in population as enabling factors.

(c) perceived health and number of illness symptoms in the prior year as need variables.

BEHAVIORAL MODEL OF HEALTH SERVICES USE

The Transtheoretical Model (TTM) (Prochaska, 1984; DiClemente & Prochaska, 1982) adds a dimension to existing theories, namely the readiness of individuals to make proposed changes in health behavior.

Six stages of change are considered: Precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska, Redding, & Evers, 2008).

TRANSTHEORETICAL MODEL

The Transtheoretical Model incorporates both intrapersonal and societal components of health behaviors, to include various processes of change in its approach to understanding and changing health behavior.

These processes include consciousness raising, the use of dramatic relief, and utilization of helping relationships.

TRANSTHEORETICAL MODEL

Change is seen as ongoing and incremental rather than static and occurring at one fixed point in time.

This adds to the social worker’s ability to intervene to change behavior by virtue of respecting “where the client is” and understanding the client within the context of a larger social environment and an ongoing process of change.

TRANSTHEORETICAL MODEL