Wednesday, October 27, 2010

MEDICAL SOCIAL WORK


Medical social work is a sub-discipline of social work, also known as Hospital social work. Medical social workers typically work in a hospital, skilled nursing facility or hospice, have a graduate degree in the field, and work with patients and their families in need of psychosocial help. Medical social workers assess the psychosocial functioning of patients and families and intervene as necessary.

Interventions may include the following:

· Connecting patients and families to necessary resources and supports in the community

· Providing psychotherapy

· Supportive counseling or grief counseling

· Helping a patient to expand and strengthen their network of social supports.

Medical social workers typically work on an interdisciplinary team with professionals of other disciplines (such as medicine, nursing, physical, occupational, speech and recreational therapy, etc.)

Medical Social Workers are graduates of schools of social work with a master's degree, and who use their knowledge and skills to provide social services for clients/patients (who may be individuals, families, groups, communities, organizations, or the society in general).

Definition

Medical Social Work is the application and adoption of the method and philosophy of social work in the field of health and medical care.

  • It is a branch of social work that deals with the social, physical and psychological aspects of a patient.

Nature

Medical Social Work is based on the assumption of the individual’s dignity

It deals with

  • The prevention of disease
  • After care of the patients
  • Rehabilitation

Mode of Operation:

  • By enabling the patient for solving his problems (building up his capacities)
  • By determining the social and psychological influence.
  • By developing the willpower and determination of the patient

· By enabling the patient to adjust with his problems.

· By developing a proper environment

History

Britain and Ireland

· Medical social workers in Britain and Ireland were previously known as Almoners, or Hospital Almoners.

· In Ireland, the origins of medical social workers go back to Dr. Ella Webb who in 1918 established a dispensary for sick children in the Adelaide Hospital in Dublin, and to Winifred Alcock who had trained as an Almoner and worked with Dr. Webb in her dispensary.

· In 1945 the Institute of Almoners in Britain was formed, which in 1964 was renamed as the Institute of Medical Social Workers.

· The Institute of Medical Social Workers was one of the founder organizations of the British Association of Social Workers which was formed in 1970.

· In Britain, Medical Social Workers were transferred from the NHS into local authority Social Services Departments in 1974, and generally became known as Hospital Social Workers.

United States

· The Massachusetts General Hospital was the first American hospital to have professional social workers on site in the early 1900s.

· The position was created by Richard Clarke Cabot to help patients to deal with areas of their life that made treatment difficult. This was important from an epidemiological point of view, as it made it easier to control and prevent outbreaks of syphilis and tuberculosis.

  • Year 1905: Boston medical institutions appointed Medical Social Worker for the first time.

India

  • Less importance was given to this important branch of health promotion
  • Tata institute of Social Sciences is only pioneering and struggling in this field
  • Less awareness and practice of this very useful extension of health care delivery in India
  • Most of the national health programmes are running at a snail pace due to non- use of this field of medicine.

The application of Medical Social Work is limited to few areas of health care in India:

  • Department of Sexually transmitted diseases
  • Department of pediatrics
  • Department of community medicine
  • Department of obstetrics

ROLE AND REQUIRED SKILLS:

The medical social worker has a critical role in the area of discharge planning. It is the medical social worker's responsibility to ensure that the services the patient requires are in place in order to facilitate a timely discharge and prevent delays in discharge that can cost the hospital thousands of dollars per day. For example, the medical doctor may inform the medical social worker that a patient will soon be cleared for discharge (a term that means that the patient no longer requires hospitalization) and will need home care services.

It is the medical social worker's job to then arrange for the home care service to be in place so that the patient can be discharged. If the medical social worker fails to arrange for the home care service, the patient may not leave the hospital resulting in a delay in discharge. In such situations the treating physician is ultimately held responsible for the delay. Nevertheless the medical social worker often bears the brunt of the blame for the delay in discharge and his or her failure to perform often attracts the attention of management.

Other skills required of the medical social worker are:

· An ability to work cooperatively with other health care staff as part of a multidisciplinary treatment team.

· Good analytical and assessment skills.

· An ability to communicate clearly with both patients and staff.

· An ability to quickly engage the patient in a therapeutic relationship.

The Medical Social Worker will inevitably have to be able to process almost a never-ending flow of paperwork, whilst retaining a willingness to advocate for the patient, especially in situations where the medical social worker has identified a problem that may compromise the discharge and put the patient at risk in the community.

For example, the medical doctor reports that a frail elderly patient is medically cleared for discharge and plans to discharge the patient home with home care services. However, after assessing the patient's psychosocial needs, the medical social worker determines that the patient does not have the requisite ability to direct a home care worker and recommends that the discharge be deferred pending further assessment of this problem. In such a case, it is the medical social worker's ethical duty to inform the medical doctor that the discharge may place the patient at risk and advocate for another, more appropriate discharge even if it means that the patient's discharge has to be postponed. It is precisely in such cases that the medical social worker proves his or her worth - by placing the needs of the patient above all other considerations.

CHALLENGES:

· As medical social workers often have large case-loads and have to meet tight deadlines to arrange for necessary services, medical social work is on the whole a very demanding job.

· Medical social workers often confront highly complex cases involving patients with multiple psycho-social issues, all of which require intervention and result in delays in discharge. For instance, in a major urban acute care medical center, it is not uncommon for the medical social worker to assess patients who experience one or many of the following social problems: homelessness, multiple chronic medical and psychiatric conditions, lack of stable employment, previous incarceration, and substance abuse problems. Any of these, separately and together, can impede timely discharge. Sometimes situations as mundane as the patient needing money for transport or clothing can lead to delays in discharge, especially if these needs are not identified early. This is why a complete and timely assessment of the patient's psychosocial needs is critical.

Working methods

  • Case study method,
  • Direct method of assistance
  • Indirect method of assistance


Case study method

  • By, case study method, MSW collects information with regard to the specific needs of the patient and works towards their fulfillment in accordance with the available means.

Direct methods of assistance

  • MSW is directly involved in the assistance.
  • Assistance is provided to the individual patient with the aim of developing his inherent capacity

Direct assistance

  • Social Group Work
  • MSW tries at strengthening the social relations of the patient and works towards the development of a healthy social environment


Indirect methods of assistance

  • Community organization
  • Social administration
  • Social insurance and social security
  • Social action
  • Social work research.

Indirect assistance

  • Community organization = organization of community resources with regard to health problem
  • Social administration= MSW guides the public opinion for enactment of new legislations or any amendment in prevailing legislations
  • Social security& insurance= enabling the patient to utilize the facilities under security and insurance
  • Social action= MSW participates in the movements of social action at the national (national health programme involvement) and international levels( world health days)
  • Social research= MSW inspires surveys and investigations regarding the socio-economic and psychological problems of the patient

Social work services in Medical Setting:

Social Worker provides services that support & maximize the psychosocial functioning & adjustment of patients & their families. These services are provided to ameliorate social & emotional stresses resulting from the interaction between the physical, social & psychological aspects of disease.

  1. Assessment forms, Administration of tests: Psychological, life satisfaction, Quality of Life, etc.
  2. Education: Support groups
  3. To obtain co-operation of patient & family in medical management
  4. Patient & family counseling to enhance recovery
  5. Providing help in decision making process for the treatment options.
  6. Co-ordination with multidisciplinary team members, (being a link between doctors, staff, patient & his family members)
  7. Planning intervention strategies / Life style changes
  8. Fund raising for patient’s treatment liaison with charities & NGOS.
  9. Rehabilitation
  10. Case evaluation
  11. Service outcome
  12. On going assessment
  13. Staff education
  14. Research activities

Social Work Responsibilities

  • The medical social workers job is to perform assessments with patients to assess for any physical, mental or emotional needs.
  • They assess the family support system and link the patient with services to help with care if needed.
  • The social worker can also provide assistance with financial concerns such as not being able to afford medications or pay household bills.
  • Some social workers provide counseling to patients who are suffering from depression or who are having difficulty coping.
  • Ultimately, a social worker links and makes referrals to agencies to assist the patient with all of these services.
  • One of the main benefits of a social worker is helping to be sure the patient knows what services are available. This can help increase patient safety and increase the possibility that the patient will not return to the hospital or ER for unnecessary medical treatment due to lack of medication or neglect.



Trends in Medical Social Work practice in Chennai:

  • Supportive Intervention
  • Individual Counseling
  • Group Work- Educational/Therapeutic
  • Work with Families and Careers
  • Bereavement counseling
  • Bereavement Programme/twice yearly
  • Crisis Intervention
  • Care planning/Discharge planning
  • Advocacy and mediation
  • Networking- liaising with statutory and voluntary services and agencies to keep patients/families/careers informed of their rights and linking them with appropriate support networks and groups.
  • HIV pre and post test counseling
  • Facilitating family meetings/case conferences

Scope of Medical Social Worker:

1. Social workers help people increase their capacities for problem solving and coping, and they help them obtain needed resources; facilitate interactions between individuals and between people and their environments.

2. The social worker practice includes rehabilitating those whose social functioning has been impaired. i.e. Cancer patients often may feel isolated and lonely because their family and friends may stay away and even stop telephoning because they can't deal with their cancer. The social worker can help reduce the feelings of isolation through support groups, and helping clients/patients to know other people who are facing the same things they are.

3. The activities of social workers are helping people become more self-sufficient; preventing dependency; strengthening family relationships; and restoring individuals, families, and groups to successful social functioning.

4. Social services include helping people obtain adequate financial resources for their needs, evaluating the capabilities of people to care for themselves, for children, or other dependents, counseling and psychotherapy, referral and channeling, mediation, advocating for social causes, informing organizations of their obligations to individuals, facilitating health care provisions, and linking clients/patients to resources.

5. Medical Social Workers provide social group work, in which small numbers of people who share similar interests or common problems convene regularly and engage in activities designed to achieve certain objectives. In contrast to group psychotherapy, the goals of group work are not necessarily the treatment of emotional problems. The objectives include exchanging information, facilitating support for clients/patients, helping them deal with their problems and education to improve the quality of life.

COMMON DEFINITIONS:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

As the patroness of health, Hygeia was charged with providing a healthy environment to prevent illness. In Greek, "hygieia" means health. Hygiene is the maintenance of healthful practices. In modern terminology, this is usually regarded as a particular reference to cleanliness.

Disease /dis·ease/ (dÄ­-zÄ“z´) any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.

Illness is an abnormal process in which aspects of the social, physical, emotional, or intellectual condition and function of a person are diminished or impaired compared with that person's previous condition.

The World Health Organization defines Disability as follows: "Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. Impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives."

Medicine:

1. Any drug or remedy.

2. The diagnosis and treatment of disease and the maintenance of health.

3. The treatment of disease by no surgical means.

CHANGING CONCEPT OF HEALTH:

The word ‘health’ was derived from the old English word ‘hoelth’, which meant a state of being sound, and was generally used to infer a soundness of the body. Prior to the period of the somewhat enigmatic physician known as Hippocrates (c 460-377 BCE, or more appropriately, from around 5 BCE), health was perceived as a divine gift. Hippocrates was credited with the pioneering the move away from divine notions of health, and using observation as a basis for acquiring health knowledge. He was credited with encouraging a focus on environmental sanitation, personal hygiene and, in particular, balanced diets – “let food be thy medicine; and let thy medicine be food”. He theorized that what we currently regard as ‘health’ might be defined as the extent of a delicate balance of four fluids: blood, yellow bile, black bile, and phlegm. Ill health, he believed, resulted from an imbalance of these fluids.

Nevertheless, a divine view of health persists to this era. For example, Prophet Mohammed view of health, sickness and death – followed by a high proportion of practicing Muslims - may be inferred from the following verse in the Holy Koran; “The Lord of the worlds; it is He who heals me when I am sick, and He who would cause me to die and live again” (Koran 26: 80).

Health Belief Systems also influence perspectives on the meaning of health. For instance, Becker’s Health Belief Model might be used to explain differences in how the concept of health is perceived by individuals and groups - particularly in non-religious contexts - and how such perceptual differences influence response to ill health. But what is ‘Health’ in the 21st century?

Scores of definitions of ‘health’ are available. The most commonly quoted definition of health is that formalized by the World Health Organization (WHO) over half a century ago; “a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity.”

Several other generally accepted definitions of the noun ‘health’ exist. Bircher defines health as “a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility”, while Saracchi defines health as “a condition of well being, free of disease or infirmity, and a basic and universal human right”. Australian Aboriginal people generally define health thus “…Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community. This is a whole of life view and includes the cyclical concept of life-death-life.

Critics argue that the WHO definition of health is utopian, inflexible, and unrealistic, and that including the word “complete” in the definition makes it highly unlikely that anyone would be healthy for a reasonable period of time. It also appears that ‘a state of complete physical mental and social well-being’ corresponds more to happiness than to health.

Bircher’s definition takes into account changing health needs, especially in relation to age, culture, and personal responsibility. Health Belief Systems, which are a essentially function of age, culture, and personal responsibility, strongly influence subjective experience of health and ill-health.

Sarrachi’s definition provides an intermediate concept, linking the WHO’s ideal to contemporary issues of human rights, equity, and justice. Aboriginal Australians incorporate community health and spiritual well being as core aspects of the definition of health.

These and other definitions introduce valuable concepts that may be used to enrich and revise the current WHO definition of health. A useful starting point for such revision and enrichment might be for the WHO to clarify its philosophy for ‘Health’ in the 21st century.

CONCEPT OF PATIENT AS A PERSON:

(Patient is any person who receives medical attention, care, or treatment. The person is most often ill or injured and in need of treatment by a physician or other health care professional, although one who is visiting a physician for a routine check-up may also be viewed as a patient.

The word patient originally meant 'one who suffers'. This English noun comes from the Latin word patiens, the present participle of the deponent verb, patior, meaning 'I am suffering.)

The word patient connotes sickness. The word patient perpetuates the assumption that a person is non-functioning and dependent. If the people around you treat you like a patient, it is pretty normal to start viewing yourself as a patient. If you view yourself as a patient, then the expectation that you should meet your needs is severely diminished. How can a person who has been stigmatized as being “sick” and non-functioning and dependent feel worthwhile or have a positive self-image? Hence it is necessary to equip a patient centered relationship. Patient-centered communication skills include active listening and providing empathy and support.

Objectives

· To explore the personal and psychosocial effects of illness in the life of a patient, productive and nonproductive means of coping with those effects, and the role of the physician in this process.

· To explore the impact of dying and death upon the students/physicians, patients and their families, and the difficult decisions concerning the treatment of the dying patient.

Goals

  1. Recognize the patient's emotional reaction, his illness, his family and his physician.
  2. Understand physician's responsibility toward his ill patient.
  3. Recognize the influences of age, culture, ethnicity, education on patient response to and manner of coping with illness.
  4. Recognize the impact of death and dying on the physician and patient/family.

The Patient's Emotional Reaction to Illness

  • Loss
  • Identity
  • Suffering

The Physician's Responsibility

  • Determine the cause of the illness
  • Treat the symptoms
  • Understand and support the human being who is experiencing those symptoms

N A S W S t a n d a r d s f o r Clinical Social Work

N AT I O N A L A S S O C I A T I O N O F S O C I A L WO R K E R S
2005

N A S W S t a n d a r d s f o r Clinical Social Work
i n S o c i a l Wo r k P r a c t i c e
National Association of Social Workers
Elvira Craig de Silva, DSW, ACSW
NASW President
Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director
Clinical Social Work Standards
Committee
Doris Tomer, LCSW, ACSW, BCD, Chair
Patricia Herrera-Thomas, LSCSW, LCSW
Janet Linder, LCSW
Mary Anne Nulty, LCSW, CSW-PIP, DAPA
Carol Seacord, ACSW, CSW, BCD
NASW Staff
Toby Weismiller, ACSW
Tracy Whitaker, ACSW
Nancy Bateman, LCSW-C
Mirean Coleman, MSW, LICSW, CT
©2005 National Association of Social Workers.
All Rights Reserved.
Contents
4 Overview of the Standards
7 Introduction
8 Goals of the Standards
9 Definitions
11 Standards for Clinical Social Work Practice
11 Standard 1. Ethics and Values
12 Standard 2. Specialized Practice Skills and
Interventions
14 Standard 3. Referrals
14 Standard 4. Accessibility to Clients
15 Standard 5. Privacy and Confidentiality
16 Standard 6. Supervision and Consultation
17 Standard 7. Professional Environment and
Procedures
18 Standard 8. Documentation
18 Standard 9. Independent Practice
19 Standard 10. Cultural Competence
20 Standard 11. Professional Development
21 Standard 12. Technology
22 References
4
Standards
for Clinical Social Work
in Social Work Practice
Standard 1. Ethics and Values
Clinical social workers shall adhere to the
values and ethics of the social work profession,
utilizing the NASW Codes of Ethics as a guide
to ethical decision making.
Standard 2. Specialized Practice Skills and
Intervention
Clinical social workers shall demonstrate
specialized knowledge and skills for effective
clinical intervention with individuals, families,
and groups.
Standard 3. Referrals
Clinical social workers shall be knowledgeable
about community services and make
appropriate referrals, as needed.
Standard 4. Accessibility to Clients
Clinical social workers shall be accessible to
clients during nonemergency and emergency
situations.
Standard 5. Privacy and Confidentiality
Clinical social workers shall maintain adequate
safeguards for the private nature of the
treatment relationship.
Standard 6. Supervision and Consultation
Clinical social workers shall maintain access to
professional supervision and/or consultation.
5
Standard 7. Professional Environment and
Procedures
Clinical social workers shall maintain
professional offices and procedures.
Standard 8. Documentation
Documentation of services provided to or on
behalf of the client shall be recorded in the
client’s file or record of services.
Standard 9. Independent Practice
Clinical social workers shall have the right to
establish an independent practice.
Standard 10. Cultural Competence
Clinical social workers shall demonstrate
culturally competent service delivery in
accordance with the NASW Standards for
Cultural Competence in Social Work Practice.
Standard 11. Professional Development
Clinical social workers shall assume personal
responsibility for their continued professional
development in accordance with the NASW
Standards for Continuing Professional Education
and state requirements.
Standard 12. Technology
Clinical social workers shall have access to
computer technology and the Internet, as
the need to communicate via e-mail and to
seek information on the Web for purposes
of education, networking, and resources is
essential for efficient and productive
clinical practice.
Adopted by the NASW Board of Directors
June, 2005.

7
Introduction
Clinical social workers represent the largest
group of behavioral health practitioners in the
nation. They are often the first to diagnose
and treat people with mental disorders and
various emotional and behavioral disturbances.
Clinical social workers are essential to a
variety of client-centered settings, including
community mental health centers, hospitals,
substance use treatment and recovery
programs, schools, primary health care
centers, child welfare agencies, aging services,
employee assistance programs, and private
practice settings.
Clinical social work has a primary focus on the
mental, emotional, and behavioral well-being
of individuals, couples, families, and groups.
It centers on a holistic approach to
psychotherapy and the client’s relationship to
his or her environment. Clinical social work
views the client’s relationship with his or her
environment as essential to treatment
planning.
Clinical social work is a state-regulated
professional practice. It is guided by state
laws and regulations. In most instances,
clinical social workers are required to have
the following credentials:
n a master’s degree from a social work
program accredited by the Council on
Social Work Education
n a minimum of two years or 3,000 hours
of post-master’s degree experience in a
supervised clinical setting
n a clinical license in the state of practice.
8
Clinical social work is broadly based and
addresses the needs of individuals, families,
couples, and groups affected by life changes
and challenges, including mental disorders
and other behavioral disturbances. Clinical
social workers seek to provide essential
services in the environments, communities,
and social systems that affect the lives of the
people they serve.
Goals of the Standards
Clinical social workers are committed to the
delivery of competent services to individuals,
families, couples, and groups. Therefore, they
shall recognize the client’s role in his or her
treatment planning and the client’s right to
have a knowledgeable, skilled practitioner
who is guided by sound ethical practice.
These Standards for Clinical Social Work Practice
set forth by the National Association of Social
Workers (NASW) are intended to guide clinical
social workers in all clinical settings. Specifically,
the goals of the standards are to:
n maintain or improve the quality of services
provided by clinical social workers
n establish professional expectations to assist
social workers in monitoring and evaluating
their clinical practice
n provide a framework for clinical social
workers to assess responsible, professional
behavior
n inform consumers, government regulatory
bodies, and others about the professional
standards for clinical social work practice.
9
The scope of clinical social work extends
across many practice settings and populations.
It is anticipated that these standards will
reinforce and support current clinical practice
in all settings, while affirming the value of
clinical social work services as a discrete
practice area.
Definitions
Client/Patient/Consumer
Social workers generally use the term “client”
to refer to the individual, group, family, or
community that seeks or is provided with
professional services. The client is often seen
as both the individual and the client system
or those in the client’s environment. The term
“consumer” is also used in settings that view
the client as the consumer, that is, one capable
of deciding what is best for her or himself and
encourages self-advocacy and self-judgment
in negotiating the social service and welfare
system. The term “patient” is more commonly
used by social workers employed in health care
settings (Barker, 2003). The term patient may
also be used for insurance reimbursement
purposes in health and mental health settings.
Clinical Social Work
Clinical social work is the professional
application of social work theory and methods
to the diagnosis, treatment, and prevention
of psychosocial dysfunction, disability, or
impairment, including emotional, mental,
and behavioral disorders (Barker, 2003).
10
Counseling
This is a procedure that is often used in
clinical social work and other professions to
guide individuals, families, couples, groups,
and communities by such activities as
delineating alternatives, helping to articulate
goals, and providing needed information
(Barker, 2003).
Person-in-Environment Perspective
This orientation views the client as part of
an environmental system. It encompasses
reciprocal relationships and other influences
between an individual, relevant others, and
the physical and social environment
(Barker, 2003).
Psychodynamic
This word pertains to the cognitive,
emotional, and volitional mental processes
that consciously and unconsciously motivate
an individual’s behavior. These processes are
the product of the interplay among a person’s
genetic and biological heritage, the
sociocultural milieu, past and current realities,
perceptual abilities and distortions, and his
or her unique experiences and memories
(Barker, 2003).
Psychotherapy
Psychotherapy is a specialized, formal
interaction between a social worker or other
mental health professional and a client (either
individual, couple, family, or group) in which
a therapeutic relationship is established to
help resolve symptoms of mental disorder,
psychosocial stress, relationship problems,
and difficulties in coping in the social
environment. Types of psychotherapy include,
11
but are not limited to family therapy, group
therapy, cognitive–behavioral therapy,
psychosocial therapy, and psychodrama
(Barker, 2003).
Therapy
This is a systematic process designed to
remedy, cure, or abate some disease, disability,
or problem. This term is often used by social
workers as a synonym for individual
psychotherapy, conjoint therapy, couples
therapy, psychosocial therapy, or group
therapy (Barker, 2003).
Standards for Clinical Social Work
in Social Work Practice
Standard 1. Ethics and Values
Clinical social workers shall adhere to the
values and ethics of the social work
profession, utilizing the NASW Code of Ethics
as a guide to ethical decision making.
Interpretation
The social work mission is rooted in six core
values: service, social justice, dignity and
worth of the person, importance of human
relationships, integrity, and competence
(NASW, 1999). All social workers have a
responsibility to embrace these values as a
service to clients, the profession, self, colleagues,
and society. In delivering clinical social work
services, the social worker’s primary
responsibility is to his or her client. Clinical
social workers shall acknowledge the right of
clients to receive competent psychosocial
services and demonstrate a commitment to act
on professional judgment and convictions,
12
which are informed by the NASW Code of Ethics
(1999).
Clinical social workers shall be prepared for
the challenges that encompass the assessment
and treatment of people with mental disorders
and behavioral or emotional disturbances.
This includes maintaining a commitment to
the client while simultaneously demonstrating
responsibility to the practice setting, society,
and local, state, and federal policies and
regulations governing the social worker’s
clinical practice. In the event that conflicts
arise among competing interests, social
workers are directed to the NASW Code of
Ethics as one of the reference points for
decision making. Services should only be
provided in a setting in which the professional
relationship can be maintained. Clinical social
workers should adhere to the NASW Code of
Ethics with regard to limits on private and/or
dual relationships with clients.
Standard 2. Specialized Practice Skills
and Interventions
Clinical social workers shall demonstrate
specialized knowledge and skills for effective
clinical interventions with individuals, families,
couples, and groups.
Interpretation
Drawing on knowledge of systems theory,
person-in-environment orientation,
psychodynamic theory, interpersonal
dynamics, and family systems, clinical social
workers shall be familiar with social,
psychological, cultural, and health factors that
influence the mental, emotional, and
behavioral functioning of the client. They
13
shall have knowledge of theories of personality
and behavior and be aware of sociocultural and
environmental influences, as well as conditions
that have an impact on the physical and
emotional state of the client.
In addition to the above, clinical social
workers shall have the ability to:
n establish and maintain a relationship of
mutual respect, acceptance, and trust
n gather and interpret social, personal,
environmental, and health information
n evaluate and treat problems within their
scope of practice
n establish achievable treatment goals with the
client
n facilitate cognitive, affective, and behavioral
changes consistent with treatment goals
n evaluate the effectiveness of treatment
services provided to the client
n identify appropriate resources and
assessment instruments, as needed
n advocate for client services
n collaborate effectively with other social
work or allied professionals, when
appropriate.
When additional knowledge and skills are
required to address clients’ needs, the clinical
social worker shall seek appropriate training,
supervision, or consultation, or refer the client
to a professional with the appropriate
expertise. Clinical social workers shall limit the
scope of their practice to those clients for
whom they have the knowledge, skill, and
resources to serve. They shall be accountable
for all aspects of their professional judgment,
behavior, and decisions.
14
Standard 3. Referrals
Clinical social workers shall be knowledgeable
about community services and make
appropriate referrals, as needed.
Interpretation
To ensure that clients receive optimal
psychosocial services, it is sometimes beneficial
to collaborate or coordinate services with
appropriate community programs to
strengthen or improve the continuity of care.
Clinical social workers shall be knowledgeable
about available community resources and
advocate on behalf of the client for
appropriate services. The clinical social
worker shall maintain collaborative contacts
with social work or other related professionals
and make appropriate referrals, as needed.
The clinical social worker shall not share
information about the client without the
client’s informed consent or as otherwise
indicated in Standard 5.
Standard 4. Accessibility to Clients
Clinical social workers shall be accessible to
their clients.
Interpretation
Clinical social workers shall be available to
provide clinical services to clients during
regularly scheduled appointment times or
sessions. In addition, the clinical social worker
shall develop emergency plans or be available
to the client for emergency coverage during
vacations, holidays, illnesses, and at other
times when the office may be closed.
Arrangements or plans and procedures for
emergency coverage shall be made in
partnership with competent mental health
15
professionals or reputable institutions and
should be discussed with the client at the
initial face-to-face interview.
In addition, the office setting should be
accessible and/or have helping devices for
persons with disabilities, or office limitations
should be discussed prior to scheduling
appointments.
Standard 5. Privacy and Confidentiality
Clinical social workers shall maintain adequate
safeguards for the private nature of the
treatment relationship.
Interpretation:
Confidentiality is a basic principle of social
work intervention. It ensures the client that
what is shared with the social worker will
remain confidential, unless there is an ethical
or legal exception. All information related to
or obtained from the client by the clinical
social worker shall be viewed as private and
confidential. Clinical social workers shall be
familiar and comply with local, state, and
federal mandates governing privacy and
confidentiality, such as the federal Health
Insurance Portability and Accountability Act
(HIPAA) requirements and state medical
records laws.
Information obtained by the social worker
from or about the client shall be viewed as
private and confidential, unless the client
gives informed consent for the social worker
to release or discuss the information with
another party. There may be other exceptions
to confidentiality as required by law or
professional ethics. Social workers should be
16
familiar with national, state, and local
exceptions to confidentiality, such as mandates
to report when the client is a danger to self or
others and for reporting child or elder abuse
and neglect. The clinical social worker shall
advise the client of confidentiality limitations
and requirements at the beginning of
treatment.
Professional judgment in the use of
confidential information shall be based on
best practice, as well as legal, and ethical
considerations.
Standard 6. Supervision and Consultation
Clinical social workers shall maintain access to
professional supervision and/or consultation.
Interpretation
Clinical social workers should ensure that
professional social work supervision is
available to them in a clinical setting for
the first five years of their professional
experience (NASW, 2004). If clinical social
worker supervisors are not available or
accessible, case consultation may be obtained
from qualified professionals of other related
disciplines. Those clinical social workers with
more than five years of clinical experience
shall use consultation on an as-needed, selfdetermined
basis. Clinical social workers
shall adhere to state and federal statutes and
regulations regarding supervision and
consultation in their states of practice.
When appropriate, clinical social workers
should offer their expertise to individuals,
groups, and organizations, as well as offer
training and mentoring opportunities to
17
beginning social workers or those making the
transition into clinical social work. In addition,
experienced clinical social workers who are
able should offer supervision to social workers
seeking state licensure for clinical social work
practice.
Standard 7. Professional Environment and
Procedures
Clinical social workers shall maintain
professional offices and procedures.
Interpretation
Agencies providing clinical social work
services and clinical social workers in private
or independent practice shall develop and
implement written policies that describe their
office procedures, such as the client’s rights,
including the right to privacy and
confidentiality; notices and authorizations;
procedures for release of information, fee
agreements; procedures for payment;
cancellation policy; and coverage of services
during emergency situations or when the
clinical social worker is not available. These
policies shall be made available to and
reviewed with each client at the beginning
of treatment. Clinical social workers should
maintain appropriate liability insurance and
have a current working knowledge of risk
management issues.
In addition to the above, the treatment setting
shall be properly maintained to ensure a
reasonable degree of comfort, privacy, and
security for the social worker and the client.
18
Standard 8. Documentation
Documentation of services provided to, or on
behalf of, the client shall be recorded in the
client’s file or record of services.
Interpretation
Clinical social workers must document all
services rendered to clients and keep the
records in a secure location, maintaining
them as private and confidential records.
Documentation must reflect an accurate
account of services. Progress notes, reports,
and summaries of services shall be regularly
recorded in the client’s file and be consistent
with all applicable local, state, and federal
statutory, regulatory, or policy requirements.
Records must meet current federal provisions
regarding privacy, security, and electronic
transactions standards and code sets.
Standard 9. Independent Practice
Clinical social workers shall have the right to
establish an independent practice.
Interpretation:
Clinical social workers may establish an
independent solo or group practice. When
doing so, they shall ensure that all services,
including diagnostic and treatment planning,
meet professional standards. When clinical
social workers employ staff, they, as
employers, bear responsibility for the
competency of all services provided;
maintaining clinical and ethical standards;
and upholding all local, state, and federal
regulations.
To avoid conflicts of interest, clinical social
workers who are both employed by agencies
19
and have independent practices shall not refer
agency clients to themselves without prior
agreement with the agency and consent of the
client. In addition, the clinical social worker
shall have offered alternative options to the
client, such as transferring the client to
another treatment provider within the agency
or terminating services.
Clinical social workers in private or
independent practice may bill third-party
payers or their clients for services rendered.
Clients shall be provided with all invoices and
receipts in a timely manner. When a client can
no longer afford services—or a third-party
payer or an agency terminates services—an
alternative mutually agreed upon with the
client may be instituted, which could include,
for example, a referral, termination of services,
a sliding scale, or pro bono services. If services
continue, consideration must be given to any
applicable federal or state laws and regulations
as well as insurance or managed care contracts
that may limit the type of continuing care.
When a client chooses to terminate treatment,
the clinical social worker will offer to aid the
client in exploring barriers to treatment and
re-examine the treatment plan to help the
client reach termination constructively. When
appropriate, the clinical social worker shall
refer the client to another qualified treatment
provider.
Standard 10. Cultural Competence
Clinical social workers shall demonstrate
culturally competent service delivery in
accordance with the NASW Standards for
Cultural Competence in Social Work Practice.
20
Interpretation
The increasingly diverse population seeking
psychosocial services requires that clinical
social workers raise their awareness and
appreciation of cultural differences. Clinical
social workers shall have, and continue to
develop, specialized knowledge and
understanding about history, traditions,
values, and family systems as they relate to
clinical practice with individuals, families,
and groups. Clinical social workers shall be
knowledgeable about and demonstrate practice
skills consistent with the NASW Standards
for Cultural Competence in Social Work Practice
(2001). In addition, clinical social workers
need to be knowledgeable about the
deleterious effects of racism, sexism, ageism,
heterosexism or homophobia, anti-Semitism,
ethnocentrism, classism, and disability-based
discrimination on clients’ behavior, mental and
emotional well-being, and course of treatment.
Clinical social workers must also recognize
racial, ethnic, and cultural differences that may
be interpreted as barriers to treatment and
develop skills to ameliorate such barriers.
Standard 11. Professional Development
Clinical social workers shall assume personal
responsibility for their continued professional
development in accordance with the NASW
Standards for Continuing Professional Education
and state requirements.
Interpretation
To practice effectively, clinical social workers
must remain knowledgeable about emerging
theories and interventions, best practice
models in the social work profession, and
changes in policies and regulatory reforms
21
such as the HIPAA regulations. Clinical social
workers shall seek to enhance their skills and
understanding by staying abreast of research
to ensure that their practice reflects the most
current knowledge. Clinical social workers
should also seek continuing education about
risk management and professional liability
issues.
Numerous opportunities in professional
development are available through NASW
and other professional organizations or
institutions, coalitions, and service agencies at
local, state, and national levels. Clinical social
workers should regularly participate in and
contribute to professional conferences and
training activities and contribute to and
promote professional publications.
Standard 12. Technology
Clinical social workers shall have access to
computer technology and the Internet, as the
need to communicate via e-mail and to seek
information on the Web for purposes of
education, networking, and resources is
essential for efficient and productive clinical
practice.
Interpretation
Clinical social workers are increasingly using
the Web, computers, and other electronic
technology to improve the quality of services
for clients, to communicate with other
professionals, and for documentation
purposes. Clinical social workers should keep
abreast of electronic changes that may affect
practice. Technology may be integrated into
clinical practice; however, appropriate
safeguards for client privacy shall be used.
22
Clinical social workers should engage in
ongoing training in technology applications
relevant to clinical social work practice
including assessment and treatment, research,
policy, education, and resource tracking and
development.
Free information on the Standards is located on
the NASW Web site: www.socialworkers.org.
Purchase full document from NASW Press at
1.800.227.3590.
References
Barker, R. L. (2003). The social work dictionary
(4th ed.). Washington, DC: NASW Press.
Health Insurance Portability and Accountability
Act of 1996, P.L. 104-191, 110 Stat. 1936.
National Association of Social Workers. (1999).
Code of ethics of the National Association of Social
Workers.Washington, DC: NASW Press.
National Association of Social Workers. (2001).
NASW standards for cultural competence in social
work practice.Washington, DC: Author.
National Association of Social Workers. (2002).
NASW standards for continuing professional
education.Washington, DC: Author.
National Association of Social Workers. (2004).
Clinical social workers in private practice: A
reference guide.Washington, DC: Author.


NATIONAL ASSOCIATION
OF SOCIAL WORKERS
750 First Street, NE
Suite 700
Washington, DC 20002-4241
202.408.8600
www.socialworkers.org

MODELS OF PREVENTION


http://currentnursing.com/nursing_theory/models_prevention.html




outline

Introduction

A model is a theoretical way of understanding a concept or idea. Models represent different ways of approaching complex issues. Health beliefs are a person’s ideas, convictions, and attitudes about health and illness. Because health beliefs usually influence health behaviour, they can positively or negatively affect a client’s health. ‘Prevention’of illness is a positive health behaviour. Common positive health behaviours include immunizations, proper sleep patterns, adequate exercise, and nutrition. There are different models of health.

Preventing illness is one aspect of wellness care that focuses on detection or prevention of disease. Primary prevention focuses on the health of a person or population. Secondary prevention includes screening for those at risk to develop an illness or those who could have disease diagnosed early in the process for prompt treatment. Tertiary prevention occurs when diagnosis of a long term disease/disability has already been made. The goal is to minimize complications and maximize function many way possible for these clients.

Definition of health

  • Traditional medicine - "absence of disease absence of disease".
  • "Health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity"- WHO(1948)
  • Murray & & Zentner –"state of well-being (where)…person uses purposeful, adaptive responses…to maintain relative stability and comfort strive for personal objectives & cultural goals".

New philosophy of health

Health is:

  • fundamental right
  • Essence of productive life
  • Intersectoral
  • Integral part of development
  • Central to the concept of quality of life
  • Involves individual, state and international responsibilities
  • World wide social goal
  • Major social investment

Millennium development goal

  • In the millennium declaration of September 2000, member states of the United Nations made a most passionate commitment to address the crippling poverty and multiplying misery that grip many areas of the world. Government sets a date of 2015 by which they would meet the millennium development goals:

Goals

  • Eradicate extreme poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/AIDS, malaria and other disease
  • Ensure environmental sustainability
  • Develop a global partnership for development

Concept of prevention

· "...prevention is any activity which reduces the burden of mortality or morbidity from disease."

· The act of preventing or impeding.

· A hindrance; an obstacle.

Clinical model

In this model, the absence of signs and symptoms of disease indicates health. Illness would be the presence of conspicuous signs and symptoms of disease. People who use this model of health to guide their use of healthcare services may not seek preventive health services , or they may wait until they are very ill to seek care. Clinical model is the conventional model of the discipline of medicine.

Role performance model

Here, health is indicated by the ability to perform social roles. Role performance includes work, family and social roles, with performance based on societal expectations. Illness would be the future to perform a person’s roles at the level of others in society. This model is basis for work and school physical examination and physician –excused absences. The sick role, in which people can be excused from performing their social roles while they are ill, is a vital component of the role performance model.

Adaptive model

Here, the ability to adapt positively to social, mental, and physiological change is indicative of health. Illness occurs when the person fails to adapt or becomes inadaptive toward these changes. As the concept of adaptation has entered other aspects of culture , this model has become widely accepted.

Agent-Host-Environmental model: by Leavell and Clark(1965)

This is useful for examining causes of disease in an individual. The agent, host and environment interact in ways that create risk factors, and understanding these is important for the promotion and maintenance of health. An agent is an environmental factor or stressor that must be present or absent for an illness to occur. A host is a living organism capable of being infected or affected by an agent. The host reaction is influenced by family history, age, and health habits.

High Level Wellness Model by Dunn(1961):

This model recognizes health as an ongoing process toward a person’s highest potential of functioning. This process involves the person, family and the community. He describes high-level wellness as “the experience of a person alive with the glow of good health, alive to the tips of their fingers with energy to burn, tingling with vitality – at times like this the world is a glorious place”.

The wellness- illness continuum (Travis and Ryan 1988) is a visual comparison of high-level wellness and traditional medicine’s view of wellness. High level wellness according to Ardell(1977) is a lifestyle focused approach which you design for the purpose of pursuing the highest level of health within your capability.

Holistic Health Model by Edelman and Mandle, 2002

Holism acknowledges and respects the interaction of a person’s mind, body and spirit within the environment. Holism is an antidote to the atomistic approach of contemporary science. An atomistic approach takes things apart , examining the person piece by piece in an attempt to understand the larger picture.

Holism is based on the belief that people (or their parts) can not be fully understood if examined solely in pieces apart from their environment. Holism sees people as ever charging systems of energy.

In this model, nurses using the nursing process consider clients the ultimate experts regarding their own health and respect client’s subjective experience as relevant in maintaining health or assisting in healing. In holistic model of health, clients are involved in their healing process, thereby assuming some responsibility for health maintenance.

Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions, such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, non-pharmacological complements to traditional medical care.

Nightingale’s Theory of Environment

Florence Nightingale’s environmental theory has great significance to nursing and community health nursing specifically, because it focuses on preventive care for populations. Her observations suggested that disease was more prevalent in poor environments and that health could be promoted by providing adequate ventilation, pure water, quiet, warmth, light and cleanliness. The crux of her theory was that poor environmental conditions are bad for health and that good environmental conditions reduce disease.

This is one way to measure a person’s level of health. This model views health as a constantly changing state, with high level wellness and death being on opposite ends of a graduated scale, or continuum. This continuum illustrates the dynamic state of health, as a person adapts to changes in the internal and external environments to maintain a state of well-being. A patient with chronic illness may view himself/herself at different points of the continuum at any given time, depending on how well the patient believes he/she is functioning with .

Milio’s Framework for Prevention

Nancy Milio developed a framework for prevention that includes concepts of community – oriented, population- focused care. Milio’s basic treatise was that behavioural patterns of the populations-and individuals who make up populations – are a result of habitual selection from limited choices. She challenged the common notion that a main determinant for unhealthful behavioural choice is lack of knowledge. Milio’s framework described a sometimes neglected role of community health nursing to examine the determinants of a community’s health and attempt to influence those determinants through public policy.

Levels of Prevention Model

This model, advocated by Leavell and Clark in 1975, has influenced both public health practice and ambulatory care delivery worldwide. This model suggests that the natural history of any disease exists on a continuum, with health at one end and advanced disease at the other. The model delineates three levels of the application of preventive measures that can be used to promote health and arrest the disease process at different points along the continuum. The goal is to maintain a healthy state and to prevent disease or injury.

It has been defined in terms of four levels:

  • Primordial prevention
  • Primary prevention
  • Secondary prevention
  • Tertiary prevention

Primordial prevention

Primary prevention in its purest form- prevention of the emergence or development of risk factors in population or countries in which they have not yet appeared. Here, efforts are directed towards discouraging children from adopting harmful lifestyles

Primary prevention

  • An action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.
  • It includes the concept of positive health, that encourages the achievement and maintenance of an “acceptable level of health that will enable every individual to lead a socially and economically productive life.
  • A holistic approach

Secondary prevention

  • Action which halts the progress of a disease at its incipient stage and prevents complications.
  • The domain of clinical medicine
  • An imperfect tool in the transmission of disease
  • More expensive and less effective than primary prevention

Tertiary prevention

All measures available to reduce or limit impairment and disabilities, minimize suffering caused by existing departures from good health and to promote the patient's adjustment to irremediable conditions

Modes of intervention

  • Health promotion
  • Specific protection
  • Early diagnosis and treatment
  • Disability limitation
  • rehabilitation

Health promotion

The process of enabling people to in areas to control over and to improve health

  • Health education
  • Environmental modifications
  • Nutritional interventions
  • Lifestyle and behavioral changes

Specific protection

  • Immunization
  • Specific nutrients
  • Chemoprophylaxis
  • Protection against occupational hazards
  • Protection from carcinogens
  • Avoidance of allergens

Rehabilitation

The combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability. Examples-schools for blind, reconstructive surgery in leprosy, provision of aids for the crippled

Intervention approaches

  • Individual-focused (personal health)
  • Community-focused (population or subgroup)
  • System-focused (procedures, rules, regulations, policy and law)

The Health Belief Model

This mode is one of the oldest attempts to explain health behaviour. It is based on the premise that for a behavioral change to succeed, individuals must have the incentive to change, feel threatened by their current behaviour, and feel that a change will be beneficial and be at acceptable cost. They must also feel competent to implement that change

Purpose of the Model.

-method to explain and predict preventive health behavior.

History

The Health Belief Model (HBM) was one of the first models that adapted theory from the behavioral sciences to health problems, and it remains one of the most widely recognized conceptual frameworks of health behavior. It was originally introduced in the 1950s by psychologists working in the U.S. Public Health Service (Hochbaum, Rosenstock, Leventhal, and Kegeles).

The model in action: an example

A parent will organize immunization for a child if he/she:

  • believes there is a danger of the child contracting the disease (perceived susceptibility)
  • believes that immunization is effective in eliminating the danger (perceived benefits)
  • trusts that the method is safe and has an acceptable level of risk (possibly through education and media information)
  • has the means to access the vaccination service (no barriers to behavior change)

Tannahill Model of Health Promotion

  • Health Education: communication activity aimed at enhancing well-being and preventing ill-health through favorably influencing the knowledge, beliefs, attitudes and behavior of the community
  • Health Protection: refers to the policies and codes of practice aimed at preventing ill-health or positively enhancing well-being, for example, no smoking in public places. Health Protection is responsible for the development and implementation of legislation, policies and programs in the areas of Environmental Health Protection, Community Care Facilities, and Emergency Preparedness
  • Prevention: refers to both the initial occurrence of disease and also to the progress and subsequently the final outcome

The Social Model

A social health model, that is, one aimed at incorporating the social and economic, as well as biophysical context of health status, is now acknowledged as having greater impact on the determinants and generation of health. However, the political will and theoretical framework must also be present for the change to a social health model to occur. It is:

  • based on knowledge of the experience, views and practices of people with disabilities.
  • locates the problem within society, rather than within the individual with a disability
  • Rules are determined within a framework of choice and independent living with strong support from organized disability communities

The biases of the social model include: limiting the causes of disability either exclusively or mainly to social and environmental policies and practices, or advancing perceptions of disability in mainly industrialized countries that emphasize individual rights rather than advancing broader economic rights that may reflect the needs of impoverished developing countries.

The Social-Ecological Model

The ultimate goal is to stop violence before it begins. Prevention requires understanding the factors that influence violence. CDC uses a four-level social-ecological model to better understand violence and the effect of potential prevention strategies. This model takes into consideration the complex interplay between individual, relationship, community and societal factors. It allows us to address the factors that put people at risk for experiencing or perpetrating violence.

Mental Health Promotion Model

purpose of mental health promotion for people with mental illness is to ensure that individuals with mental illness have power, choice, and control over their lives and mental health, and that their communities have the strength and capacity to support individual empowerment and recovery. The person with mental illness is the central focus: participating in her/his community, involved in decision-making about mental health services, and choosing which supports are most appropriate. There are four key resources which should be available to the person to support their mental health: a) mental health services; b) family and friends; c) consumer groups and organizations; and d) generic community services and groups.

AIDS Risk Reduction Model

It believes change is a process. Individuals must go through with different factors

affecting movement. This model proposes that the further an intervention helps clients to progress on the stage continuum, the more likely they are to exhibit change. Individuals must pass through three stages;

A) Labeling - one must label their actions as risky for contracting HIV (i.e. problematic). Three elements are necessary

- Knowledge about how HIV is transmitted and prevented,

- Perceiving themselves as susceptible for HIV and

- Believing HIV is undesirable.

B) Commitment – this decision-making stage may result in one of several outcomes

- Making a firm commitment to deal with the problem

- Remaining undecided,

- Waiting for the problem to solve itself, or

- Resigning to the problem: Weigh cost and benefits-

giving up pleasure (high risk) for less pleasure (low risk)

C) Enactment – This includes three stages:

- Seeking information,

- Obtaining remedies, and

- Enacting solutions.

Summary

Nursing must expand its efforts to design and implement interventions which support promotion of health and prevention of disease/illness and disability. Preventing illness and staying well involve complex, multidimensional activities focused not only on the individual, but also on families, groups and populations. Approaches to prevention should be comprehensive, encompass primary, secondary and tertiary levels of prevention and involve consumers in their formulation. Prevention strategies are more likely to be adopted by citizens who participate in influencing and developing such strategies. Nurses have developed many health models to understand the client’s attitudes and values about health and illness so that effective health care can be provided. These nursing models allow nurses to understand and predict client’s health behaviour, including how they use health services and adhere to recommended therapy.

Prevention has long been part of nursing's scope of practice. Nurses delivering care to clients across the life span in a variety of practice areas can support individuals and coalitions structured to promote health and prevent disease. Nurses have involved themselves in activities that move individuals, families, groups and communities toward higher levels of health and wellness. In all direct or indirect practice arenas nurses must continue a strong orientation toward prevention.

Reference

1. Craven RF, Hirnle CJ. Fundamentals of Nursing Human Health and Function.5th edn. Lippincott; Philadelphia:2007, Pp-259-284.

2. Taylor C, Lillis C, Lemone P. Fundamentals of nursing the art and science of nursing care. 5th edn. Lippincott; Newdelhi:2006, 63-65.

3. Potter PA, Perry AG. Fundamentals of nursing.6th edn.Mosby;Newdelhi:2005 Pp-91-4.

4. Black JM, Hawks JH. Medical Surgical nursing clinical management for positive outcomes. Vol1. 7th edition. Saunders; India : 2005, Pp 134-136.

5. Allender JA, Spradley BW. Community health nursing concepts and practice. 5thedition.Lippincott;Philadelphia:2001, Pp 10-12.

6. Park K. Text book of Preventive and social medicine, 18th editiion,13-29.

7. Kulkarni. Text book of community medicine,6th edition, page no.456-460.


SINCERE THANKS TO PROF. RAMESH