social health assessment of soldiers’ operational...

Van Breda: Social Health Assessment of Soldiers’ Operational Readiness

SOCIAL HEALTH ASSESSMENT OF SOLDIERS’ OPERATIONAL READINESS

MAJOR ADRIAN D. VAN BREDA

(M SOC SC, WITH DISTINCTION, UCT)

Manager: Military Health Research Centre Military Psychological Institute

Private Bag X02 Gezina 0031

South Africa

[email protected]

Paper presented at the 34th International Congress on Military Medicine,

Sun City, South Africa, 15-20 September 2002.

Adrian Van Breda received his Masters Degree in Clinical Social Work with distinction

from the University of Cape Town in 1997. He is currently reading for a Doctoral

Degree in multicultural scale development in social work at the Rand Afrikaans

University. He practised as a social worker in the SA Navy from 1992-1997. He

established and ran the Social Work Research & Development department of the

Military Psychological Institute for five years and is now the head of the Military Health

Research Centre of the South African National Defence Force.


SOCIAL HEALTH ASSESSMENT OF SOLDIERS’ OPERATIONAL READINESS

MAJOR ADRIAN D. VAN BREDA

The comprehensive or holistic health assessment of soldiers’ readiness for

participation in a military operation has, over the past two years, become an integral

part of the military health service in South Africa. One dimension of this assessment

is a social health assessment, conducted by the Directorate Social Work. This paper

introduces the Resilience Model that is used in this assessment. The process through

which soldiers go during the social health assessment – entailing group preparation,

verbal group administration of the an assessment instrument, scoring of the

instrument, individual assessment interviews and a final social health status

recommendation – is described. The value that an assessment of this nature adds to

the military organisation is outlined and further developments required in the social

health assessment process are detailed.

Keywords: military social work, assessment, resilience, mission readiness

INTRODUCTION

An important service rendered by the South African Military Health Service (SAMHS)

since 2000 is the Concurrent Health Assessment, that until recently has taken place

every six months. The Concurrent Health Assessment (CHA) was introduced as a

mechanism to ensure a pool of healthy soldiers who could be deployed in cross-border

operations at very short notice – what are referred to as High Order Combat-Ready

User Systems.

The CHA entails a comprehensive and holistic assessment of the health of soldiers,

including physical/medical health, oral health, psychological health, social health,


immunisation and fitness. The CHA created a novel demand on the Directorate Social

Work of the SAMHS – how to assess the social functioning of several thousand soldiers

over a period of a couple of weeks.

Social work in South Africa does not have a history of mass screening or psychometric

assessment, as can be found in psychology. We had no precedent to follow, no

instruments to use and not even an established process to develop such an

assessment process.

The Directorate Social Work therefore requested its Social Work Research &

Development department to propose a plan for conducting these assessments.

Through discussions with various stakeholders, a plan was formulated and

implemented a few months later. The initial process has undergone minor

adjustments, but has proven largely effective.

The purpose of this paper is to provide a brief overview of the assessment model and

process used by social workers during the CHA, and then to indicate the main areas of

ongoing work in this regard. It is hoped that our experience may open interesting

possibilities for other defence forces.

PURPOSE OF THE SOCIAL WORK CHA

The purpose of the CHA was formulated in straightforward terms, viz, to “determine

and elevate the social health status of all military employees”(1).

This purpose begs the question, “What is social health?” We intuitively understood

that social health referred to the ability of soldiers and their families to retain good

social functioning in the face of deployment. Our previous work on deployments and

families had generated the concept “deployment resilience” which describes the


capacity of soldiers and families to resist the stress of deployment(2). We considered

therefore that social health was in some way related to deployment resilience.

Our clinical intuition also informed us that social health was more than the mere

absence of social pathology. A soldier or family could have a social problem, but if

they had adequate supports or coping abilities, the soldier could probably still be

described as socially healthy and be able to deploy.

These intuitions and hunches led to a thorough literature study of resilience theory(3)

and the formulation of a model of social health that underpins the entire social work

CHA.

THE RESILIENCE MODEL

Resilience theory has a long history, across many professions, and under many

different names. Another paper presented at this conference is dedicated to

addressing the place of resilience theory in military social work(4). One of the

important aspects of resilience theory that has developed over the past few decades,

is the application of resilience theory to families, by various authors, most notably

Hamilton McCubbin(5).

McCubbin’s model of family resilience, developed largely to describe how families

respond to military separations, has increased in complexity over the past 25 years.

The model has become increasingly accurate in predicting how families respond to life

stress, but has also become less accessible for practitioners.

Consequently, we revised McCubbin’s models of family resilience, incorporating the

findings of hundreds of papers on resilience theory, to formulate a streamlined and

hopefully more clinically accessible model of social health. This model comprises


three main dimensions that predict social functioning, viz the stressor, the family’s

vulnerability and the family’s resilience, as illustrated in the diagram at the end of this

paper.

In light of this model, social health is defined as “the relatively low vulnerability and

high resilience of people that enables them to deal effectively with life stress, notably

the stress of a military operation”(1). Social health is thus the result of a stressor such

as a military deployment impacting on a family system, mediated by the relative

absence of social problems, pile-up, family life cycle difficulties and work-to-family

interference and the relative presence of social support, problem solving abilities,

positive stressor appraisal and generalized resistance resources.

The first dimension of the model, stressor, is defined in this case as a military

operation. The stress of such an operation can be measured by considering the

duration of the pending deployment, the frequency of deployments over the previous

6-12 months, the predictability of the deployment and the distance from home that

the deployment requires. Other factors that can also influence the stressfulness of the

stressor include the degree of danger that can be expected, the individual’s level of

experience with previous deployments, and political/national support for the mission.

The second dimension of the model, vulnerability, is defined as the presence of

factors in the family’s current and recent past that increase the likelihood of social

malfunctioning in the presence of a life stressor. Vulnerability here comprises four

components, viz social problems, pile-up, family life cycle experiences and work-to-

family interference or spillover.

Social problems is the presence of persistent (non-crisis) social pathology in the

family system over the previous six months, which combines to create vulnerability

and social unhealth. Social problems can be located within any individual within the


family or in the family system itself or in the system of relationships that family

members are connected to. Social problems do not refer to problems in the macro

environment, unless these problems impinge directly and consciously on the family.

Social problems are defined according to the perceptions of one member of the family

system – the member that is assessed. Social problems are persistent and enduring

over a period of time, rather than crises or short-term events.

Pile-up is the accumulation, over a six-month period, of multiple life stressors, crises

or events, originating from outside the family system, which require complex and

multiple role changes in the family system, which contributes to increased

vulnerability and social unhealth. Pile-up refers to non-normative life events (such as

the death of a colleague), rather than normative family life cycle events (such as the

death of a parent). Although pile-up can occur within the family system (eg the injury

of a family member), the stressors do not originate from within the family system

itself.

Family life cycle refers to the difficulties related to transitional events in the family

life cycle, which contribute to increased vulnerability and social unhealth. The focus is

on significant and stressful events originating from within the family system – in

contrast to pile-up, which refers to events originating from without the family system.

No normative family life cycle process is required – any event in the life of a family

constitutes family life cycle.

Work-to-family interference is the presence of stressors in the workplace that may

spill over into the family system, which combines to create vulnerability and social

unhealth. The focus is exclusively on events and processes within the soldier’s

workplace (ie the military) that may impact negatively on family resilience and well-

being. This may include the lack of military support for families or the poor

management of military deployments.


The third dimension of the model, resilience, is defined as the presence of factors in

the family’s current and recent past that increase the likelihood of positive social

functioning in the presence of a life stressor. Resilience here comprises four

components, viz social support, problem solving, stressor appraisal and generalised

resistance resources.

Social support is the ability of the family system to access quality and sufficient

support systems in times of need, which contributes to increased resilience and social

health. The source of social support is not of interest here – families can obtain

support from any source. The quality and adequacy of social support is, however,

important. The quality of social support comprises emotional support (feeling cared

for and loved), esteem support (feeling valued), network support (feeling of

belonging) and instrumental support (practical help).

Problem solving is the ability of the family system to identify problems, generate

alternatives, implement solutions and evaluate solutions, which contributes to

increased resilience and social health. The focus here is on the family’s ability to

follow a systematic process of solving problems, rather that on the family’s ability to

communicate in a constructive manner about problems or the belief of family

members in their ability to solve or overcome problems. Problem solving addresses

the process of solving problems, not the resolution of problems as such.

Stressor appraisal is the way in which the stress of deployments is perceived

(seen), appraised (evaluated) and interpreted (given meaning) by family systems,

which contributes to increased resilience and social health. The ‘stressor’ is defined as

a military deployment – the appraisal of the stressor thus focuses specifically on

deployments (stressor appraisal) or more broadly on the military (situation appraisal).

Stressor appraisal focuses on the cognitive processes concerning deployments, rather


than on the deployment itself – it is not a measure of the stressfulness of the

deployment, but rather of the thinking about the stressor.

Generalised resistance resources is the presence of a variety of creative and

dynamic resources in family members and the family system, that enable families to

resist life stress, which contributes to increased resilience and social health. Social

supports and problem solving processes, although also resistance resources, are

excluded here as they constitute specific rather than generalized resistance resources.

The focus here, unlike with stressor appraisal, is on life stress in general, rather than

on the stress of deployments in particular.

The combination of the stressor, the family’s vulnerability and the family’s resilience,

is believed to determine to a large extent the chances of families and soldiers

maintaining healthy social functioning over time. Families with low vulnerability and

high resilience are believed to be in the best position to cope with a stressful

deployment. The immediate purpose of the social work CHA is to identify families

with medium to high vulnerability and medium to low resilience, and withhold them

from deployment until such time as the resilience profile improves.

SOCIAL WORK CHA PROCESS

The CHA process is divided into five stages.

Firstly, soldiers participate in a group preparation for the assessment. The group

discussion aims to reduce soldiers’ anxiety about the assessment and to reduce the

likelihood of soldiers ‘faking good’ on the questionnaire. They discuss what it means

to have social problems and explore the impact of such problems on the organisation’s

mission and family well-being. The CHA process and intent is discussed, and soldiers

are informed what happens to soldiers who are assessed as not being socially healthy.


The second part of the process is the verbal administration of a pencil & paper

instrument, viz the Heimler Scale of Social Functioning(6). The Heimler Scale, a social

work instrument developed in Britain and validated in the SANDF(7), measures a

person’s broad social functioning. In our experience, the Heimler Scale is not well

understood by our soldiers. The verbal administration of the scale increases the

accuracy of completion of the instrument.

After all soldiers have completed the instrument, it is scored using a computer

application developed in a collaboration between the Directorate Social Work and the

State Information Technology Agency. The application scores the questionnaire and

uses various rules to determine whether or not the soldier is at risk of social unhealth.

These rules utilise a combination of scale scores and percentage of responses

completed.

Approximately one quarter of the soldiers assessed are identified for clinical

assessment by a social worker. The social workers collect assessment information in

a structured manner, based on the resilience model. Through this interview, social

workers determine the degree of vulnerability and resilience of the soldier and family.

We find that about one quarter of the soldiers assessed are confirmed to be socially

unhealthy.

In the fifth and final stage, a decision is made regarding the soldier’s social health

status, based on the above processes. Green means the soldier is fit for cross-border

deployment. Yellow means the soldier needs some form of social work intervention

before being recoded as green. And Red means the soldier may need to be

permanently transferred into a post that does not require deployment or even to be

boarded out of the SANDF.


FURTHER DEVELOPMENTS OF THE SOCIAL WORK CHA

The development of the social work CHA, indeed the entire CHA, is a broad and

ongoing process of research and development. Social work’s efforts are directed to

three main objectives:

v Firstly, we are in the process of developing a new social work scale that is nested

within the resilience model and that is multiculturally valid. We hope to achieve

several results from this:

Ø Firstly, we hope that such a scale will fit better within the CHA process. The

Heimler Scale bears no relation with our resilience model, which confuses the

assessment process.

Ø Secondly, by developing the scale in multiple languages for a multicultural

target group, we hope to avoid administering the scale verbally. This will

reduce the cost of administering the CHA.

Ø Thirdly, we hope that such a scale will be more accurate in identifying soldiers

for interview – we hope to reduce the number of people interviewed by half or

more, which would double the percentage of interviewees classified Yellow.

Ø Fourth, we are designing the scale to address not only individual and family

factors, but also organisational factors. We hope that this will equip social

workers to increase the resilience and responsiveness of the military system.

v Secondly, we are beginning to explore a more complex model for determining

social health in conjunction with psychological health that will incorporate

intradeployment factors, home unit functioning, etc. It is hoped that by

broadening the focus, we will be more effectively able to identify and reduce risk

factors during deployments.

v Thirdly, we plan to explore the predictive validity of our assessments, by

comparing CHA data collected before deployment with data concerning the social

and other functioning of soldiers during and after deployments. We expect to

achieve higher levels of accuracy in our assessments through this effort.


CONCLUSION

The social work concurrent health assessment is a large process, requiring hundreds

of professional hours. The process has been founded on a powerful model of

individual and family resilience, and is supported by decades of research, both in

South Africa and abroad, on how families respond to deployments. The assessment

process is well tested in practise. Through the ongoing work on scale development,

we hope to achieve a more streamlined process that is highly accurate in predicting

how soldiers and families will respond to military deployments.

REFERENCES

1. Directorate Social Work. Concurrent health assessment: Social work manual.

Unpublished manuscript, Directorate Social Work, South African National

Defence Force, Pretoria, South Africa; 2001.

2. Van Breda A. D. Developing resilience to routine separations: An occupational

social work intervention. Families in Society. 80 (6) 1999: 597-605.

3. Van Breda A. D. Resilience theory: A literature review. South African Military

Health Service, Military Psychological Institute, Social Work Research &

Development: Pretoria, South Africa; 2001.

4. Van Breda A. D. The utilisation of resilience theory in military social work.

Paper presented at the 34th International Congress on Military Medicine, Sun

City, South Africa; 2002.

5. McCubbin M. A., McCubbin H. I. Resiliency in families: A conceptual model of

family adjustment and adaptation in response to stress and crises. In:

McCubbin H. I., Thompson A. I., McCubbin M. A. (eds) Family assessment:

Resiliency, coping and adaptation: Inventories for research and practice.

University of Wisconsin: Madison, WI; 1996: 1-64.


6. Heimler E. Heimler Scale of Social Functioning Rev. IV. Eugene Heimler Trust:

London, UK; 1990.

7. Van Breda A. D. The Heimler Scale of Social Functioning: A partial validation in

South Africa. British Journal of Social Work In Press.

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