SALUTOGENIC CONCEPT OF HEALTH

SALUTOGENESIS:Salutogenesis was originally coined by American-Israeli medical sociologist Aaron Antonovsky. The word "salutogenesis" is derived from the Latinsalusmeaning health and the Greekgenesismeaning origin. It relates to how certain individuals cope successfully with stress whilst others do not and may succumb to disease. Hence salutogenesis is described as focus on the positive adaptation in stress related situations.1 Salutogenesis, the origin of health, is a stress resource orientated concept, which focuseson resources, maintains and improves the movement towards health. It gives the answerwhy people despite stressful situations and hardships stay well. It is the opposite of thepathogenic concept where the focus is on the obstacles and deficits. The Salutogenic model for health is the study of health and determinants of health.2In the past public health focused on disease and risk factors in the search for causal relationships like cancer and smoking, cholesterol and heart disease. Stress was seen as a negative event that increased the susceptibility and risk of breaking down people. Over time the understanding has become more relative where the nature of the stress agent, the abilities of the people involved and the environment play important roles. Both health and stress research initially considered the stress factors (or stressors) as problematic negative events in the life of people. In contrast, Antonovsky stated that disease and stress occur everywhere and all the time and it was surprising that organisms were able to survive with this constant mass exposure. His conclusion was that chaos and stress were part of life and natural conditions and how come we can survive all this led to the origin of salutogenesis.3Aaron Antonovsky did observation on a group of women in their menopause who had extreme experiences in the past in concentration camps. 29% of them were still in a relatively good state of health. Hereby the rising question was: which factors kept these people healthy? To be able to answer this question, Antonovsky developed a theoretical model that describes the factors which are believed responsible for the development towards health. The salutogenic orientation in his sense is basically the study of persons, where ever they are on the health - dis-ease continuum, moving towards the healthy end.4People who have developed the ability to implement the salutogenic way of living will not only live longer but enjoy a better quality of life and mental wellbeing. In addition, they can stand stress better than the average and have more constructive health behavior. Even if they become ill or get a chronic disease they will cope up to it better than the average.2

Putting the salutogenic model into practice in the field of prevention is equal to implementing the WHO concept of health promotion. Sense of Coherence is a personal resource that dominates in the model of salutogenesis. The basic premises of Antonovskys model for health implies the need to create an environment which offers children and adolescents enough resources to build a strong sense of coherence.5The salutogenic approach was developed as an alternative to pathogenic approaches and essentially grew out of Antonovskys concerns that a different paradigm was required in order to research health, which was quite different from that which looks at the underlying processes of illness and disease. By focusing on salutogenesis, in contrast to pathogenesis, Antonovsky hoped that researchers might start to identify pathways and mechanisms leading in the direction of health. Salutogenic research therefore implies a focus on health maintenance processes rather than disease processes.6

HISTORICAL BACKGROUND TO THE SENSE OF COHERENCE CONCEPTWorld War II had a great impact on the lives of Aaron Antonovsky and a psychiatrist named Viktor Frankl. It influenced the development of their theories concerning health, stress, coping, and life meaning. After the horrors of the imprisonment and murder of millions of people in the Nazi concentration camps both Viktor Frankl and Aaron Antonovsky asked the question: how did some people manage to survive despite the fact that they lived in constant fear of death, were often close to starvation, suffered constant beatings, were subject to physical and mental torture, lived in appalling disease ridden conditions, and suffered the loss of most or all of their friends and family? They both considered what factors contributed to an individuals survival during such adversity. They went on to apply this question to the context of the less extreme conditions normally encountered in everyday life like why do some people cope with stressful situations, while others do not.7There are many similarities between the theories of Frankl and Antonovsky, for example, both stress the importance of self-responsibility. Frankl stated that people should respond to the demands of life by being responsible for their own lives. Antonovsky stated that the work of Frankl influenced him in his development of the meaningfulness factor of his Sense of Coherence concept. This influence can be seen in Antonovskys work, for example, relationships and creativity, form some of the resistance resources identified by Antonovsky.8Despite the similarities, Frankl adopted a more pathogenic focus(identifying what causes disease and seeking to treat it) focus than Antonovskys salutogenic focus(identifying what contributes to health and promoting that which contributes to health) in his Sense of Coherence concept. In addition Antonovskys concept is broader than that of Frankls; it has two more factors in addition to meaningfulness to explain individual stress reactions and coping.7In his books and research Antonovsky talks about how individuals deal with their experience of life. He investigated how it was possible for the women in his study, who had been in concentration camps in World War II and subsequently gone through all the problems of life in the newly created state of Israel, to be reasonably healthy and happy, to have successfully raised families, and continued to enjoy social and community activities. With these and additional interviews with others who survived Nazi concentration camps and victims of discrimination and poverty Antonovsky sought a common factor that enabled people to cope with stressful situations. In defining Sense of Coherence he explained that it is a generalised, long lasting way of seeing the world and ones life in it. It is a crucial element in the basic personality structure of an individual.8Over the last thirty years the work of Antonovsky has become very influential. The SOC concept and salutogenic theories have caused fundamental changes in how we think about stress, coping and health, and they have been applied across many different disciplines to promote health.7

SALUTOGENESIS V/S PATHOGENESISPathogenesis is described as the genesis of pathology. Pathogenesis or pathogenic model proposes that disease is caused by factors such as microbiological agents, lack of vitamins, physical stress, psychological stress etc. Central to the pathogenic approach is the view that stress causes ill health or disease. The pathogenic model tend to categorize individuals as either well or unwell and focuses primarily on specific areas of the body like malfunctioning of an organ and not on the combination of psychological emotional and physical factors causing illness. Pathogenic approach tends to be more physical and ignores the view that human consciousness and human choice may influence health and wellness. Pathogenic approach just focuses on disease and its prevention.1Salutogenesis is described as the antonym of pathogenesis. Salutogenesis emphasizes on promotion of health and the prevention of disease rather than the origins of disease. Salutogenesis includes economic, social and environmental factors as determinants in health. Antonovskys work has encouraged a paradigm shift from pathogenesis to salutogenesis. Some distinction between the two approaches is required.1Pathogenesis works retrospectively from disease to determine how individuals can avoid, manage, and/or eliminate that disease. Salutogenesis works prospectively by considering how to create, enhance, and improve physical, mental, and social well-being. Antonovsky differentiated salutogenesis from pathogenesis by describing salutogenesis as a model or framework focused on discovering the causes and precursors of health and identifying health or salutary factors. Pathogenesis in a complementary fashion focused on discovering the causes and precursors of disease and identifying disease risk factors. There is no need to act in regard to ones health until some problem occurs. These assumptions lead professionals using pathogenesis to be reactive because they respond to situations that are currently causing or threatening to cause disease or infirmity. The assumption of salutogenesis, that action needs to occur to move the individual toward optimum health, prompts professionals to be proactive because their focus is on creating a new higher state of health than is currently being experienced.8, 9 According to a salutogenic perspective, each person should engage in health promoting actions to cause health while they secondarily benefit from the prevention of disease and infirmity. Pathogenesis, on the other hand in a complementary fashion primarily focuses on prevention of disease and infirmity, with a secondary benefit of health promotion. Both models assume if the primary focus is attained, the secondary purpose will follow.10The pathogenic paradigm is remedial and reactive in terms of stress and coping, whereas Antonovskys salutogenic paradigm takes a preventative and proactive approach. It seeks to facilitate the development of an individuals self-protecting and self-healing powers.7The pathogenic approach seeks to rid the individual of stressors, whilst the salutogenic approach seeks to identify how an individual can cope with unavoidable stressors and enable more stressors to be salutary.7 The pathogenic model is characterized by the dichotomy between healthy and sick individuals, the salutogenic model places individuals on a healthy ease/disease continuum.11Antonovsky proposed that there should be a greater degree of focus on studying the origins of health (salutogenesis) rather than on the origins of disease (pathogenesis). The pathogenic orientation classifies people on a healthy/sick dichotomy and the salutogenic orientation views individuals on a multidimensional ease/disease (i.e., healthy/unhealthy) continuum. The implication for research is that whereas in the pathogenic orientation only a small portion of the population those who are sick are studied, salutogenic orientated research is interested in studying everyone.7 The pathogenic orientation is more interested in fighting factors that cause disease whereas the salutogenic orientation is interested in strengthening factors in Antonovskys theory defined as general resistant resources (GRRs) that facilitate health. The pathogenic orientation views all stressors as potentially pathogenic whereas the salutogenic orientation contends that stressors can either be neutral, pathogenic or salutogenic depending on how a stressor is interpreted and dealt with by an individual. pathogenesis tends to focus on specific diseases whereas salutogenesis, in contrast, is interested in a persons whole well-being, both physical and psychological, due to its focus on movement towards the healthy end of the ease-disease continuum.12Pathogenic orientation tends to use labels such as schizophrenic or manic depressive. This can have the effect that a person can be reduced in their minds and the minds of others from being all that they are as a human being, i.e. a father, a sister, a pianist, a great story teller etc., into being a schizophrenic or manic depressive. The salutogenic orientation on the other hand treats an individual as a complex multifaceted entity and searches for salutary factors, such as personality strengths, compensatory factors, significant social roles, positive self images, etc., to negate the negative roles and identity associated with a diagnosis of schizophrenia or manic depression.12 It does this to reveal, encourage and instill forces that aid the individual in combating disease and generating health regardless of the existence of any particular disease diagnosis. The SOC concept acknowledges that if a person is on the sick end of the ease-disease continuum and if they are viewed by others negatively, then this will reinforce feelings of invalidity, non personhood and roleless status and ultimately this can negatively affect his or her health.7

Table 1. The differences between Pathogenic and Salutogenic perspectives of Health10 Pathogenesis

Salutogenesis

Employs a dichotomy between healthy and sick individualsPlaces individuals on a health ease/ dis ease continuum and considers that everyone has potential to move in either direction of this continuum

Is about avoiding problems and its causes

Is about approaching potential and its causes

Works to eliminate risk factors

Works to create health (salutary) factors

Takes a reactive approach - react to signs, symptoms, and indications of disease

Takes a proactive approach - create conditions of physical, mental, and social well-being

Views all stressors as potentially pathogenic

Stressors can either be neutral, pathogenic or salutogenic depending on how a stressor is interpreted and dealt with by an individual

Follows idealistic perspective - treat diseaseFollows realistic perspective - go get health

Focus is to prevent pain or lossFocus is to promote gain or growth

Tends to focus on specific diseases

Focuses a persons whole well-being, both physical and psychological

Focuses on those who succumb to a pathogen

Focuses on those who do not succumb when exposed to a pathogen

Interested in fighting factors that cause disease

Interested in strengthening factors that can facilitate health

Only those who are sick are studied

Everyone is studied in relation to health

Primary focus - Prevention of negative healthPrimary focus - Promotion of positive health

Secondary benefit - Health Promotion

Secondary benefit - Prevention of disease and infirmity

Outcome - absence of problem

Outcome - presence of a gain

Minimization of problemsOptimization of potential

The pathogenic model has resulted in massive advances in medicine and it forms the basis of most healthcare services. Nevertheless, medical healthcare is very costly and is not able to provide the cure for all diseases, and so within both medicine and society in general there has been a general shift in emphasis away from solely seeking cures for disease towards a greater emphasis on promoting health and individuals responsibility in his or her own health maintenance. This change in focus from illness cure to health promotion and health generation represents a paradigmatic shift: it changes the way human beings view themselves, each other and the world around them.13Antonovsky envisioned a future healthcare system that effectively combines pathogenic and salutogenic approaches to generate the best possible levels of physical and mental health. While one approach is not more important than the other; both are needed to facilitate the goal of better health and a safer and more health enhancing environment. The time has come for more salutogenic thinking, research, and practices. Pathogenesis improves health by decreasing disease and infirmity and salutogenesis enhances health by improving physical, mental, and social well-being. Together, these strategies will work to create an environment that nurtures, supports, and facilitates optimal well-being.14

Figure 1: A combined pathogenic and salutogenic approachHEALTH DISEASE CONTINUUMHealth is seen as a movement in a continuum on an axis between total ill health (disease) and total health (ease). In the biomedical model, disease is seen as a deviation from the norm of health. This assumption is not tenable, or at least is not valid as the sole standard for the definition of health. Epidemiological data demonstrate that at least a third, perhaps even the majority of the population of a modern industrial society suffers from some illness.8When discussing health and disease, it is usually assumed that these two states are mutually exclusive, that is, that only one of the two states is present at any one time. According to this dichotomy, one is either healthy or ill. The classification is made according to a physicians diagnosis, who finds a specific illness, or by the patient himself or herself and his or her environment. People who are classified as healthy are left unnoticed by the public health care system, after medical check-ups and early detection examinations. Antonovsky juxtaposed this dichotomy with a continuum he calls the health ease/dis-ease continuum on which people can be rated as more or less ill or healthy.5Antonovsky criticized the common healthy/sick dichotomy with which scientific medicine and the medical care system work. Antonovsky juxtaposed this division with the conception of a continuum with the poles ease (health) and dis-ease (illness).

(Health- ease)(Dis- ease)Figure 2: Health Disease Continuum Antonovsky himself drew the the ease/dis-ease continuum as a horizontal line between total absence of health (H-) and total health (H+) and explained that all people are positioned somewhere on this line. We encounter stressors every day that we have to deal with. Stressors can upset our position and we come under tension. Here there are two options either the pathogenic forces overtake us and we break down or we regain our health through salutogenesis and move towards total health(H+). Conceptually salutogenesis means the movement towards the total health(H+).16

RIVER OF HEALTHTraditionally, the difference between the biomedical model and public health has been described metaphorically as a river. All approaches ultimately strive to improve health, but out of different perspectives.

The river as a metaphor of health development has often been used. According to Antonovsky, it is not enough to promote health by avoiding stress or by building bridges keeping people from falling into the river. Instead people have to learn to swim.11 This paper presenting the Salutogenesis in the context of health promotion research uses a new analogue of a river, River of Health. The river of Health is a simple way to demonstrate the characteristics of medicine (care and treatment) and public health (prevention and promotion) shifting the perspective and the focus from medicine to public health and health promotion towards population health. It presents the following stages: (i) cure or treatment of diseases; (ii) health protection/disease prevention; (iii) health education/health promotion and (iv) improving health perception/wellbeing/Quality of Life (QoL).14

(i) Cure or treatment of diseases:The curative perspective on health means that we save people from drowning using expensive high technology and well-educated professionals. Upstream thinking would offer people support and interventions at an earlier stage.

(ii) Health protection/ disease prevention:This stage can be divided in two phases, i.e. the protective and the preventive. The protective perspective means that the interventions arelimiting the risks of disease. The efforts and interventions are population-based and passive. In the metaphor of the river, the interventions are aimed at preventing people from falling into the river by building fences. The preventive perspective aims at preventing diseases by active interventions characterized by an empowering attitude where people are actively involved. People are here supplied with a life vest. The rationale is to reduce the negative effects and risks thus maintaining the health of the public. The interventions are both population-directed (protective) and individual-based (preventive).

(iii) Health education/health promotion: This stage consists both of health education and health promotion. Health education has a long tradition in public health practice. Originally, it was a question of the professionals informing people of health risks and giving advice how people should live their lives. Today, people are, in general, more actively involved than in the previous stages. The interventions are directed towards both individuals and groups. Improved health literacy is the key outcome of health education.16 The efforts here are aimed at teaching people how to swim. In health promotion, health is seen as a human right. The responsibility of health promotion action extends far beyond the health sector and health behaviour to wellbeing and Quality of Life. It is a humanistic approach having the human being, human rights at focus again. The individual becomes an active and participating subject. The task for the professionals is to support and provide options, enabling people to make sound choices, point out the key determinants of health, to make people aware of them and able to use them.4

Figure 3: River of Health

(iv) Improving health perception/wellbeing/quality of life:The ultimate objective of health promotion activities is to create prerequisites for a good life. Perceived good health is a determinant for QoL. The salutogenic framework can create a fusion of the complexity of health and QoL development.14 It is necessary to learn how to reflect on the options of ones life situation, such as what generates health, what improves QoL and what develops SOC.From the River of Health to the River of Life:Perceived good health is a determinant for quality of life. salutogenesis we have changed the River into a different and more salutogenic framework placing Health in the River of Life. Here the main flow of the river is in the direction of life while illness, disease and risks are seen as disruptive forces one will encounter in life - still life as such is the main force and the main direction. Here the river flows vertically across your view. Along the front side of the river, there is a continuous waterfall following the whole stretch of the river meaning wherever you are there is always a possibility to encounter risks, disease and death. However, the main flow and direction of the river is not down the waterfall but running vertically in the direction of life.

Figure 4: Health in the river of Life

At birth, we drop into the river and float with the stream and over life learn how to swim. Some are born at ease where the river flows gently, where there is time to learn and the prerequisites for life are good with many resources at disposal. Others are born close to the waterfall, at dis-ease, where the struggle for survival is hard and the risk of going over the rim is much greater. 15

The river, just like life, is full of risks and resources, however, our outcome is based on our orientation and learning through our life experiences thus acquiring an ability to identify and use the resources necessary to improve our options for a better health and ultimately life. Health process can be seen as a life-long-learning process where we reflect on what will create health and what are the options for life and improves Quality of Life.15

REFERENCES1. Long SI. Salutogenic constructs in stress and coping. Available at https://152.106.6.200/bitstream/handle/10210/1541/Chp3kob.pdf?sequence=15 accessed on 10/6/2014.2. Barbara Buch Center on Salutogenesis. Trollhttan: University West. Available at http://www.salutogenesis.hv.se/eng/Salutogenesis.5.html accessed on 10/06/2014.3. Lindstrom B, Eriksson M. Contextualizing salutogenesis and Antonovsky in public health development. Health Promotion International. 2006 May 22: 21(3); 238-244.4. Buch B. Salutogenesis. Available at http://www.salutogenesis-shamanism.com/2.php accessed on 10/6/20145. Bengel J, Strittmatter R, Willmann H. What Keeps People Healthy? The Current State of Discussion and the Relevance of Antonovskys Salutogenic Model of Health. Cologne: Federal Centre for Health Education (FCHE); 1999.6. Eriksson M, Lindstrom B. Validity of Antonovsky's Sense of Coherence Scale: A Systematic Review. Journal of Epidemiology and Community Health. 2005: 59(6); 460-466.7. Griffith CA. A Critical Analysis of Antonovskys Sense of Coherence Theory in Relation to Mental Health and Mental Disorder and the Effect of a Lifelong Learning Intervention on the Sense of Coherence of Mental Health Service Users. Available at http://eprints.mdx.ac.uk/6286/1/Griffiths_A_Critical_Analysis.pdf accessed on 10/06/2014.8. Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass Inc; 1979.9. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996: 11; 11-18. 10. Becker CM, Glascoff MA, Felts MW. Salutogenesis 30 Years Later: Where do we go from here? International Electronic Journal of Health Education. 2010; 13: 25-32.11. Antonovsky A. Unraveling the Mystery of Health. How People manage Stress and Stay Well. San Francisco: Jossey-Bass Inc; 198712. Antonovsky A. The structure and properties of the sense of coherence scale. Social Science and Medicine. 1993; 36: 725733.13. Ickovics JR, Park CL. Paradigm Shift: Why a Focus on Health Is Important. Journal of Social Issues. 1998; 54(2): 237244.14. Eriksson M, Lindstrom M. A salutogenic interpretation of the Ottawa Charter. Health Promotion International. 2008; 23(2): 190-198.15. Lindstrom B. Salutogenesis an introduction. Available at http://www.centrelearoback.org/assets/PDF/04_activites/clr-GCPB121122 Lindstom_pub_introsalutogenesis.pdf. Accessed on 10/06/2014.16. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000; 15: 259267.