Salutogenic Approach to Wellness

Introduction[edit | edit source]

The salutogenic approach or salutogenesis is a term applied in health sciences, and more recently in other fields, to refer to an approach to wellness focusing on health and not on disease (pathogenesis). Salutogenesis translates to “the origins of health”, from the Latin 'Salus' meaning Health, and the Greek 'Genesis' meaning origin or beginning. The term was first coined in 1979 by the medical sociologist Aaron Antonovsky in his book Health, Stress and Coping.[1] Antonovsky developed a theory that suggested that the way people view their life has a positive or negative influence on their health.

In 1971, Antonovsky presented the results of an epidemiological study[2] in which he interviewed a group of Israeli women who had been in concentration camps during the Holocaust. Despite all the terrible things they had been through, some of them had managed to stay in good health while others had not. Trying to find an explanation for these differences was the motivation for Antonovsky to develop the salutogenic theory.

In the beginning, Antonovsky’s research focus was on social class and health, but after a few years, his attention changed to the impact of stress on health.[3] During this time, throughout the late 1980s, the focus was on risk factors and disease; and stress was considered a high risk factor for breakdown. However, Antonovsky observed that change, chaos, stress and disease are a constant in life and therefore “natural” conditions of it; that human beings are in a heterostatic state rather than in homeostasis. All these observations raised the question of how we can survive with this disequilibrium. Over time, this consideration has given a more central role to the nature of the stress agent, as well as the ability of people to cope with it and the environment they are in.[4]

Figure.1 The Ease - Disease Continuum

Salutogenic Concepts[edit | edit source]

Antonovsky developed the salutogenic theory based on two concepts: the Sense of Coherence and the General Resistance Resources, and despite of having a mainly individualistic approach, both concepts can be applied at a societal level.[5]

Integrating concepts and main ideas from the Salutogenic Theory, a Health Promotion Movement, which focused on the respect of human rights, began at the end of the 20th Century. This movement proposed that people are active participating subjects. In 1986, the World Health Organization's first International Conference on Health Promotion was held in Ottawa.[6] At the centre of this process, professionals and the general public were mutually engaged in an empowering process of developing personal skills for strengthening communities and enabling people to live a good life.

Sense of Coherence[edit | edit source]

Sense of Coherence can be explained as the ability to manage the resources one has in order to cope with the innumerable stressors of life, and a way of viewing or perceiving life as: comprehensible, manageable and meaningful.[3]

Figure.2 The original view of the Sense of Coherence and its Three Dimensions (Antonovsky, 1987) [7]

Comprehensible[edit | edit source]

Cognitive Component: “The stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable”.[8]

Manageable[edit | edit source]

Instrumental or Behavioural Component: “The resources are available to one to meet the demands posed by the stimuli”.[8]

Meaningful[edit | edit source]

Motivational Component: “These demands are challenges, worthy of investment and engagement”.[8] In his 1987 book, Unravelling the Mystery of Health. How People Manage Stress and Stay Well,[3] Antonovsky developed the 29 Item Orientation to Life Questionnaire to measure the Sense of Coherence, including:

  • 11 items to measure comprehensibility
  • 10 items to measure manageability
  • 8 items to measure meaningfulness


The response alternatives are on a scale of 1 to 7 points, and the accumulated score may range from 29 to 203. Another version of 13 questions was also developed by Antonovsky, and other scales have been created to measure the Sense of Coherence at community or family levels. Antonovsky’s Scales have been used in at least 49 languages and at least 48 different countries. The broad fields of application as well as recent research, have proved the Sense of Coherence to be a multidimensional construct, rather than unidimensional.[9]

Figure.3 The Sense of Coherence as a Multidimensional Construct.[10] 1) Antonovsky, 1987, 2) Sandell, Blomberg, & Lazar, 1998 , 3) Sakano & Yajima, 2005

General Resistance Resources[edit | edit source]

On the other hand, “the General Resistance Resources are the biological, material and psychosocial factors that make it easier for people to perceive life as understandable, structured and consistent.”[11]

Figure. 4 The definition of Generalised Resistance Resources (Antonovsky, 1979, s. 103)[12]


Some examples of General Resistance Resources include:[13]

  • Money
  • Knowledge and intelligence
  • Experience
  • Self-esteem
  • Healthy behaviour
  • Social support
  • Ego / identity
  • Commitment and cohesion with one’s cultural roots
  • Cultural stability
  • Ritualistic activities
  • Religion and philosophy (e.g., stable set of answers to life’s perplexities)
  • Genetic factors
  • Preventive health orientation


If a person has access to these kinds of resources, there is a better chance for them to deal with the challenges of life and to construct coherent life experiences. “The general resistance resources lead to life experiences that promote a strong sense of coherence, the capability to perceive that one can manage in any situation independent of whatever is happening in life”.[14] General resistance resources would therefore represent a type of health kit that could help individuals and their communities to improve or retain health.[11]

Salutogenic Interventions[edit | edit source]

In the same way, based on this theory, some authors[15] suggest that salutogenic strategies should be produced to:

  • Facilitate communities to create shared life visions and to be part of decision making (meaningfulness)
  • Develop shared mental models about the change process and desired outcomes (comprehensibility)
  • Enable communities to identify life demands (e.g., stressors, challenges)
  • General resistance resources that need to be balanced (manageability) as well as life opportunities (e.g., assets, learning situations) that stimulate health development”[11]


“Other authors have developed theoretical models to implement the salutogenic paradigm in different sectors, such as in schools [16], communities or neighbourhoods[17], health systems[18], or within different population groups such as children[19], people with chronic diseases"[11][20], or migrants[21]. A study by Bonmatí-Tomas et al.[21] investigated the effect of a 6 month health promotion programme for migrant women at risk of social exclusion. It evaluated the effectiveness of a salutogenic health promotion programme focused on the empowerment of these women. The study acknowledged the health inequities that migrants experience based on variables like gender, country of origin or socioeconomic status. The objectives of the interventions in this study were addressed to improve self-knowledge, and to identify family and community roles (comprehensibility and manageability - sense of coherence) and personal capacities discussing future projects (manageability and meaningfulness - sense of coherence). Based on the increase in self-esteem and the physical quality of life, as well as on the reduction of perceived stress of migrant women, the authors suggest that the salutogenic model of health should be applied in health promotion programmes and included in policies to reduce health inequity among migrant populations.[21]

Álvarez et al.[11] conducted a scoping review of salutogenic interventions and their health effects. They identified 4 types of interventions:[11]

  1. Individual Interventions: Focus on health education activities, counselling and/or psychotherapeutic methodologies from different approaches (Cognitive Behavioural Therapy, Psychodynamic, Occupational Therapy). These were developed, among others, in relation to physical morbidity (Human Immunodeficiency Virus, Mental Health and perceived Quality of Life and Health.[11]
  2. Group Interventions: Developed in groups with similar health problems. Interventions include health education activities and different types of Psychotherapy (Cognitive Behavioural Therapy, Psychodynamic, Holistic, Community). These focused on different health topics, including the management of chronic diseases, mental health and subjective well-being, as well as social dimensions such as social trust, social capital and social compromise.[11]
  3. Mixed Interventions: Incorporate combined actions at individual and group level. “[M]ixed interventions presented a wide range of topics linked to management of chronic pain, functional capacity improvement, HRQoL, drug consumption, and psychosomatic disorders”[11]
  4. Intersectoral Interventions: Carried out by collaborators from two or more different background areas (multidisciplinary teams) aiming to intervene not only on people and communities, but also within the environment in which the health problems take place. “These approaches were focused in urban development, the implementation of community interventions, self-care programs, social prescription, social participation, development of public policies and basic services, governance, health behaviours approach, social capital, and mental health.”[11]

Health Outcomes of Salutogenic Interventions[edit | edit source]

Although a number of different limitations were reported, Álvarez et al.[11] found that 85% of studies reviewed had positive findings in relation to health outcomes with no adverse effects. The specific results of each type of intervention were:[11]

Individual Interventions led to:[11]

  • Decrease in HIV rates
  • Reduction in anxiety-related symptomatology
  • Increase in perception of quality of life
  • Higher personal satisfaction
  • Reduction in psychopathological symptomatology
  • Reduction in eating disorders

Group Interventions showed improvements in different fields, such as:[11]

  • Reduction in disease prevalence and morbidity burden
  • Improvements in perceived health
  • Greater well-being and perceived quality of life
  • Decrease in psychopathological symptomatology, as well as other symptoms relating to anxiety and depression
  • Improved functional capacity
  • Lower burnout
  • Reduction in stress symptomatology


Mixed Interventions indicated progression linked to a:[11]

  • Reduction in pain-related symptomatology
  • Drop in insomnia and an increase in dream quality
  • Improvements in HRQoL
  • Increase of the functional capacity
  • Decrease of kinesiophobia
  • Higher psychological, physical and social well-being
  • Greater physical and mental health


Intersectoral Interventions derived to:[11]

  • Improvements in HRQoL
  • Increase in perceived well-being and self-rated health
  • Greater mental health
  • Reduction in depressive symptomatology
  • Decrease in preventable mortality for diabetes mellitus, influenza, heart disease and infant mortality


As can be seen, it is appropriate to say that the Salutogenic Model is more than just the measurement of a sense of coherence.[13] “Salutogenesis can be seen as an umbrella concept with many different theories, concepts, approaches and strategies with salutogenic elements and dimensions.”[9]

Figure.5 The Salutogenic Umbrella; Salutogenesis as an umbrella concept [22]

Summary[edit | edit source]

Although more research needs to be conducted in respect of the salutogenic model, there is plenty of evidence that proves the model to be an effective health promotion resource that increases resilience and has an affirmative effect in the perceived physical and mental state, quality of life and wellbeing of people as individuals and even within their society.

Since it is a valid, reliable, multidimensional, and applicable instrument for measuring health in different cultures,[23] more policies for health promotion through the model should be suggested and implemented at an international level. The interventions should continue to be focused not on disease but on salutogenesis.

References[edit | edit source]

  1. Antonovsky, A.Health, Stress and Coping. San Francisco: Jossey-Bass, 1979
  2. Antonovsky A, Maoz B, Dowty N, Wijsenbeek H. Twenty-five years later: A limited study of the sequelae of the concentration camp experience. Social Psychiatry. 1971 Dec 1;6(4):186-93. https://doi.org/10.1007/BF00578367
  3. 3.0 3.1 3.2 Antonovsky, A. Unraveling the Mystery of Health. How People Manage Stress and Stay Well. San Francisco: Jossey-Bass, 1987.
  4. Lindström B, Eriksson M. Contextualizing salutogenesis and Antonovsky in public health development]. Health promotion international. 2006 Sep 1;21(3):238-44. Available from: https://doi.org/10.1093/heapro/dal016
  5. Eriksson M. The sense of coherence in the salutogenic model of health. InThe handbook of salutogenesis 2017 (pp. 91-96). Springer, Cham. https://doi.org/10.1093/heapro/dal016
  6. World Health Organization. Ottawa Charter for Health Promotion First International Conference on Health Promotion, 1986. Geneva: WHO. 2010.
  7. Eriksson M., Mittelmark M.B. (2017) The Sense of Coherence and Its Measurement. In: Mittelmark M. et al. (eds) The Handbook of Salutogenesis. Springer, Cham. https://doi.org/10.1007/978-3-319-04600-6_12
  8. 8.0 8.1 8.2 Vinje HF, Langeland E, Bull T. Aaron Antonovsky’s Development of Salutogenesis, 1979 to 1994. 2016 Sep 3. In: Mittelmark MB, Sagy S, Eriksson M, et al., editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Chapter 4. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435860/ doi: 10.1007/978-3-319-04600-6_4
  9. 9.0 9.1 Eriksson M, Mittelmark MB. The Sense of Coherence and Its Measurement 12. The handbook of salutogenesis. 2017;97. https://doi.org/10.1007/978-3-319-04600-6_12
  10. Eriksson M., Mittelmark M.B. (2017) The Sense of Coherence and Its Measurement. In: Mittelmark M. et al. (eds) The Handbook of Salutogenesis. Springer, Cham. https://doi.org/10.1007/978-3-319-04600-6_12
  11. 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 Álvarez ÓS, Ruiz-Cantero MT, Cassetti V, Cofiño R, Álvarez-Dardet C. Salutogenic interventions and health effects: a scoping review of the literature. Gac Sanit. 2021 Sep-Oct;35(5):488-494.
  12. Eriksson M. The Sense of Coherence in the Salutogenic Model of Health. 2016 Sep 3. In: Mittelmark MB, Sagy S, Eriksson M, et al., editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Fig. 11.4, [The definition of generalized resistance resources (Antonovsky, , s. 103)]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435812/figure/ch11.Fig4/ doi: 10.1007/978-3-319-04600-6_11
  13. 13.0 13.1 Idan O, Eriksson M, Al-Yagon M. The salutogenic model: The role of generalized resistance resources. InThe handbook of salutogenesis 2017 (pp. 57-69). Springer, Cham. https://doi.org/10.1093/heapro/dal016
  14. Lindström B, Eriksson M. Salutogenesis. Journal of Epidemiology & Community Health. 2005 Jun 1;59(6):440-2. https://doi.org/10.1093/heapro/dal016
  15. Bauer GF, Roy M, Bakibinga P, Contu P, Downe S, Eriksson M, Espnes GA, Jensen BB, Juvinya Canal D, Lindström B, Mana A. Future directions for the concept of salutogenesis: a position article. Health Promotion International. 2020 Apr;35(2):187-95. https://doi.org/10.1093/heapro/dal016
  16. Jensen BB, Dür W, Buijs G. The application of salutogenesis in schools. In The Handbook of Salutogenesis 2017 (pp. 225-235). Springer, Cham.https://doi.org/10.1093/heapro/dal016
  17. Vaandrager L, Kennedy L. The application of salutogenesis in communities and neighborhoods. InThe handbook of salutogenesis 2017 (pp. 159-170). Springer, Cham. https://doi.org/10.1093/heapro/dal016
  18. Pelikan JM. The application of salutogenesis in healthcare settings. The Handbook of Salutogenesis. 2017 Jun 8:261. https://doi.org/10.1093/heapro/dal016
  19. Taylor JS. Salutogenesis as a framework for child protection: literature review. Journal of advanced nursing. 2004 Mar;45(6):633-43. https://doi.org/10.1046/j.1365-2648.2003.02954.x
  20. Aujoulat I, Mustin L, Martin F, Pélicand J, Robinson J. The application of Salutogenesis to health development in youth with chronic conditions. InThe Handbook of Salutogenesis 2017 (pp. 337-344). Springer, Cham. https://doi.org/10.1007/978-3-319-04600-6_32
  21. 21.0 21.1 21.2 Bonmatí-Tomas A, Malagón-Aguilera MC, Gelabert-Vilella S, Bosch-Farré C, Vaandrager L, García-Gil MD, Juvinyà-Canal D. Salutogenic health promotion program for migrant women at risk of social exclusion. International journal for equity in health. 2019 Dec 1;18(1):139. https://doi.org/10.1186/s12939-019-1032-0
  22. Eriksson M., Mittelmark M.B. (2017) The Sense of Coherence and Its Measurement. In: Mittelmark M. et al. (eds) The Handbook of Salutogenesis. Springer, Cham. https://doi.org/10.1007/978-3-319-04600-6_12
  23. Eriksson M, Lindström B. Antonovsky’s sense of coherence scale and the relation with health: a systematic review. Journal of epidemiology & community health. 2006 May 1;60(5):376-81. https://doi.org/10.1136/jech.2005.041616