Salutogenic Approach to Wellness

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Introduction

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). Literally, salutogenesis translates to “the origins of health”, from the Latin `salus ́ (health), and the Greek `genesis ́ (origin or beginning). The term was first coined in 1979 by the medical sociologist Aaron Antonovsky in his book Health, Stress and Coping1, after developing a theory that suggested that the way people view their life has a positive or negative influence on their health.

Back in 1971, Antonovsky had presented the results of an epidemiological study2 in which he had interviewed a group of Israeli women who had been in concentration camps during the Holocaust, and 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 health3. During this time, the late 1980s, the importance 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 observationsraised the question of how we can survive with this disequilibrium. Over time, this consideration has given 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

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Aaron Antonovsky developed the salutogenic theory based on two concepts: the Sense Of Coherence (SOC) and the General Resistance Resources (GRRs), and despite of having a mainly individualistic approach, both concepts can be applied at a societal level5. The SOC 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:

• Comprehensive (cognitive component): “the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable”;
• Manageable (instrumental or behavioral component): “the resources are available to one to meet the demands posed by the stimuli”; and
• Meaningful (motivational component): “these demands are challenges, worthy of investment and engagement”. (Antonovsky, 1987)

On the other hand, according to Suárez Álvarez Ó. et. al. (2020), “the GRRs are the biological, material and psychosocial factors that make it easier for people to perceive life as understandable, structured and consistent.” Examples of GRRs are: money, knowledge and intelligence, experience, self-esteem, healthy behavior, 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, among others6. If a person has access to these kind of resources, there is a better chance for her to deal with the challenges of life and to construct coherent life experiences. “The GRRs lead to life experiences that promote a strong SOC - the capability to perceive that one can manage in any situation independent of whatever is happening in life” (Lindström, B., & Eriksson, M., 2006). GRRs would therefore, represent a type of health kit that could help individuals and their communities to improve or retain health.7

In his 1987 book Unraveling the Mystery of Health. How People Manage Stress and Stay Well, Antonovsky developed the 29 item Orientation to Life Questionnaire to measure the SOC, including 11 items to measure comprehensibility, 10 items to measure manageability, and 8 items to measure meaningfulness. The response alternatives are on a scale of 1 to 7 points, and the accumulates 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 SOC 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 SOC to be a multidimensional construct, rather than unidimensional, as Antonovsky used to consider.

Integrating concepts and main ideas from the salugotenic theory, a Health Promotion Movement focused on the respect of human rights began at the end of the 20th century, which proposed people as active participating subjects. The principles of this health promotion were concentrated in the Ottawa Charter (WHO, 1986)9, and at the center of the process, professionals and the general public were mutually engaged in an empowering process developing personal skills for strengthening communities and enabling people to live a good life.

Salutogenic Interventions

In the same way, based on this theory, “some authors10 suggested 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) and GRRs that need to be balanced (manageability) as well as life opportunities (e.g., assets, learning situations) that stimulate health development”. (Suárez Álvarez, Ó., et al., 2020)

“Other authors have developed theoretical models to implement the salutogenic paradigm in different sectors, such as in schools11, communities or neighbourhoods12, health systems13, or within different population groups such as children14, people with chronic diseases15” (Suárez Álvarez, Ó., et al., 2020), or migrants16. This last study of a 6 months’ health promotion program for migrant women at risk of social exclusion, evaluated the effectiveness of a salutogenic health promotion program focused on the empowerment of these women, with the acknowledgement of the health inequities that migrants experience based on variables like gender, country of origin or socioeconomic status. The objectives of the interventions in this case were addressed to improve self-knowledge, and to identify family and community roles (comprehensibility and manageability –SOC-) and personal capacities discussing future projects (manageability and meaningfulness –SOC-). Based on the increase of self-esteem and the physical quality of life, as well as on the reduction of perceived stress of the migrant women, the authors suggest that the salutogenic model of health should be applied in health promotion programs and included in policies to reduce health inequity among migrant populations.

The salutogenic model has applied many other strategies, like the ones revised by Suárez Álvarez Ó. et. al. (2020), who identified 4 types of interventions:

• “Individual interventions, focused on health education activities, counselling and/or psychotherapeutic methodologies from different approaches (cognitive- behavioral therapy, psychodynamic, occupational therapy).” “These were developed, among others, in relation to physical morbidity (human immunodeficiency virus [HIV]), mental health and perceived quality of life and health.”
• “Group interventions, developed in groups with similar health problems, include health education activities and different types of psychotherapy (cognitive-behavioral, psychodynamic, holistic, community).” “These targeted different healthtopics, ranging from the management of chronic diseases, to mental health and subjective well-being, to social dimensions relating to social trust, social capital and social compromise.”
• “Mixed interventions, which incorporate combined actions at individual and group level.” “These mix presented a wide range of topics linked to management of chronic pain, functional capacity improvement, Health-Related Quality of Life (HRQoL), drug consumption, and psychosomatic disorders.”
• “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 behaviors approach, social capital, and mental health.”

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