What defines your health?

An introduction to salutogenesis

When asked, most people would reply with the absence of disease, suffering. By avoiding poor health behaviours such as smoking, excessive drinking, eating fatty foods we will be well.

Is this really the case?

In this short article I will introduce the concept of salutogenesis which is currently shaping attitudes towards health, wellbeing and quality of life. In short, health is not merely the absence of sickness by avoiding “unhealthy” things (although this helps a lot).

Traditional beliefs regarding health

Generally, people believe that when we follow certain “lifestyles” we become either healthy or unhealthy. Our bodies biological processes, our psychological state and our role in society are interconnected: otherwise known as the bio-psycho-social model. Social inequality results in health inequality. Why? because they smoke, drink excessively, eat fatty foods.

Fig 1: The biopsychosocial model

1930s: research into psychosomatic causes of disease was revolutionary. The stress theory shows massive insights into physical manifestations of chronic stress. Chaotic lifestyles, instability, traumatic or stressful life events leads to elevated levels of cortisol in the blood, rendering the individual at an increased risk of disease.

Traditional models are important but still focus on the cause of disease. Just like an absence of bad behaviour does not lead to good behaviour, the absense of sickness is not equal to health. With current models we also ignore the exceptions. There are people meeting all the criteria of an “unhealthy lifestyle” yet survive with the same levels of morbidity as those with a “healthy lifestyle”. And vice versa.

An emerging theory

• We are inherently flawed human beings. Sickness and disease is inevitable. Therefore health is a spectrum.
• We need to focus on promoting health, rather on avoiding illhealth (behaviours to avoid are still important but the avoidance does not equate health)

Salutogenesis was first coined by sociologist and anthropologist Aaron Antonovsky. He proposed that having a sense of meaning and purpose allows an individual to hold onto life, which he named: ‘sense of coherence’.

1970s: Antonovsky’s research was comparing menopausal women who had lived in concentration camps during the Holocaust with those who had not. Most of the former group were experiencing worsening health and symptoms related to menopause compared with the control group. However, 30% did not follow this pattern. Despite considerable life events, they seemed to be managing life without a state of chronic stress.

What made that 30% healthy? The outcome of stressor or trauma can be either positive or negative. An individual can either develop an emotional coping mechanism or develop a state of chronic stress.

Figure 3: Antonovskys own way of explaining the different reactions after a ‘stressor’. Taken from ‘Salutogenesis: An introduction by Bengt Lindstrom’

Why do individuals exposed to the same experiences respond in different ways? A strong “sense of coherence” (SOC) separated the 30% from the rest. This is described as comprehensible, manageable and meaningful orientation.

When confronted with a stressor a person with strong SOC will:

• be motivated to cope — meaning
• believe the challenge is understood — understanding
• believe there are resources available to cope — manage

Research results

With the advantage of 30–40 years down the line, the concept of salutogenesis is being looked at again. Since 2005 the Health Promotion Research Programme at the Folkhälsan Research Centre in Helsinki have taken the task of continuing Antonovskys earlier work, collecting and systematically reviewing all studies across the world focusing on salutogenesis.

What are the results? Pretty outstanding. Those with a stronger sense of coherence tend to:

• Live longer
• Choose positive life behaviours
• Manage stress and negative life events better
• Manage better during an acute or chronic disease

In addition, a strong SOC:

• relates strongly to good mental health, perceived health and quality of life
• protects against anxiety, depression, burnout, hopelessness.
• positively related to optimism, hardiness, control, coping.

Practical applications

The Working Group on Salutogenesis of the International Union of Health Promotion and Education put it very well:

“People well connected to the setting they live develop strong SOC. Therefore finding synergy between individuals, groups, surrounding socio economic, cultural and psychoemotional structures is important for healthy orientation of life”

So its clear that we need to alter our thinking when it comes to health. Going back to the biggest problem to tackle: inequality.

I think we can split this into two approaches:

• Governmental role and public health policy
• Individual and community development

However, they both overlap and should be interconnected

I am not an expert on public health policies so I cannot exactly comment on the first approach. Fortunately, Harry Burns is an expert and spent 8 years as Chief Medical Officer of Scotland, with a background career in general surgery:

“Too often, however, we organise public bodies to do things to people rather than work with them. Our present approach to people in difficulty focuses on their problems, needs and deficiencies. We define them as being ‘deprived’ and see their health problems as being due to their health-damaging behaviours. We design services to fill the gaps in peoples’ lives and fix their problems. As a result, individuals and communities can feel disempowered. People become passive recipients of services rather than active agents in their own lives.”

He further identifies that these current methods completely counter the evidence that supports:

“the need to develop the personal assets which individuals and communities harbour, often unrecognised, and which allow them to participate fully in the creation of wellbeing for themselves and their neighbours.”

Societal structures provide communities with needed provision of and access to services — fulfilling our basic needs and providing us with a sense of security. The empowerment of communities, however, comes from within.

We can allow neighbours to become connected and supportive. We can abolish hopelessness and alienation. We can move from charity and towards co-creation.

Do you know the assets your community holds? Do you know who is a part of your community? How can we work with others to enhance confidence and meaningfulness for all?

Figure 4: Diagram used by Scottish Government to visual the ‘Equally Well’ initative, linking the causes of inequality with health policies. 2010 (Accessed on: http://www.gov.scot/Publications/2010/06/22170625/4)

References

Research articles:

• The salutogenic model as a theory to guide health promotion. Aaron Antonovsky. Health Promotion International. 1996. Accessed on: http://heapro.oxfordjournals.org/content/11/1/11.full.pdf
• Salutogenesis 30 Years Later: Where do we go from here? Becker et al. Health Education and Promotion, East Carolina University. 2010. Accessed on: http://files.eric.ed.gov/fulltext/EJ895721.pdf
• What causes health? Harry Burns. Journal of Royal College of Physicians, Edinburgh. 2014. Accessed on: https://www.rcpe.ac.uk/sites/default/files/burns.pdf

Online text:

• Salutogenesis: An introduction. Bengt Lindstrom. Accessed on: http://www.centrelearoback.org/assets/PDF/04_activites/clr-GCPB121122-Lindstom_pub_introsalutogenesis.pdf

Video:

• What causes wellness. Harry Burns. Tedx Talk (Glasgow 2014). Accessed on: https://www.youtube.com/watch?v=yEh3JG74C6s

Website:

• Centre on Salutogenesis at Unversity West, Sweden. (http://www.salutogenesis.hv.se/eng/Salutogenesis.5.html)