Salutogenesis
Salutogenesis is the study of the origins of health and focuses on factors that support human health and well-being, rather than on factors that cause disease. More specifically, the "salutogenic model" was originally concerned with the relationship between health, stress, and coping through a study of Holocaust survivors. Despite going through the dramatic tragedy of the Holocaust, some survivors were able to thrive later in life. The discovery that there must be powerful health causing factors led to the development of salutogenesis. The term was coined by Aaron Antonovsky, a professor of medical sociology. The salutogenic question posed by Aaron Antonovsky is, "What makes people healthy?" He observed that stress is ubiquitous, but not all individuals have negative health outcomes in response to stress. Instead, some people achieve health despite their exposure to potentially disabling stress factors.
Antonovsky identifies the dominant paradigm of Western medicine as pathogenic, which in turn leads to an understanding of health as dichotomous – one is either healthy or sick. For a salutogenic approach, the ease/dis-ease continuum, rather than the health-disease dichotomy is appropriate. Antonovsky identified four criteria to be used in determining a person's position on the continuum: pain, functional limitation, prognostic implication, and action implication; each ranging from “not-at-all” at the ease end to “severe/life-threatening/requiring intervention” at the dis-ease end. Later he wrote: “A continuum model, which sees each of us, at a given point in time, somewhere along a ‘health/dis-ease’ continuum is, I believe, a more powerful and more accurate conception of reality, one which opens the way for a strong theory of health promotion.
In his 1979 book, Health, Stress and Coping, Antonovsky described a variety of influences that led him to the question of how people survive, adapt, and overcome in the face of even the most punishing life-stress experiences. In his 1987 book, Unraveling the Mysteries of Health, he focused more specifically on a study of women and aging; he found that 29% of women who had survived Nazi concentration camps had positive emotional health, compared to 51% of a control group. His insight was that 29% of the survivors were not emotionally impaired by the stress. Antonovsky wrote: "this for me was the dramatic experience that consciously set me on the road to formulating what I came to call the 'salutogenic model." Antonovsky viewed his work as primarily addressed to the fields of health psychology, behavioral medicine, and the sociology of health. However, it has been applied in many different fields such as workplace, nursing, psychiatry, integrative medicine, and healthcare architecture.
The World Health Organization Health Promotion glossary of terms defines Salutogenesis as follows:
Salutogenic model of health
The Salutogenic Model of Health shows how the interrelationships between stressors and management of tension, generalised and specific resistance resources, life experiences and the sense of coherence impact health status. In salutogenic theory, people continually battle with the effects of hardship and stressors. On the other hand, there are generalized resistance resources and specific resistance resources, which are all of the resources that help a person cope and are effective in avoiding or combating a range of psychosocial stressors.Generalized resistance resources enable individuals to make sense of and manage events. Antonovsky argued that over time, in response to positive experiences provided by successful use of different resources, an individual would develop an attitude that was "in itself the essential tool for coping". Examples of GRRs are money, ego-strength, or social support.
Specific resistance resources support coping “in particular situations of tension.” The relationship between GRRs and SRRs is that via the sense of coherence, GRRs enable one to recognize, pick up and use SRRs in ways that keep tension from turning into debilitating stress, assuming useful SRRs are available.
Generalized resource deficits will cause the coping mechanisms to fail whenever the sense of coherence is not robust to cope with the current situation. This causes illness and possibly even death. However, if the sense of coherence is high, a stressor will not necessarily be harmful. But it is the balance between generalized resource deficits and resources that determines whether a factor will be pathogenic, neutral, or salutary.
Sense of coherence (SOC)
The "sense of coherence" is a theoretical formulation that provides a central explanation for the role of stress in human functioning. Antonovsky defined the sense of coherence as:In his formulation, the sense of coherence has three components:
- Comprehensibility: is the cognitive dimension of SOC and may be defined as a belief that things happen in an orderly and predictable fashion and a sense that you can understand events in your life and reasonably predict what will happen in the future.
- Manageability: is the behavioural dimension of SOC and may be defined as a belief that you have the skills or ability, the support, the help, or the resources necessary to take care of things, and that things are manageable and within your control.
- Meaningfulness: is the motivational dimension of SOC and may be defined as a belief that things in life are interesting and a source of satisfaction, that things are really worthwhile and that there is good reason or purpose to care about what happens.
Mechanisms shaping SOC: Life experiences
How does the interaction of life situation, stressors and GRRs contribute to shaping and strengthening the SOC? Antonovsky answers that it is through the pattern of one's life experiences and how they determine the three dimensions of the SOC: “consistent experiences provide the basis for the comprehensibility component; a good load balance, for the manageability component; and, least clear of all, participation in shaping outcome, for the meaningfulness component.” Although chronic resources and chronic stressors, lay the foundation for the SOC, Antonovsky also states: “Paradoxically, then, a measure of unpredictable experiences – which call forth hitherto unknown resources – is essential for a strong sense of coherence”. Stressor life events thus strengthen the SOC through “potentiation”, demanding a re-orientation and use of new resources “thereby enriching one’s repertoire.”Degrees of consistency: Antonovsky explains that humans’ need for stability is formed by consistent experiences. “But without rules, guidelines, criteria for setting priorities; without some significant thread of continuity between past, present and future; without some degree of harmony, we are lost. A strong SOC is linked to perceptions of stable values and rules that can be applied flexibly across situations, and which are constantly examined and developed by incorporating new experiences into the guiding set of rules.
Load balance: “Load experiences are those which make demands upon us to act, to mobilize resources for task performance.” Overload occurs when there are not enough resources to meet demand and underload occurs when “life is so structured that one’s skills, abilities, interests and potential have no channel for expression.” “Much as unused muscles atrophy, so do unused skills, capacities and potentialities.” Again, Antonovsky stresses that this varies across cultural settings. Load balance occurs when we believe we have resources at our disposal to meet the demand. Antonovsky notes that even when the demands are on an individual, the resources may be collectively provided – also described as “in the hands of legitimate others.”
Participation: Antonovsky points out that life experiences that shape meaningfulness are those that we have chosen to take part in, to engage with the problems posed by the experience. “When others decide everything for us – when they set the task, formulate the rules, and manage the outcome – and we have no say in the matter, we are reduced to objects. A world thus experienced as being indifferent to what we do comes to be seen as a world devoid of meaning.” Elsewhere, Antonovsky stresses that it is the ‘taking part’ that is significant and that the activity should be socially valued.
Measurement of the Sense of Coherence
The Orientation to Life Questionnaire, consisting of 29 items, was developed by Antonovsky using a facet theory to measure the sense of coherence. The scale includes items to measure the three components of SOC: comprehensibility, manageability, and meaningfulness. Responses are given on a semantic differential scale from 1 to 7, and after recoding reverse-scored items, they are summed to produce a total score ranging from 29 to 203. A shorter version, SOC-13, provides a total score between 13 and 91 points.The SOC scales have been translated into over 50 languages and are considered applicable across cultures in assessing one's ability to maintain health despite stress. In addition to SOC-29 and SOC-13, which measure individual sense of coherence, other versions have been developed, such as scales to measure family coherence and an adaptation specifically for children.