SALUTOGENIC CONCEPT OF HEALTH

SALUTOGENESIS:
Salutogenesis was originally coined by American-Israeli medical sociologist Aaron
Antonovsky. The word "salutogenesis" is derived from the Latin salus meaning health and the
Greek genesis meaning 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 focuses
on resources, maintains and improves the movement towards health. It gives the answer
why people despite stressful situations and hardships stay well. It is the opposite of the
pathogenic concept where the focus is on the obstacles and deficits. The Salutogenic model for
health is the study of health and determinants of health.
2

In 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.
3

Aaron 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.
4

People 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.
5

The 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
CONCEPT
World 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.
7

There 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.
8

Despite 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.
7

In 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.
8

Over 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 PATHOGENESIS
Pathogenesis 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.
1

Salutogenesis 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.
1

Pathogenesis 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.
10

The 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.
7
The 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.
11

Antonovsky 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.
12

Pathogenic 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 Health
10


Pathogenesis



Salutogenesis
Employs a dichotomy between healthy and sick
individuals
Places 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 disease Follows realistic perspective - go get health
Focus is to prevent pain or loss Focus 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 health

Primary 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 problems

Optimization 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.
13

Antonovsky 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 approach
HEALTH DISEASE CONTINUUM
Health is seen as a movement in a continuum on an axis between total ill health (dis
ease) 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.
8

When 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.
5

Antonovsky 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).

Figure 2: Health Disease Continuum
(Dis- ease) (Health- ease)
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 HEALTH
Traditionally, 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 are limiting 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






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