Salutogenesis is the study of the origins (genesis) of health (salus) and focuses on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis). 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 AntonovskyAntonovsky, A. "Health, Stress and Coping" San Francisco: Jossey-Bass Publishers, 1979Antonovsky, A. "Unraveling the Mystery of Health: How People Manage Stress and Stay Well" San Francisco: Jossey-Bass Publishers, 1987 (1923–1994), 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.Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 11(1), 11-18.
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,Gregor J. Jenny, Georg F. Bauer, Hege Forbech Vinje, Katharina Vogt, Steffen Torp, The Application of Salutogenesis to Work. In: The Handbook of Salutogenesis, 3 September 2016, pp. 197-210. . nursing,England, M., & Artinian, B. (1996). Salutogenic Psychosocial Nursing Practice. Journal of Holistic Nursing, 14(3), 147-195. psychiatry,Bergstein, M., Weizman, A., & Solomon, Z. (2008). Sense of Coherence Among Delusional Patients: Prediction of Remission and Risk of Relapse. Comprehensive Psychiatry, 49, 288-296. integrative medicine,Rakel D, Fortney L. The Healing Encounter. In: Integrative Medicine. 4th ed. Philadelphia, PA: Elsevier; 2018:20-26. and healthcare architecture.Dilani, A. P. D. (2008). Psychosocially supportive design: A salutogenic approach to the design of the physical environment. Design and Health Scientific Review, 1(2), 47-55.Golembiewski, J. (2010). Start making sense; Applying a salutogenic model to architectural design for psychiatric care. Facilities, 28(3).
The World Health Organization Health Promotion glossary of terms defines Salutogenesis as follows: "Salutogenesis describes how social and individual resources help people to manage stress and to thrive. Salutogenesis focuses attention on the study of the origins (genesis) of health (salus) and of positive health outcomes—moving towards the positive end of an ease/dis-ease continuum—in contrast to the more usual study of the origins of disease and risk factors (pathogenesis). Salutogenesis emphasizes the importance of sense of coherence—an individual or collective orientation towards life as being comprehensible, manageable, and meaningful. In health promotion, the salutogenic approach focuses on strengthening resources and assets that help people to cope with adversarial life situations, and promote wellbeing and thriving."WHO. (2021). Health Promotion Glossary of Terms 2021. Geneva: World Health Organization
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 (SOC) 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 (GRRs) and specific resistance resources (SRRs), 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.Mittelmark, M. B., Daniel, M., & Urke, H. B. (2022). Specific Resistance Resources in the Salutogenic Model of Health. In M. B. Mittelmark, G. Bauer, L. Vaandrager, J. Pelikan, S. Sagy, M. Eriksson, B. Lindström, & C. M. Magistretti (Eds.), The Handbook of Salutogenesis, Second Edition (pp. 107-114). New York: SPRINGER.
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:
"a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement."
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.
Although all three components of the SOC are necessary, they are of unequal centrality. Meaningfulness seems the most crucial. Without this motivational component, strong comprehensibility and manageability are likely to be temporary. When a person is committed and caring, however, the way is open to gaining understanding and resources.Antonovsky, A. (1990). Pathways leading to successful coping and health. In M. Rosenbaum (Ed.), Learned resourcefulness: On coping skills, self-control, and adaptive behavior (pp. 31–63). Springer Publishing Co.
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 (see section on Life situation), 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: AntonovskyAntonovsky, A. (1991). The structural sources of salutogenic strengths. In C. L. Cooper & R. Payne (Eds.), Personality and Stress: individual differences in the stress process (pp. 67-104). Chichester: John Wiley and Sons. 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.”Antonovsky, A. (1990). A somewhat personal odyssey in studying the stress process. Stress medicine, 6(2), 71-80.