Who invented coherence?

Salutogenesis

Toni Faltermaier

Summary

The model of salutogenesis was introduced by health scientist Aaron Antonovsky as an alternative to pathogenesis and is one of the most important models for explaining health. It is intended to answer the question of how health is created, how people can stay healthy despite the risks and how their health can be promoted in practice. The model is based on an understanding of health and disease as a continuum; it is intended to explain movements on this continuum. Stressors, the way they are coped with and the available resistance resources are used as determinants of health. A key concept is the sense of coherence, which develops in the course of life on the basis of resources and states whether one's own life is experienced as understandable, manageable and meaningful. A high sense of coherence leads to positive health, a low sense of coherence leads to negative health. The model of salutogenesis represents a central theoretical basis for the practice of health promotion, it formulates which conditions for health must be promoted.

Catchwords

Health, Health-Disease Continuum, Stress, Stressors, Coping, Coping, Resistance Resources, Sense of Coherence, Sense of Coherence, Resilience, Health Promotion


The term “salutogenesis” marks a central theoretical perspective in the health sciences and an important practical orientation, especially in the field of health promotion. It was introduced by the founder of salutogenesis, the American-Israeli health scientist Aaron Antonovsky (1923-1994) as an antithesis to pathogenesis. In his reasoning, he argues that advances in knowledge about the health of the population can only be expected if we do not concentrate exclusively on the question of pathogenesis, i.e. why diseases develop and how they can be treated. In view of the epidemiological findings that diseases are not the exception, but that a large part of the population is sick at a certain point in time, maintaining health is the actual task. The central and so far hardly answered question is therefore how health arises (salus = healthy; genesis = emergence), how people can stay healthy despite risks and stressors and promote their health. Antonovsky devoted himself intensively to this question of salutogenesis in two monographs (1979, 1987) and formulated a model of salutogenesis from the state of knowledge at the time, which stimulated extensive research worldwide and led to the development of new practical approaches.

Antonovsky's (1997) salutogenesis model describes a complex set of conditions that are intended to explain health (and not disease) (see Fig. 1).

The salutogenesis model can essentially be described by four components:

  • In this model, health is not understood as the opposite of illness, but as Health-disease continuum ("Health Ease - Dis-Ease", HEDE continuum) (see Fig. 1). People are not simply classified dichotomously as healthy or sick, which is often difficult in reality and leads to the fact that health care is largely concentrated on the sick as patients and the healthy are often neglected. Rather, people can be localized in their health status to points of a multidimensional continuum, which is limited by extreme poles of absolute health and absolute illness (but not really reaching them). The model is therefore not intended to explain health or illness, but rather the movement of people on the continuum in a positive or negative direction. This conception has the advantage that all people can be understood as more or less healthy and can be placed on the continuum. Even people with severe or chronic illnesses have the chance that their health can also be moved in a positive direction.
  • Stress (stress and stress management) is considered to be one of the most significant and well-documented influencing factors on health and illness. Correspondingly, in Antonovsky's model of salutogenesis, a central path is formulated, that of psychosocial, physical or biochemical Stressors leads to the health continuum (see Fig. 1). Potential stressors (such as stressful life events, workloads or bacteria and environmental pollutants) affect the individual, trigger a physical and psychological state of tension and are then tried to cope with. Based on the well-known stress theory of the American psychologist R.S. Lazarus also assumes Antonovsky that only the subjective assessment of the stressors and the type of Coping attempts ("coping") decide what health effects stressors have. In contrast to the pathogenic conception, stressors in salutogenesis can not only lead to diseases, but also have positive effects on health. People who successfully manage their tensions will move in the positive direction on the continuum; People who cannot cope with tension successfully will get into a state of stress which, if the organism is vulnerable, can also lead to the development of diseases. Antonovsky assumes that stressors are omnipresent in life and therefore cannot be completely prevented; it therefore depends on how stressors are dealt with and what coping potential people have.
  • Antonovsky considers the general resistance resources ("Generalized Resistance Resources") seen. They describe “every characteristic of a person, group or environment that can facilitate effective stress management” (Antonovsky 1979, p. 99, translation T.F.). General resistance resources can be effective in a variety of stressful situations and include genetic, constitutional, and psychosocial traits. People with many and well-developed resources are able to better cope with the pressures they will face in the course of their lives and are therefore moving in the positive direction on the health continuum. Psychosocial resistance resources are particularly interesting because they are potentially changeable. On the one hand, they include characteristics of the person, e.g. B. Knowledge and intelligence, preventive attitudes, skills (coping skills) and characteristics (ego identity, self-esteem), but also physical and constitutional characteristics (such as a stable constitution or high immune competence). On the other hand, the resources also include characteristics of their social and societal environment, e.g. B. strong social ties and support possibilities, strong religious or philosophical convictions, a life in cultural stability or material resources (money, property and wealth). Resistance resources build up from the beginning and in the course of life and have their roots in social framework conditions as well as in biographical and family conditions. How and where people grow up determines which resources they can develop. If they have many resistance resources at their disposal, they can tend to have experiences in life that give them consistency, enable social participation and personal control, as well as create a balance between excessive and insufficient demands.
  • If people can have these positive life experiences on the basis of many resistance resources, then they develop an orientation in life, the Antonovsky, in the course of childhood, adolescence and early adulthood "Sense of Coherence" is called. With this theoretical construct of the sense of coherence, Antonovsky formulates a key concept of salutogenesis; He means people's deep conviction and confidence that their lives are in principle understandable, meaningful and manageable. This life orientation consists of three components that are closely related to one another: firstly, the feeling of Understandability ("Sense of compehensibility"), that is, the feeling that one's own life is understandable, cognitively clear and structured (not chaotic); second, the feeling of Manageability ("Sense of manageability"), that is, the confidence that the demands and stresses in life are essentially to be mastered; third, the feeling of Meaningfulness (“Sense of meaningfulness”), that is, the basic feeling that one's own life is meaningful and that the demands that come with it are worth investing energy in. People with a high sense of coherence are better able to cope with their stressors and to choose the necessary resources; they are therefore moving in a positive direction on the health continuum. On the other hand, people with a low sense of coherence have difficulties coping with the pressures in their life and therefore tend to move in a negative direction. The sense of coherence can be measured scientifically; Antonovsky and other researchers have developed questionnaire instruments that have been used in many studies and have mostly correlated positively with measures of health.

Antonovsky's model of salutogenesis is a complex theory of health with many interactions. It is therefore difficult to investigate empirically, and often only partially mapped. Nevertheless, the many studies of the international show Salutogenesis Researchthat essential assumptions of the model can be confirmed (see Faltermaier 2017). The sense of coherence correlates positively with indicators of health, especially with mental health; This can also be seen in very meaningful longitudinal studies and in representative samples of the population, which were carried out mainly in the Scandinavian region. A high sense of coherence also contributes to better coping with a large number of stresses in life (critical life events, workloads, illnesses), i.e. it acts as a moderator between stressors and health (ibid.).

Nevertheless, Antonovsky's formulation of salutogenesis is only to be understood as a first draft that needs to be expanded and supplemented in order to explain health even better. Above all, the lack of a subject level in the model is criticized, insofar as health can also be established through active efforts on the part of people (health behavior) in the lay system (Faltermaier 2016) (subjective health: everyday health concepts; health behavior, illness behavior, health action). It is also noted that the model takes too little account of social differences in health, i.e. does not specifically explain why health varies according to socio-economic status, gender, age and culture. And finally, Antonovsky's assumption is called into question that the feeling of coherence only builds up until the age of 30 and then hardly changes. Recent studies show that people can change their sense of coherence even in the middle and later phases of life. In this respect, further developments of the model of salutogenesis are possible and necessary. B. Faltermaier (2017) carried out an integrative model of salutogenesis.

More recently, the Resilience (Resilience and protective factors), especially in popular science, represent a concept that is very close to salutogenesis. In fact, resilience as a psychological resistance to overload or the protective factors mentioned shows clear similarities to stress management and to the resistance resources in salutogenesis (cf. Bengel, & Lyssenko 2012). Nevertheless, the concept of resilience cannot replace salutogenesis, because it does not represent a comprehensive bio-psycho-social theory of health and has so far been scientifically related primarily to the psychological development of people.

The approach of salutogenesis showed great attractiveness for the practice in the health system and above all became an important basis for new approaches and the movement for health promotion. The Ottawa Charter for Health Promotion, formulated by the WHO in 1986, bears very significant traits of salutogenesis. It relies on the promotion of resources, positive health goals and the participation and empowerment of people to strengthen their health (Faltermaier 2018; Faltermaier & Wihofszky 2012). Salutogenesis thus represents an important and innovative concept for the theory, research and practice of health care, which has great potential for the health of the population, but which is far from exhausted in its scientific development.

Literature:

Antonovsky, A. (1979). Health, stress and coping. London: Jossey bass.
Antonovsky, A. (1987). Unraveling the mystery of health. London: Jossey bass.
Antonovsky, A. (1997). Salutogenesis. To demystify health. Tübingen: DGVT-Verlag.
Bengel, J., & Lyssenko, L. (2012). Resilience and psychological protective factors of health in adulthood. Cologne: BZgA.
Faltermaier, T. (2016). Laypeople Perspectives on Health and Disease. In M. Richter, & K. Hurrelmann (eds.). Sociology of Health and Disease (Pp. 229-241). Berlin: Springer-Verlag.
Faltermaier, T. (2017). Health psychology. Grundriss der Psychologie, Volume 21. 2., revised and expanded edition, Stuttgart: Kohlhammer.
Faltermaier, T. (2018). Salutogenesis and resource orientation. In C.-W. Kohlmann, C. Salewski, & M. A. Wirtz (Eds.). Psychology in Health Promotion (Pp. 85-97). Bern: Hogrefe.
Faltermaier, T., & Wihofszky, P. (2012). Participation in health promotion: salutogenesis - subject - lifeworld. In R. Rosenbrock, & S. Hartung (eds.). Handbook for Participation and Health (Pp. 102-113). Bern: Huber.

References:

Health behavior, illness behavior, health action, resilience and protective factors, stress and stress management, subjective health: everyday concepts of health