Gaceta Sanitaria Gaceta Sanitaria
Editorial
Seizing the opportunity – a salutogenic approach to public health
Bengt Lindstrom
Department of Public Health and Nursing Science, Norwegian University of Science and Technology, Trondheim, Norway

Because 2016 became a year when several regional and global health charters were declared (the IUHPE Curitiba Declaration on Equity1, The ETC Healthy Learning statement2, The EUPHA Vienna Declaration3 and the WHO Shanghai Declaration on Health Promotion), I take this opportunity to reflect on both the history of contemporary Public Health and how a synthesis could redirect Public Health into a coherent efficient action in the future, here based on a salutogenic reflection.

Recently, Halfdan Mahler, one of the most prominent directors of WHO died at the age of 93. He was the head of the WHO for 15 years (1973-1988). In his time, the WHO changed direction from mainly supporting and building health care services and documenting disease and risks in the world to a reach out to society and community and develop primary health where people live, love and work - accumulating action far beyond the traditional Health and Public Health sector in line with Mahler's earlier efforts with FAO and UNICEF.

Mahler was interviewed in connection to the 30th anniversary of the Alma Ata Conference where the WHO set out its new strategy for primary health followed by WHOs global health strategy, Health for All 2000 (HFA). He stated: “We get nowhere with the population primary health movement unless we include and act according to the basic values and principles of HFA” (these were: Adding Health to Life and Adding Life to Years through intersectoral action, equity in health and sustainable development). Mahler expressed his concern with the slow development in the primary health area. (By coincidence, the Alma Ata meeting took place almost the same year as the first scientific book on the salutogenesis was published by Antonovsky [1979]4. Both events were unaware of each other–just as the victims of the Holocaust never knew they would trigger the development of the United Nations and the Declaration of Human Rights, and furthermore that some of them would initiate the salutogenic approach to health).

The traditional focus of public health and the health sector has been “Adding Health to Life”; this means the combat of disease, implementing interventions aiming at the reduction and elimination of risks in human populations much in accordance with the 1948 WHO Declaration of Health5; acting on the “absence of disease” part which of course must continue. However, what was new in HFA was the inclusion of the other part of the health declaration into the action programme, i.e. dealing with “a complete state of wellbeing in a physical, mental and social dimension”; launching the vision of “Adding Life to Years6. At the time, it was still too early to add the fourth dimension of health–the spiritual or existential dimension of health. This was only touched upon by Halfdan Mahler in 1987 almost 40 years after the original health declaration. Finally, under Mahler's leadership the health promotion movement was launched through the Ottawa Charter of 1986 to become a tool to implement the HFA strategy7.

What was new here was the focus on health as an intrinsically positive resource for life and finding ways to build assets for a healthy life course where the supporting community or setting was an important contributing factor. Further, a key change of perspective was envisioning health as a life-long process not as a state, a fundamental difference from the first WHO Declaration of Health. Opening up these new scenarios would have made it possible to respond to some of the visions of early Public Health Mastodonts calling for evidence-based and theory-based public health interventions. However, public health was slow to redirect its activities from its traditional risk approach and problem descriptions while its irritating little sister, health promotion, kept buzzing and boasting about what could be achieved, however, never really taken seriously by Big Brother. The problem was HP could not create a focus or find a theoretical foundation and just went in all directions. In a sense, the reluctance from the public health standpoint was understandable because HP was too eager to conquer the world of Health rather than systematically building a solid evidence base and developing a sound theoretical construct for its actions.

Looking back, the potential was in fact already there because the key players of health promotion at WHO Euro in 1993 initiated a dialogue with Aaron Antonovsky, the founder of salutogenesis, who suggested salutogenesis could form a theory base for health promotion (published posthumously in 1996)8. Unfortunately, at the time there was not much evidence of its effectiveness and Antonovsky's premature death the year after almost brought the salutogenesis to a standstill, some saying it had been an acute appendicitis that should be removed as soon as possible. This could have been the end of the story where everything eventually went back to normal.

What is the secret of salutogenesis and how can public health benefit? Salutogenesis is seen as an umbrella concept encompassing several theoretical approaches and concepts that all have in common a resource approach to health. The first and most well-known is Antonovsky's Sense of Coherence Theory (1979)4 originally based on an epidemiological study of women who had undergone extreme stressful life events, some of them victims of the Holocaust, but still, as anybody else, were able to fully live and manage life. In-depth interviews of the women brought forward the theory and research instrument. The key was the ability to find a reorientation of one's life perspective, pick up the pieces, reflect and continue and set up a different path for one's life course in spite of everything and find constructive support for a continuation through internal or external resources. The focus is on life where health serves acts as a resource. This ability to use one's resources was named Sense of Coherence (SOC) by Antonovsky. The stronger this ability the better the capability to manage life and all its challenges. In Antonovsky's view this was a systemic approach where the coherence between individuals and their supporting structures creates an interactive system. Therefore, one can think in terms of a collective SOC looking at communities, institutions and society overall. The key here is again how can a sustainable system for the support of life be created through the use of available resources.

Another concept under the salutogenic umbrella is resilience dealing with the ability to withstand hardship in life and still manage. Both concepts underline the importance of life experiences that form a culture and community prepared to encounter any challenges and difficulties in a constructive way. In other words, creating a resilient salutogenic culture. For instance, it is known that communities that are living under constant hardship and external pressures (such as many developing societies) are better at finding solutions than protected societies that never have had to deal with difficulties. This requires both experience, ability and innovation to tackle new unknown future challenges and manage them well. Over time a repertoire of life experiences form a cultural salutogenic tool box. Of interest for public health and epidemiology is the fact that risks that traditionally are seen as destructive pathological phenomena over time can serve as an asset. The ability to resist the risk is the important process not the risk itself. Risk therefore becomes not an absolute but a relative concept. If these shortly are the theoretical aspects of salutogenesis what is then the evidence that supports its effectiveness?

What can be seen in both longitudinal and cross sectional studies over time is that the mean value of SOC increases over life; older populations have a stronger mean SOC than younger. This gives two clues to salutogenesis: it is not something we are born, with it is something we learn over time. Here, of course, the society's culture plays an important role as a supportive factor for life. We can also, secondly, conclude that the wisdom of life is harbored in the older generations.

What empirical evidence tells us is that people who develop this ability live longer than the average, in terms of Health for All; Adding Years to Life. One aspect is the ability to cope with chronic conditions such as non-communicable diseases (NCDs). People with a strong salutogenic capacity manage these conditions better than the average. Although SOC strengthens both the social, existential and physical dimensions of health through its capacity to handle stress its strongest correlation is connected to the mental dimension of health in terms of well-being, quality of life or perceived health, i.e. salutogenesis responds to HFA and the call “Adding Life to Years”. Longitudinal, cross-sectional, qualitative and quantitative studies indicate the same (2010)9.

In conclusion, where do we stand today and how does the salutogenesis support contemporary public health issues? The original salutogenic questionnaires have been translated into more than 50 languages and roughly speaking they have been used in more than a third of the nations of the world on all inhabited continents. We are moving into a global world where health issues have become important on the political agenda and the United Nations has set new Sustainable Development Goals (SDGs) that are adapted on the Global Health Agenda by many agencies within and outside the health sector. It seems many of our efforts in public health have a strong political backing. The WHO, in its last health promotion meeting in Shanghai December 2016, approved a strategy to tackle the SDGs, here Health Literacy was given a central role10. However, scrutinizing in detail how HL experts plan to achieve this it seems a bit premature and rather incoherent largely lacking theory and empirical evidence. A bit of salutogenic thought would have been of great use to avoid this inconsistency.

Aging populations have become a big concern for public health. As stated before, people who develop their salutogenic capacity will live longer than the average. Often, aging is considered to be an expensive extension of life, draining the GNP through enormous health care costs for society. A call for urgency was presented in gerontology in a desperate book, “Next Medicine”, where the author calculated future medicine would be an economic impossibility if we continue along on the present path; reducing cost effectiveness to almost nil (2010b)11. He had never been introduced to salutogenesis. Another US example; caesarean sections without any medical indications cost the US health budget 17 billion dollars per year while women with a salutogenic approach to birth prefer natural birth.

However, looking at the overall picture, it is not only a longer life that is expected through salutogenesis, it is also a life with increased wellbeing. Evidence also speaks for a lesser burden of chronic disease and a longer healthy and happy life which overall decreases costs in comparison with the average. Salutogenesis cannot cure NCDs but ameliorates their effect and makes it easier to live with them, and thus lowering the cost for society. Detailed economic health calculations are still lacking. However, it seems people who fall out of the work force but have a strong salutogenic capacity are inclined to return to work. A health impact calculation in Finland indicated the overall cost of early drop out of the work force costs as much as a full nationwide annual work force working day and a loss of 30 billion euros per year. With salutogenic strategies in workplaces, this could largely be avoided (2010). It has also been shown that productivity of organisations increases when salutogenesis is implemented12.

Public Health can gain a lot by actively implementing salutogenesis in its framework, basically working from an evidence- and theory-based platform redirecting its activities from a more or less total risk approach into an asset framework. In 2016 European public health made a call for health promotion in its Vienna Declaration. The European Training Consortium presented its healthy learning concept based on salutogenesis. IUHPE made its call for equity in health while the WHO at the end of the year the WHO presented its Shanghai Charter. Overall, we can see a conversion into the overarching aims of the United Nations Sustainable Development Goals. Overall, it seems many Central Public Health Institutions are joining together for once.

Finally, Professor Pekka Puska, the former director of the National Public Health Institution in Finland (today The Institute of Health and Wellbeing/Welfare) was also the initiator of the North Karelia CVD prevention project in the 1970's. He has been a firm supporter of the high-risk approach in Public Health as he also stated in an introduction to a book on “Wellbeing and Beyond” (2010)13, a global anthology on wellbeing. His life mission in public health has been devoted to a high-risk approach which has been highly successful but he foresees “the future of public health may well be embedded in a complementary salutogenic approach”. What is needed is a synthesis for public health enforced by a strong theory and evidence based asset approach to health, in addition a political will and visionary leadership.

Authorship contributions

The text is written by Bengt Lindstrom.

Funding

None.

Conflicts of interest

None.

References
1
The Curitiba Declaration. Available at: www.iuhpe.org
2
Evolution of Salutogenic Training. The ETC Healthy Learning Process. Available at: www.etcsummerschool.wordpress.com
3
The Vienna Declaration. Available at: www.eupha.org
4
A. Antonovsky
Health stress and coping
Jossey Bass, (1979)
5
The WHO Constitution. Available at: www.who.int
6
The Health for All Strategy. Available at: www.who.int
7
The Ottawa Charter. Available at: www.who.int
8
The salutogenic model as a theory to guide health promotion 1 Health Promot Int. 1996;11:11-8. doi:10.1093/heapro/11.1.11
9
B. Lindstrom,M. Eriksson
The Hitchhiker's guide to salutogénesis
Folkhalsan Research Report, (2010)
10
The Shanghai Declaration. Available at: www.who.int
11
W. Bortz
Next medicine
OUP, (2010)
12
M. Mittelmark,S. Sagy,M. Eriksson,G.F. Bauer,J.M. Pelikan,B. Lindström
Handbook on salutogenesis
Springer, (2016)
13
Wellbeing and beyond. 2014. Available at: www.edgaronline.com
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