Morton Wagenfeld, Ph.D

The Changing Landscape of Health Care

The intellectual origins of the salutogenic orientation are an interesting commentary on the workings of scientific inquiry. Antonovsky (1990) was conducting a study on adjustment to menopause in a cohort of Israeli women. At that time, almost all survey research included a question on whether the respondent had been a Holocaust survivor. The expectation was that those women who had not been in concentration camps would show a better adjustment to menopause. This finding was confirmed in about two-thirds of the cases.

Most researchers would have been happy to report these results. However, Antonovsky turned the question around and wondered how one-third of the respondents survived this mephitic experience and exhibited good adjustment. This chance observation set him on a course that eventually produced the salutogenic perspective.

Finding Its Place in the Physical and Social Sciences

For over 300 years, the biomedical model of disease has been the dominant paradigm in the western world, seeking to discover the causes of disease—the pathogenic approach. This approach implies that disease is a relatively uncommon occurrence. While it has helped to bring about significant advances in the health of populations, current thinking suggests that it is outmoded because

• epidemiological evidence suggests that the majority of the population suffers from one or more health changes in a given year; and
• individuals are continually subject to a variety of physical, chemical, biological, and psychosocial stressors. 

In view of the ubiquity of stressors and this growing evidence, I propose that the pathogenic model asks the wrong question.

The Salutogenic Model

The right question is “What are the factors that prevent breakdown?” The answer has been captured in the salutogenic model (Antonovsky, 1979, 1987, 1990). Broadly speaking, this model is part of psychology’s resilience tradition, emphasizing the strengths of individuals (Strumpfer, 1990).

The salutogenic model is embodied in the concept of sense of coherence (SOC). SOC is an enduring, though dynamic feature of personality that views the world as manageable, meaningful, and predictable.

Operationalized in the Orientation to Life questionnaire, the foundations of SOC—Will it be weak or strong?—are termed Generalized Resistance Resources (GRRs). The SOC is a measure of the strength or weakness of the GRRs. These six assets help to ameliorate the noxious effects of the stressors in our lives.

Antonovsky viewed these GRRs as (a) ranging on a continuum from the cellular (an intact neurological and immune system) to the macrosociocultural (religion, belief systems) and (b) encompassing biology, psychology, and sociology.

The Changing Landscape of Health Care

Reasons for the increasing acceptance of salutogenesis include the following:

1. Antonovsky’s book was published at a propitious time when an increasing disillusionment with the biomedical model was occurring.
2. There is growing recognition that medical intervention plays only a minor role in health and longevity.
3. More people are acknowledging that the major determinants of illness are lifestyle, environment, and genetic heritage.
4. Psychoneuroimmunology has called into question some of the traditional mind/body relationships.
5. The growing popularity of complementary or alternative medicine also has emphasized the importance of mind/body interaction.
6. Considerable empirical evidence has emerged linking morbidity and mortality with belief systems, such as religion.
7. The vast majority of studies have shown a consistent and robust relationship between a strong SOC and various states of health, stressful life events, and occupational burnout.

Conceptualizing and Investigating SOC

Given its wide use internationally, the psychometric properties of the SOC scale have been extensively studied. In his original formulation, Antonovsky (1993) argued that the scale was relatively fixed by early adulthood. Furthermore, the three dimensions of manageability, meaningfulness, and comprehensibility were conceptually integrated into a single factor.

Eriksson and Lindstrom (2005) conducted the most comprehensive and current review of the scale’s reliability and validity, examining almost 500 publications and doctoral dissertations. They concluded that the scale was a very reliable, valid, and cross-culturally applicable instrument, but not as stable as Antonovsky had claimed. They found that SOC appears to increase with age. Additionally, they felt that the scale was multidimensional, not unidimensional.

Strumpfer (1995) argued that, while salutogenesis was certainly important and a significant determinant of health, it was an intermediate point toward the outcome of life satisfaction, termed fortigenesis (sources of strength). This concept is a fascinating idea and, to my knowledge, has not been pursued.

Where Do We Go From Here?

SOC continues to attract international attention, and the body of evidence linking it to various states of health is impressive. Several areas of investigation would be fruitful, including the following:

• How can the SOC scale be used as a screening tool for individuals in crisis or at risk for some health or emotional change?

How feasible is it to design salutogenic interventions?

• How do we develop a qualitative version of the SOC scale?
• How can SOC be incorporated into policy to improve the health of populations?
• Considering SOC as a dependent variable, what are the life circumstances that contribute to high or low coherence?
• How can we develop and utilize a fortigenesis scale?
• Lastly, how can this model be applied to different knowledge areas and fields of practice?

References

Antonovsky, A. (1979). Health, stress, and coping. San Francisco: Jossey-Bass.

Antonovsky, A. (1987). Unraveling the mystery of health. San Francisco: Jossey-Bass.

Antonovsky, A. (1990). A somewhat personal odyssey in studying the stress process. Stress Medicine, 6, 71–80.

Antonovsky, A. (1993). The structure and properties of the sense of coherence scale. Social Science and Medicine, 36(6), 725–733.

Eriksson, M., & Lindstrom, B. (2005). Validity of Antonovsky’s sense of coherence scale: A systematic review. Journal of Epidemiology and Community Health, 59(6), 460–466.

Strumpfer, D. J. W. (1990). Salutogenesis: A new paradigm. South African Journal of Psychology, 20(4), 265–276.

Strumpfer, D. J. W. (1995). The origins of health and strength: From salutogenesis to fortigenesis. South African Journal of Psychology, 25(2), 81–89.