The utility of salutogenesis for guiding health promotion: the case for young people's well-being

The utility of salutogenesis for guiding health promotion: the case for young people’s wellbeing Irene García-Moya Department of Developmental and Educational Psychology, University of Seville, Spain e-mail: [email protected] Antony Morgan Glasgow Caledonian University, UK e-mail: [email protected] Corresponding author: Irene García-Moya. Department of Developmental and Educational Psychology, University of Seville. C/ Camilo José Cela s/n. C.P: 41018, Sevilla (Spain). E- mail: [email protected] Funding: This work was supported by the Spanish Ministry of Education [grant numbers: FPU 2009- 0978, Est13/00084 to I. G-M.] How to cite this work: García-Moya, I. & Morgan, A. (2016). Salutogenesis’ utility as a theory for guiding health promotion practice: the case of young people’s well-being. Health Promotion International. Advanced online publication. doi: 10.1093/heapro/daw008 This is a pre-copyedited, author-produced version of an article accepted for publication in Health Promotion International following peer review. The version of record, García-Moya, I., & Morgan, A. (2017). The utility of salutogenesis for guiding health promotion: the case for young people’s well-being. Health Promotion International, 32(4), 723–733. is available online at: https://doi.org/10.1093/heapro/daw008 The utility of salutogenesis for guiding health promotion: the case for young people’s wellbeing Abstract Twenty years has passed since the publication of the seminal paper ‘The salutogenic model as a theory to guide health promotion’ (Antonovsky, 1996), in which Antonovsky proposed salutogenesis and its central construct sense of coherence (SOC) as a way of boosting the theoretical basis for health promotion activities. Since then there has been a notable amount of conceptual and empirical work carried out to further explore its significance. The aim of this paper is to critically assess the current theoretical status of salutogenesis and its utility to advance effective health promotion practice for young people. The assessment was carried out in the context of contemporary international policy agendas on wellbeing. An analytic framework was developed using previous literature on the definition and function of theory. This organizing framework comprised four criteria: description, explanation, prediction and measurability. The paper concludes with a perspective on the status of salutogenesis as a theory and how it can be further developed. Specifically, the critical assessment highlighted that salutogenesis has been subjected to considerable empirical testing over the last few decades resulting in convincing evidence of the relevance and subsequent advancement of the idea. However, less emphasis seems to have been placed on a systematic process of testing and iteration to develop its theoretical basis. The paper identifies a number of aspects that should be developed to support the progression of salutogenesis to the next level. A research-practice cycle approach is proposed that can facilitate that important next step. Keywords: salutogenesis, sense of coherence, young people, wellbeing INTRODUCTION Nearly 30 years ago salutogenesis was introduced into our lexicon as an idea that could explain health or, more specifically, demonstrate how health could be promoted (Antonovsky, 1987). In the midnineties, Antonovsky (1996) went further and suggested it as a theory to guide health promotion. He claimed that ‘the basic flaw’ in health promotion’s ability to progress was due to a lack of solid theoretical foundation and suggested salutogenesis could help advance health promotion practice. Since then much work has taken place to further understand salutogenesis and its links to a range of health, wellbeing and related outcomes. Interest in the idea also re-emerged in the 21stcentury in the context of public health and its efforts to reduce health inequalities (Morgan and Ziglio, 2007; Eriksson and Lindström, 2008). Most notably, the work of Lindstrom and Eriksson (2010) and others (García-Moya et al., 2013b; Mittelmark and Bull, 2013) have highlighted its theoretical potential both in academic and practice circles and have gone some way to enhance the evidence base to demonstrate its worth as a health concept. Pivotal works include the seminal systematic reviews on the links of sense of coherence (SOC – the central construct of salutogenesis) with wellbeing and quality of life (Eriksson and Lindström, 2006, 2007), and a systematic review about SOC in adolescent samples (Rivera et al., 2013) – see methods section for further details. In addition, further conceptual development has made more explicit connections to the guiding principles of the Ottawa Charter for health promotion and contemporary international public health agendas (Eriksson and Lindström, 2008; Lindström and Eriksson, 2010). The ideas behind salutogenesis have been associated with a shift in thinking in policy and practice. That is, it has contributed to making the case for more emphasis to be placed on positive approaches to health and wellbeing programmes (as opposed to the usual deficit approach). In this context, salutogenesis is seen as a useful idea to support the implementation of an approach which seeks to maximise capability rather than deficiency and need (Morgan and Hernán, 2013). With the increasing amount of attention placed on wellbeing in policy, Morgan (2014) argues that the principle tenets of salutogenesis (and its central construct – SOC) have the potential to make explicit the types of initiatives and programmes that lead to wellbeing as an outcome. Given the importance of explaining pathways to health related outcomes, it seems timely to assess whether after twenty years of conceptual and empirical developments the original claims made in the paper ‘The salutogenic model as a theory to guide health promotion” (Antonovsky, 1996) can be upheld. The aim of this paper therefore, is to critically assess the current theoretical status of salutogenesis and its utility to advance effective health promotion practice for young people. An analytic framework will be used to assess its ability to explain and predict wellbeing. The assessment will conclude with a perspective on how salutogenesis can be utilised now in practice and what further research is needed to continue to improve its validity and robustness. An international policy context The concept of wellbeing is increasingly set in policy agendas as a necessary accompaniment to those that seek to elongate life and prevent premature mortality. Enhancing the wellbeing of European citizens is one of the targets of the European Health 2020 policy (WHO, 2012). International policy efforts have a long standing tradition of including the notion of wellbeing in strategic documents (WHO, 2012, 2014b). However, despite its accumulating prominence an analysis of the impact of the previous European Child and Adolescent Health strategy has revealed that its translation into a set of concrete actions for practice has been limited (WHO, 2014a). Part of the challenge in promoting wellbeing may be related to its complexity as a construct and differing definitions (Dodge et al. 2012; Pollard and Lee, 2003). Nevertheless, as the interest in it has grown, efforts have been made to make its parameters more explicit. Whilst there may be no consensus on a definitive and all encompassing definition, most researchers and professionals now agree that wellbeing is a multi-dimensional construct which encompasses psychological, social and emotional dimensions (Diener et al., 2009). Based on previous evidence demonstrating the links between salutogenesis (or at least its central construct – SOC) and a range of wellbeing outcomes (Eriksson & Lindström, 2006), Morgan (2010) argues that more should be made of it to inform and evaluate practical actions. Specifically salutogenesis fits with two popular approaches currently taking central stage in strategies that focus on young people’s positive development – that is the life course and asset-based approaches to health and wellbeing. Life course approaches are central to many international strategies and initiatives for young people (WHO, 2014a, 2014b). These strategies recognise that wellbeing can be achieved as a result of accomplishing the goal that all young people move into adulthood equipped with “any necessary skills and competences to enjoy a productive, healthy and happy life” (WHO, 2014a) and these skills cumulate as a result of positive development in the early years . The evidence associated with the life course approach suggests that positive and negative factors for wellbeing accumulate throughout life and a policy response which seeks to maximise protective factors whilst minimising risks can be successful in achieving wellbeing and health gains (Marmot, 2010). In this context salutogenesis and SOC in particular presents itself as an example of a key skill that can help young people thrive even in difficult circumstances. In addition, policy documents (WHO, 2012; South, 2015) increasingly contextualize wellbeing in the context of an ‘asset based approach’. With respect to young people, WHO and the Health Behaviour in School Aged Children (HBSC) study emphasised that a range of ‘health assets’ necessary for the growth and development of children and young people could lead to higher levels of positive mental health. Salutogenesis (sources of health), or more specifically, SOC has been described as a potential health asset for wellbeing (Morgan and Ziglio, 2007) and a possible intermediary factor that can help to link and explain the range of antecedents necessary for the achievement of wellbeing during childhood and beyond. Therefore, if its theoretical potential can be realised, salutogenic thinking can support policy and practice and redress the balance between programmes that aim to create environments for health and those that solely focus on addressing problems that already exist. The use of theory in health promotion In order to see how far salutogenesis has developed in its ability to guide health promotion, we need to understand the relevance of theory in securing effective practice. So what is theory and why is it important? Evidence based health promotion has grown in importance over the last couple of decades and the need to find solutions for effective practice has become an imperative to securing improvements in health and reductions in health inequalities (Learmonth and Mackie, 2000). It is also acknowledged that practice is more likely to be effective if it is based on appropriate theory (Judge and Bauld, 2001). Discussions around evidence based practice and theory development go hand in hand when seeking to improve the basis for health promotion activities (Green, 2000; Van den Broucke 2012). Whilst there seems not to be a definitive definition of what good theory looks like, a number of distinctions in the literature have been made. Glanz and Rimer (2005) distinguish explanatory theory and theory of change. They argue that the former focuses on description, as it explains the reasons why a phenomenon exists aiming to identify the factors that significantly contribute to an understanding of the phenomenon of interest. The latter on the other hand aims to explain concepts enabling them to be translated into a set of strategies and processes for implementation including program design and evaluation. It could be assumed therefore, that explanatory theory needs to be sufficiently developed before a theory of change can follow through. In a similar vein, Van den Broucke (2012) explains that theory can be formulated at two differing levels of abstraction, both of which are considered to be essential and complementary. Theory can broadly provide basic values, foundations for practice and general directions in which the field should progress. In addition, it can provide a more detailed roadmap that guides the planning, implementation and evaluation of specific programmes. Glanz and Rimer (2005) further elaborate that the nature and function of theory is to describe a ‘set of interrelated concepts, definitions and propositions that present a systematic view of events or situations by specifying relations among variables, in order to explain and predict the events of situations’. Three main functions arise from the work of these authors - description, explanation and prediction. These provide a useful organising framework for a critical assessment of the current status of salutogenesis. The notion of ‘measurability’ is a useful addition to this framework as it emanates from the idea that the implementation of health promotion activities should be scientific, theory based and evaluated (Glanz and Rimer, 2005; McQueen, 2001). METHODOLOGY An analytic framework was developed to summarise what we already know about salutogenesis; discuss current issues and debates; make an assessment of its fitness for purpose; and set out the gaps in knowledge and need for further research. The readiness of salutogenesis to guide health promotion was analytically assessed using four aspects of theory: description, explanation, prediction and measurability. These are described below along with the associated salutogenic themes: Description The theory provides an accurate and adequate characterization of the phenomenon being studied. The salutogenic themes used to assess this were: approach to the study of wellbeing, segments of the population to which it applies, and relevance of the proposed concept SOC. Explanation The theory goes beyond description by specifying relationships between variables of interest and identifies mechanisms which underlie the observed events. The salutogenic themes assessed were: links between SOC and wellbeing, underlying mechanisms, developmental course, stability vs changeability of SOC and sources of SOC. Prediction The theory has been tested in empirical research. That is, the relationships among variables and the mechanisms proposed at the explanatory level are tested in a number of populations and situations. This allows expected outcomes in different contexts and population to be reliably estimated. The salutogenic themes assessed were: evidence regarding different cultural and ethnic groups and causal links. Measurability A valid and reliable way to operationalize the theory is available, so that its main tenets can be translated into testable sets of hypotheses. SOC was presented initially by Antonovsky (1996) as the core construct of salutogenesis. Additionally, most empirical papers on salutogenesis to date have used the SOC scale as a central measurement tool. This paper therefore focuses on SOC measurement as a means of analysing the measurability aspects of salutogenesis, but this should not be translated to mean that salutogenesis is synonymous with SOC. The salutogenic themes used to assess measurability were: psychometric properties of the SOC scale and cut-off points to define high and low SOC. The above framework was used to gather and synthesis published literature on salutogenesis. A 3-step strategy was used: - Step 1: Antonovsky’s 1996 paper along with monographic books and existing review level material, which cover an overall description of salutogenesis and both conceptual and empirical explorations on its links with health and its precursors, were selected (The list is available as supplementary material in appendix 1). - Step 2: Reference lists from material identified in step 1 were used to identify additional primary papers. - Step 3: The latest data from systematic review evidence was up to 2011. Therefore, material identified from steps 1 and 2 was supplemented by a search of more recent papers (published between 2011 and 2014) in Proquest, PubMed, Ovid SP, Wiley Online Library and ISI Web of Knowledge using salutogenesis, salutogenic and sense of coherence as keywords. As stated in the aims, our assessment focuses on the utility of salutogenesis for the promotion of young people´s well-being and on the current theoretical status of salutogenesis. Accordingly, a priority subset of papers was identified within the above databases using the appearance of the following words (‘strings’ ) in the title, abstract or keywords as a criterion: adolesc*, children, young, youth, students or school-age. Similarly, identifying any conceptual/theoretical papers available was important for the aim of the paper, so the database created as a result of steps 1, 2 and 3 was used to identify any papers with a focus on conceptual and theoretical issues. TESTING SALUTOGENESIS AS A HEALTH PROMOTION THEORY: A CRITICAL ASSESSMENT Salutogenesis and description In the context of young people´s well-being, salutogenesis has a number of descriptive strengths. First, salutogenesis provides a positive paradigm approach to the promotion of wellbeing amongst young people and fits with the increasingly evident ‘glass half full’ approach to policy and practice. By definition it is positive, because it asks what creates health rather than merely focusing on finding solutions to prevent or alleviate disease (Antonovsky, 1987). Salutogenesis is also in line with developmental psychology thinking to shift from studying the potential risks associated with adolescent years to perspectives in which adolescents’ strengths and resources are considered to be similarly important but seriously understudied (Lerner et al., 2009). Second, salutogenesis is broad in scope. Specifically, it can be applied at the level of the whole population. Unlike some approaches to health promotion, it has relevance to everyone irrespective of their social status or population group. If we classify youth according to risk and outcome status (Tiêt and Huizinga, 2002) we can make a comparison of salutogenesis with, for example, a deficit approach or such concepts as resilience that can be useful to illustrate this point (see Fig. 1). In this context, the deficit approach directs attention to segments of the population that have problems and seeks to identify risk factors associated with them. Approaches based on resilience despite focussing on positive adaptation, still maintain adversity as its defining characteristic (Luthar et al., 2000). Deficit and resilience approaches therefore rule out certain segments of the population, since most people do not encounter severe adversity and do not suffer physical or mental health problems. - Fig. 1 around here - Salutogenesis embraces everyone regardless of their position on the continuum of health and disease, their life circumstances or the stressors they have experienced. This is advantageous, as it places salutogenic theory with the persuasion often articulated that the mere absence of illness does not necessarily equate with wellbeing (Seligman and Csikszentmihalyi, 2000). From the perspective of young people, it helps to overcome some of the difficulties associated with a popular confusion that the absence of risk taking behaviour and internalizing or externalizing symptoms is synonymous with positive development (Lerner et al., 2009). Seen as more holistic, salutogenesis allows us to pay attention to all young people. As such there is congruence with the idea of proportionate universalism, which recognises that health actions need to be universal (to all people) but with a scale and intensity that is proportional to the level of disadvantage or vulnerability (Marmot, 2010). The central construct of salutogenesis – sense of coherence (SOC) - adds strength to it as a theory at the descriptive level. SOC is described as a ‘global orientation’ (Antonovsky, 1987) that comprises an array of significant factors that help to explain an individual´s ability to do and feel well in life.SOC includes three interrelated dimensions: the ability to find order and structure in life (comprehensibility), the confidence in the ability to deal with life demands successfully (manageability) and a view of life that is meaningful and worthy of commitment and engagement (meaningfulness). SOC relates to other prominent concepts and theories in the explanation of individual differences in wellbeing. For example, SOC is linked to the importance attributed to cognitive appraisals for successful coping (Lazarus and Folkman, 1984) as well as to the concepts of self-efficacy and coping styles (Amirkham and Greaves, 2003; Posadzki et al., 2010). In addition, Antonovsky (1987) acknowledged himself that meaningfulness is quite similar to Frankl´s concept of purpose in life (Frankl, 1962). SOC’s relation to other similar concepts which have been shown to have an association with wellbeing may be a strength. Morgan and Hernán (2013) suggest that SOC could be seen as a supra-order asset that operates by increasing the ability to mobilize internal and external resources for wellbeing. However, whilst the aforementioned links to other constructs support the relevance of SOC, the overlaps present a challenge to understand its unique benefits. Geyer (1992) saw this as one of the main criticisms of the SOC construct. A helpful starting point for the assessment of similarities and differences between salutogenesis and other positive constructs is to map them. The salutogenic umbrella by Eriksson and Lindstrom (2010) is helpful in this respect. The umbrella identifies 21 other concepts or theories that have the potential to explain health and quality of life. Eriksson and Lindström (2010) and others (e.g., Almedon, 2005; Lundman et al., 2010) have made head way into assessing the extent of overlaps among some of these constructs but it is fair to say that much work remains to be done to test the uniqueness of the different concepts empirically (Konttinen, Haukkala and Uutela, 2008). Therefore, investigation of the interrelationships between SOC and other key constructs in the study of wellbeing, such as optimism, emotional regulation, mindfulness, etc. should be a priority. Clarifying to what extent SOC is different (or similar) to these constructs is a prerequisite to unravel how they interact to promote wellbeing amongst young people. Such work would facilitate making progress in the other aspects assessed in this paper: explanation, prediction and measurability. Salutogenesis and explanation Substantial progress has been made in documenting the associations between salutogenesis via its central construct of SOC and wellbeing. Numerous studies over recent decades have provided evidence of SOC’s positive contributions to wellbeing and quality of life in general populations (Eriksson and Lindström, 2006, 2007). Whilst less research has being carried out amongst young people (Rivera et al., 2013), there is some evidence that has shown similar associations between higher levels of SOC and significant positive outcomes such as greater subjective wellbeing (García- Moya et al., 2013c; Mosknes et al., 2013). Gaps in the evidence base exist that could afford better understanding of the mechanisms underpinning the aforementioned links between SOC and wellbeing. In this regard, Antonovosky’s (1987) original formulation of salutogenesis pointed to three possible pathways: (1) that a high SOC may make individuals less likely to perceive life demands as stressful (direct effect); (2) that SOC may act as a mediator between stressful situations and coping; and (3) that SOC may act as a moderator, i.e. buffering the potentially negative consequences of stressful situations in health (Antonovsky, 1987). Some associational evidence does exist to support the first of these pathways. For example, analyses of the HBSC study have shown that high-SOC adolescents seemed to be less prone to perceive school life as stressful (García-Moya et al., 2013d; Torsheim et al., 2001). This mirrors evidence from the adult literature which demonstrated that high-SOC adults tended to report a lower number of negative life events (Volanen et al., 2007). Establishing causality seems to be the next logical step. 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