WHAT IS SALUTOGENESIS?

WHAT IS SALUTOGENESIS?
The Royal College of Midwives
15 Mansfield Street, London W1G 9NH
http://www.rcm.org.uk
The term salutogenesis will be new to many people, what follows is an explanation both of
the original concept and how it can be applied to birth.
Salutogenesis is a concept created by the medical sociologist Aaron Antonovsky to refer to a
new approach to health promotion and needs assessment. Salutogenesis examines the creation
of wellbeing by looking at successful coping strategies and health. In this respect the
Salutogenic orientation is opposed to the pathogenic orientation underpinning the biomedical
and NHS worlds, which focuses on the particular diagnosed disease entity. Salutogenesis
examines the underlying social constructs, the broader picture, in order to both define the
health problem and to search for coping resources or mechanisms.
This holistic view of health and illness is not new but Antonovsky proposes a new research
concept and health promotion tool for those working in public health, such as health visitors
and midwives. Salutogenesis also lays the foundations for a new discourse on how to tackle
the increasing inequalities in the health of our nation.
Holistic healthcare
Antonovsky advocates the idea that one cannot have a concept of the individual that is
without a social or historical perspective - people do not exist in a vacuum. All too often
biomedicine seeks to find a cure in total isolation of all the hundreds of factors which
influence disease, illness and health and which are very often non-biological in nature.
Salutogenisis in its basic form seeks first to understand and deal with all that is creating
disorder in a person's life (i.e. the root cause of the problem). It then seeks out those forces
which promote order and influence a person, their family, and then the wider community in
which the family lives. Salutogenesis looks at health and how to promote it, not illness and
how to cure it. Health is regarded as a process in flux that is negotiated by people throughout
their lifetimes. Some are good negotiators, others bad. It is a process intertwined with and
shaped by socio-cultural factors of the individual, their family, and their community.
Coping resources
The health of a person depends on their ability to cope and the supports or resources they can
turn to for help. The resources a person draws on in times of need act as,
"buffering, ameliorating or mediating mechanisms, thought of as blunting the invariably
negative impact of stressors and thus preventing breakdown" 1
These resources can be internal such as self-esteem, the cognitive ability to learn how to
cope, for example with a new baby; or they can be external, such as the local environment
and cultural influences. These internal and external resources are sometimes interchangeable
and a person accumulates them through life experiences from childhood onwards.

Sense of coherence: sense of wellbeing
Collectively, resources promote the development and maintenance of a strong 'sense of
coherence', which is synonymous with health. The stronger the sense of coherence a person
has, the better ability they have to employ cognitive, affective and instrumental strategies
which are likely to improve coping 2 and thus wellbeing. There is not one coping strategy but
many, and a person who copes well, who has a strong sense of coherence, is able to select the
best way of dealing with the particular stressor. Each person's sense of coherence, or sense of
wellbeing, requires certain inherent prerequisites for coping successfully, as follows:
1) Meaningfulness: the deep feeling that life makes sense emotionally; that life's
demands are worthy of commitment. It is essentially seeing coping as desirable.
2) Manageability: the extent to which people feel they have the resources to meet the
demands, or feeling that they know where to go to get help.
3) Comprehensibility: the extent to which a person finds or structures their world to be
understandable, meaningful, orderly and consistent instead of chaotic, random and
unpredictable. 3
The extent to which a person develops these prerequisites - the extent to which a person has
pervasive, enduring and dynamic feelings of confidence that things will work out as well as
can be reasonably expected - is determined by that person's sense of coherence. 4 This is
firmly grounded in the person's own context and culture and Antonovsky emphasises that a
person's socialisation is fundamental to how a person sees the world and how strong their
sense of coherence will be. For this reason salutogenesis considers social and health capital as
determining factors in the creation of a sense of coherence.
Social capital can be described as levels of reciprocity in the community, trust, co-operation
and social cohesion. Health capital are those factors which influence health and could include
socio-economic background, childhood history and coping skills.
From theory to practice
The possible conclusions from Antonovsky's work are that one can expose a child to life
experiences which will contribute to a strong sense of coherence and therefore increase that
child's overall wellbeing. Although he feels it is less likely to be able to successfully
intervene in adult perceptions of health and coping strategies, others would say it is possible
to maximise their resources and accessibility to a strong sense of coherence and thus
wellbeing.
Antonovsky's theory postulates that health visitors should be given the resources to
experiment with salutogenesis in a public health promotion facet. This will contribute greatly
to a NHS which is conversing only in disease and clinical rhetoric.
Salutogenesis is a research tool which can be used as a starting point by all those concerned
with promoting health. By being able to understand how people manage their health, what
resources they use (they could be negative, for example a neighbour may suggest adding
alcohol to milk to pacify a baby) and then working to increase that person's positive
resources. This may then extend to working with people in the community, from housing
planners, social workers to community groups. This is the essence of salutogenesis; that
experts should be open "to what is going on in seemingly unrelated fields in an attempt to
2

consider the underlying problems shared by many, and, above all to learn from coping
successes" 5 in order to improve health.
Salutogenesis applied to birth
Used in the context of birth, salutogenesis would recognise women and their ways of seeing
and of birthing. It would entail respect for the subtle hormonal interaction between mother
and infant, which is intrinsic and essential to the wellbeing of both in the future.
A salutogenic birth would generate positive short and long-term wellbeing for the mother,
baby, family and caregiver. It would follow the same pattern of assessing a woman's
resources, sense of coherence and thus wellbeing. Fundamentally, instead of looking at 'risk
factors' it would look at health factors. It is acknowledged that although the concept of
salutogenesis is not immediately user-friendly, its components are essentially applicable to
the maternity service. 6
Downe argues the concept is, "fundamentally both a descriptor of a normal birth process and
an outcome of that birth process". And equally importantly, includes "the possibility that the
small number of women who may need technological help could birth positively if the
presence" of manageability, comprehensibility and meaningfulness for each woman is held to
be the measure of optimum birth. 7
The theory can fit easily with birth because it is about the promotion of wellbeing - 'health
creation'. It also goes some way to examine why certain sectors of society are disadvantaged
in their health-seeking options and the care they receive. By looking at the process by which
people draw on their internal and external resources, midwives will be able to ascertain why
their health and that of their baby is suffering. They can also work in a public health role to
increase a woman's resources - manageability and meaningfulness and overall wellbeing. It
will also influence a woman's ability to adapt to motherhood and to be a competent parent. In
a way it is helping to empower women - not treating just the clinical but the social, economic,
political, personal factors which this theory postulates determine the resources a woman can
draw on to both promote health and combat illness.
References
1. Antonovsky A (1993) The implications of salutogenesis: an outsiders's view. In: Turnbull
AP, Patterson JM, Behr SG et al (eds.) Cognitive coping: families and disability. Baltimore:
Brookes
2. ibid.
3. Colorado State University Counseling Center: Stress Management Services. Effective selfhelp
for stress (http://www.colostate.edu/Depts/Counseling/SMP/ezstress.htm)
4. Cowley S, Billings J (1999) Resources revisited: salutogenesis from a lay perspective.
Journal of Advanced Nursing 29(4): 994-1004
5. Antonovsky A (1993) The implications of salutogenesis: an outsiders's view. In: Turnbull
AP, Patterson JM, Behr SG et al (eds.) Cognitive coping: families and disability. Baltimore:
Brookes
6. Downe S (2001) Defining normal birth. MIDIRS Midwifery Digest 11(Supp 2): S31-3
7. ibid.
May 2002
Royal College of Midwives
Virtual Institute for Birth: Salutogenesis in support of normality
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