1.8 Models of health care delivery: the salutogenic model
Whereas pathogenesis (the way disease processes develop) underpins the biomedical model, the concept of positive health, or salutogenesis, focuses on how and why people stay well. Salutogenesis can be seen either as a model in its own right or as an example of the biopsychosocial approach (Antonovsky, 1979, 1987). Antonovsky's salutogenic model was designed to advance understanding of the relationship between stressors, coping and health, with the aim of explaining how some individuals remain healthy despite stressors in their everyday life.
Unlike previous health research on stress, which looked at different kinds of stressors and the conditions most likely to lead to stress, Antonovsky's model highlights the inadequacy of pathogenic explanatory factors and concentrates on the adaptive coping mechanisms underscoring the movement to the healthy end of the ‘ease–dis-ease’ spectrum. Antonovsky proposed that generalised resistance resources (wealth, ego strength, cultural stability, social support) can promote a sense of coherence, which is central to people's ability to cope with stress. Antonovsky defines the sense of coherence as:
a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.
(Antonovsky, 1987, p. 19)
Antonovsky describes the substantive structure of the sense of coherence as comprising three components: comprehensibility, manageability and meaningfulness. These develop as people's experiences are influenced by consistency, balancing underload–overload and shaping outcomes respectively. Unlike concepts such as locus of control, self-efficacy and problem-oriented coping, the sense of coherence model is intended to be a construct that is universally meaningful and cuts across divisions of gender, social class, religion and culture.
A salutogenic model rejects the current tendency to hold individuals responsible for the fate of their health. It recognises that optimal functioning requires social stability, rewarding occupations and freedom from anxiety, stress and persecution. The salutogenic model stresses health as a balance: ‘an ecological process, within and without the individual’ (Fulder, 1998, p. 153). Thus, it has much in common with alternative models of health, which are discussed in the next section.