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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.13 no.34 Murcia abr. 2014




Current status of the salutogenesis in Spain. Fifteen years of research

Estado actual de la salutogénesis en España. Quince años de investigación



Ruano Casado, Luisa*; Mercé Valls, Elisa**

*PhD. Nursing Department. Faculty of Nursing and Podiatry University of Valencia. E-mail:
**Nursing. Lledó Centre for the Elderly. Castellón de la Plana. España.




After centuries with a pathogenic vision of care of health, in the 1970s the medical sociologist Aaron Antonovsky introduced a model of health that had become a concept established in the public health and the promotion of health, 'Salutogenesis', that proposes to understand health as a continuum between welfare and disease, instead of a vision where health and disease are mutually exclusive, by coinciding with the current approach of World Health Organization.
The main goal of this paper is to lead a review and analysis of its study and use in Spain, where it is progressively introducing with more than 10 articles, an European Conference, a Symposium with experts from all over the world, an European Seminar, the creation of a Salutogenesis Spanish Group and with a National Convention of Healthy-Salutogenics Universities among other activities.
Is necessary to work from the public health policies, in coordination with the health services and education, highlighting the importance of the universities, in order to train future professionals from the active view of health promotion.

Keywords: Public health; Health promotion; Salutogenesis; Sense of coherence; Training.


Tras siglos de visión patogénica del cuidado de la salud, en los años 70 el sociólogo y médico Aaron Antonovsky introdujo un modelo de salud que con los años se ha convertido en un concepto establecido en la salud pública y la promoción de la salud, la 'Salutogénesis', que propone entender la salud como un continuo entre bienestar y enfermedad en lugar de una visión en que salud y enfermedad se excluyen mutuamente, coincidiendo con el actual enfoque de la Organización Mundial de la Salud.
Este trabajo tiene como objetivo principal realizar una revisión y análisis de su estudio y utilización en España, donde va introduciéndose de forma progresiva, con más de 10 artículos publicados, una conferencia europea, un simposio con expertos de todo el mundo, un seminario a nivel europeo, la creación de un grupo español de salutogénesis y con un convenio nacional de Universidades Saludables-Salutogénicas.
Es necesario trabajar desde las políticas públicas de salud, en coordinación con los servicios sanitarios y en la formación, remarcando el peso de las universidades, para capacitar a los futuros profesionales de enfermería desde la visión activa de promoción de la salud.

Palabras clave: Salud Pública; Promoción de la salud; salutogénesis; sentido de coherencia; capacitación.


1. Health promotion and the birth of salutogenesis

Since 1946, when the Magna Carta for world health (Constitution of the World Health Organization) was signed, and Health was defined as a state of complete physical, mental and social well-being and not merely the absence of disease or illness many important milestones regarding Health Promotion have taken place, among which we could cite the Lalonde report (1974), the first International Conference on Primary Health Care (1978), or the First International Conference on Health Promotion in Ottawa (1986), where production was synthesized so far, and represented the consensus reached by representatives attending from 35 countries. Five action areas for health promotion were identified in the charter: building healthy public policy, creating supportive environments for health, strengthening community action for health, developing personal skills, and reorienting health services, recommending community participation in the decision-making processes in the planning and implementation of health activities.(2)

Parallel to these events, in the 1970s, the physician and sociologist Aaron Antonovsky, developed his theory of health, called 'Salutogenesis' from studies that included survivors of the Holocaust, in which he found that, after having suffered the horrors of this war, many of them, not only recovered and survived, but thrived. Antonovsky suggested that there must be factors that create health.(3,4)

In 1992, the underlying theories of research of health promotion were discussed at a seminar held at the WHO Regional Office in Copenhagen. Antonovsky attended this workshop and introduced his model as one direction for health promotion(5). This model proposes that the objective of health research should be to identify, define and describe the routes, factors and causes of positive health to complement our knowledge about how to prevent, treat, and manage our health from the biomedical model focused on the discovery of the reasons and precursors of disease and the identification of risk factors for diseases(3, 4).

Salutogenic theory has not been as used as expected, despite its theoretical similarities with the essence of the Ottawa Charter(6) partly due to the fact that the approach to health that has been adhered to for many years tends to value and study everything that can harm us or make us sick, but not anything that can be healthy. The negative definition of health, as the absence of disease, is barely operational, forcing us to differentiate between "normal" and "pathological" (the difference is not always possible, and is influenced by the concept of variable "normal)(7).

This model has received more attention in recent decades and is being used in different fields such as prevention, public health, neurology and psychotherapy among others, focusing on humans and human rights.

Every person becomes an active and participating subject. The task of health professionals is to support and offer options, to point out the major determinants of health, raising awareness and empowering people to use them(8, 9)

In 2007, the thematic working group on Salutogenesis was established in the International Union for Health Promotion and Education (IUHPES), during the 19th World Health and Education Promotion Conference, in Canada. The first international research seminar was held in 2008 in Helsinki, Finland. Since then, there have been a range of other seminars and congresses(10)

Despite the publication of over 500 articles, a number of seminars and conferences held in different parts of the world related to the model, it appears that in Spain, scientific production and policies used to date are scarce. For this reason, the main objective of this study is to conduct a review and analysis of the study of Salutogenesis and how it is applied in our country.


2. Methodology

Databases of MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Psycinfo, Cochrane Library Plus, VHL (Virtual Health Library), TESEO, CSIC (Consejo Superior de Investigaciones Científicas), Knowledge Management and Dissemination Web Portals such as Dialnet and libraries of several Spanish universities were consulted.

The search strategy for English databases, MEDLINE and CINAHL was developed with descriptors Medical Subject Heading (MESH) "Spain", "Sense of coherence" combining descriptors with AND. The same descriptors were used in all other English-language databases. All items are included without restriction regarding the dates of publication for all international databases. Regarding the Spanish-language databases, in BVS the Health Sciences Terms Descriptors (DeCS) used were "sentido de coherencia", "promoción de la salud" and "salud pública" and we used the free terms "España", "salutogénesis", "Antonovsky" "sentido de coherencia" and "orientación salutogénica", using several combinations in the other databases.


3. Results

3.1 Articles and papers on salutogenesis published in Spain

In 1997, a paper analyzing the relationship between health, sense of coherence, resistant personality and self-esteem was presented, with many correlations found between these and their respective components. The 29 item version of Antonovsky's sense of coherence questionnaire (SOC) was translated and adapted to the Spanish language (4), with internal consistency requirements in its three components. That was the first psychometric characteristics report of the questionnaire in Spain (11).

In 1999, the role of the SOC as a mediator between stress and burnout syndrome at work and perceived health was studied in 115 school teachers, using the same questionnaire version. It concluded that SOC played, depending on their level, the role of inhibitor or facilitator of stress, burnout and perceived symptoms, specifically considering the dimensions of the construct(12).

Subsequently, in 2006, the relationship between the variables involved in the adaptation stress process in caring for a child with autism was discussed, with a sample of 39 mothers. They used the 29 items SOC questionnaire. Support and SOC had a direct and negative relationship with stress, acting as a moderator variable. However, the direct and negative relationship between stressor and SOC suggested that when the severity of the disorder and behavioral problems increased, a fall in SOC levels took place. Regarding the relationship between SOC and support, there was a theoretical direct relationship, but it was not significant in the empirical contrast(13).

In 2007, the acceptability, internal consistency, scaling assumptions, factorial structure, construct validity and accuracy of Antonovsky's 13 item sense of coherence questionnaire (OLQ-13,) was studied and analyzed in 419 elderly Spanish people (70 years). Optimal data reliability and new contributions of convergent validity of the SOC, with self-reported physical health measures, quality of life and depression, concluded that the OLQ-13 is a valid and reliable scale for use with elderly Spanish people, including groups with low educational levels(14).

Also in 2007, another study was conducted with students of the Ponferrada University College of Health Sciences, at the University of León, to check the reliability of the SOC questionnaire in health sciences students and ascertain the relationship between sense of coherence and their psychological health. The sample consisted of 261 students. They used the SOC-13 questionnaire. They found a high sense of coherence values and a statistically significant relationship between sense of coherence and psychological health(15)

In 2008, in the University of Oviedo, the relationship between health and personality dimensions and the sense of coherence, in fibromyalgic patients was analyzed. In this report, the authors reported using the SOC-29 questionnaire, the results showed an unstable sense of coherence in fibromyalgic patients (n = 60) in contrast to rheumatoid arthritis patients (n = 14) and healthy controls (n = 13). The patients with fibromyalgia stood out for their lesser ability to perceive how intelligible problems are (comprehensibility), that resources to control them were available (manageability) and that problems were worthy of investment and engagement (meaningfulness) and, after the results, alleged that patients with fibromyalgia had personality traits and beliefs of control that could not work properly, thereby favoring the onset of disease and altering their subjective perception of it(16) .

In 2011, a study whose main objective was to determine the relationship between physical activity, health and sense of coherence was published, with a sample of 80 adults over the age of 60 who were self-perceived as healthy and who were daily attendees of a special elderly day center for participation in several kinds of activities. Two questionnaires, one of which was the SOC questionnaire, were applied. The results indicated that the majority of those interviewed, even when they had any chronic degenerative disease, were self-perceived as healthy. People who practiced a physical activity, showed a statistically significant greater sense of coherence than those who did not(17).

The same year, burnout syndrome related to resistant personality and sense of coherence was researched in order to determine if these could be understood as predictors of burnout. A descriptive and transversal study was performed. 144 intensive healthcare workers answered the Spanish adaptation of the Orientation to

Life Questionnaire (OLQ-13)(13). They detected a medium-high degree of burnout among the participants and a negative correlation between resistant personality and burnout. Regarding SOC, resistant personality and comprehensibility, a sense of coherence component was modulating the effects of work stressors on burnout syndrome(18) .

In 2012, a study on the influence of some families' dimensions of the sense of coherence (SOC) in adolescence, controlling for the possible effects of demographic variables, gender and age, was published. The influence of neighborhood in SOC development was studied with the same population. The final sample, in both studies, consisted of 7580 adolescents between the ages of 13 and 18 who were administered the SOC-29 questionnaire. In the first study, results showed that there were no significant differences in relation to gender in the levels of SOC, but there were by age. It also suggested that the family context plays an important role in providing meaningful experiences for the development of a strong SOC in adolescence and the second study showed the importance of social relationships, a safe neighborhood, and the availability of suitable places (recreational) to meet with neighbors entailed benefits in SOC(19,20)

3.2. Reviews

In 2009, five articles were reviewed, none Spanish, about the knowledge of the role played by sense of coherence in the workplace. While the results of previous studies indicated their relationship, they concluded that the research available is rather unconvincing, with the performance of longitudinal studies being necessary.(21)

In 2010, a review was published which related assets model, positive health, resilience and Salutogenesis, especially in children and adolescents, presenting the feasibility of generating a map of assets, based on the potentialities and the interests of the community, as an alternative to traditional health diagnostics based on deficit. They showed the differences between the theories and the practice based on a deficit model of care and health promotion models(22).

In 2011, a review was released of the articles and papers published to that date, using the SOC questionnaire in Spain. The review studied the model's status in the country, its evolution through history and its relationship with other health promotion theories, and included a breakdown of the model's components and the relationship of this approach to life, health, quality of life and its implications and challenges for public health(23).

In 2012 a review including 5 descriptive studies and one systematic review of 15 papers, none conducted in Spain, presented the relationship between Salutogenesis and employed and unemployed nurses. The SOC related to mental health, well-being and quality of life was shown as a protective factor against the working environment stressors and the difficulties of work-life balance high level jobs and was associated with health problems such as depression or burnout and certain personality characteristics in low level jobs(24)

3.3. Posters

In the IV Research Seminar on Salutogenesis (2011), a poster whose objective was focused on a multi-dimensional analysis of family quality of life (FQL), based on a model which proposes that the adaptation depends on the interrelationships between child characteristics, social support, the perception of the problem (sense of coherence) and coping strategies, was submitted. The sample consisted of 59 fathers and 59 mothers. Empirical data were consistent with the theoretical model and there were gender differences. SOC was significant in the adaptation as a moderator of the effects of child behavior problems in family quality of life()

At the same seminar, another Poster showed a Health Plan, based on the principles of salutogenesis, that had been drawn up by the Health Council of the Regional Government of Andalusia. It showed The Andalusian School of Public Health (EASP) as one of the leading Spanish institutions in the knowledge management of the salutogenic model, developing research of salutogenic knowledge and the establishment of strategies for training health professionals(26)

3.4. Thesis and dissertations

In 2009, a European dissertation was submitted at the Polytechnic University of Madrid. It developed and evaluated a program based on principles and methods of psycho-social action and therapy through sport and movement, games and participatory and group techniques. The sample consisted of 56 indigenous women from two groups of rural areas immersed in a context of violence and conflict, in the Sololá Department, Guatemala, C.A. The sample consisted of 508 people. They employed the SOC-29 version with the reference sample (n = 452) and the SOC-13 version with the pre and post intervention sample (n = 33). The analysis showed a personal improvement in cognitive and psychological resources. Self-esteem and sense of coherence (especially 'comprehensibility') increased significantly and there were differences between the two intervention groups(27).

In 2009, in a further dissertation, presented at the University of León, the relationships between psychological health, stress, sense of coherence, dimensions of personality and self-esteem, emotional exhaustion and coping were analyzed in 960 students. To measure the sense of coherence, a different version of the SOC-13 validated by Virués-Ortega et al.(19) was used. It showed good psychometric properties, confirmation of the three-dimensional structure and a statistically significant relationship in connection with coping, stress level, coping level, emotional stability, neuroticism, extroversion and psychoticism(28)

In 2010, in a thesis prepared at the University of Gerona, SOC level was studied in 55 nursing professionals employed at four local primary health care centers (CAP) using the SOC-13 questionnaire(19). The SOC was moderate-high, the highest compared to similar studies, but not statistically related with other variables(29)

3.5. Seminars, conferences and congresses

In 2010, from 27 to 28 January, a seminar for health prevention experts took place in Granada. There the relationship between young people and health, the approach of Salutogenesis in childhood and adolescence, and the relationship between personal, family, school and social health variables, following the results of the HBSC study (Health Behaviour in School-aged Children) about school health-related behaviors, were discussed. Dr. Lindstrom, spoke about the difficulty of physicians to change the vision and join life to health, and not to diseases and death(30).

In April 2010, in Seville, the symposium 'Health Assets for Young People's Wellbeing' was held. The main objective was to contribute to the promotion of the assets model for young people's welfare, highlighting the actions required by researchers, policymakers and professionals for it to become a reality(31).

From 28 to 29 June 2010, the Conference ' Mental Health and well-being in Older People - Making it Happen' took place in Madrid. It was concluded that there will be a greater number of older workers and retirees due to demographic change in the European Union and better policies are required for ensuring good mental health and well-being of this population, promoting active partnerships, collaboration and exchange networks. It was proposed that salutogenic principles should be applied in professional practice, including the participation of older people themselves in policy development and practice(32).

3.6. Health promoting policies

In 2011, with the salutogenic theory and the assets model as guides, the Interior Ministry created a Guide for Mental Health Promotion in Prisons. It proposed the adaptation of people to the challenges of life in prison and the improvement of their sense of coherence through comprehension, manageability and meaningfulness: making what they do satisfactory and valuable, generating health through relationships and social spaces within the prison, modifying the environment, redirecting services and health care towards welfare, despite the many "punishment-obstacles" that exist in a penitentiary context(33).

On October 10, 2011, the framework agreement for the development of the Spanish Network of Healthy Universities (REUS) was signed, considering them as an ideal framework of labor, social and cultural activity, viewing health from a salutogenic stream, involving not only the resources to achieve health education and promoting the health of its workers and students, but also to integrate health and well-being in the university culture, processes and in the global university system(34). Simultaneously, over the past several years, the Andalusian Network (RAUS), the Catalan Network (RED CAT) and the Madrid Network of healthy universities (REMUS) began to operate.

In Gerona, in July 2012, the start-up meeting of the Salutogenesis Working Group, with the support of the Health Promotion Chair and linked to the Global Working Group of the International Union of Health Promotion and Health Education (IUHPE), was established. The main objective was to share experiences, publications and documents with salutogenic working groups in Spain and Latin America, coordinated by the Research Health Promotion Group, of the Folkhàlsan Research Center (Finland)(35).

In 2012, in the Declaration of Girona, it was stated that to reformulate the way of understanding and promoting health, our gaze must be shifted towards the salutogenic and assets approach. A global, cross-sectorial and local action strategy and an invitation to different stakeholders to participate, from a range of healthy scenarios, including the digital environment, in the development of healthy policies where the healthy choice is the easy choice, and in raising awareness by placing the human being at the core of healthy public policies(36).

3.7. Programs and activities

In Asturias a map of health assets of the province is being developed since 2009. It began in the Participation and Community Health Activities Workshops, in 2009, by initiating a process to collect information from several community health activities, establishing a database (called Asturias Act, integrated in the Asturias Health Observatory) involving 101 activities. Along with Partycipa, some community mapping has been initiated in certain parts of Asturias(37).


4. Conclusions

In Spain, scientific production regarding the salutogenic model, albeit in a fledgling state, has taken relevant steps, such as the adaptation of both versions of the SOC questionnaire in the Spanish population. Studies so far, with varied population samples, have been focused on academic and social contexts and health policies, as well as programs and activities that are currently being implemented and are still incipient, but appear to have a hopeful future.

With regards the future, the systematic development of salutogenic indicators in the public health field and the strengthening of the perspective of promoting health is necessary to develop, educate and train professionals and patients and encourage academic and professional groups to research and report on effective salutogenic practice, as noted in the European Health Development Model (EUHPID). (38) At the same time, as stated by Dr. Lindstrõm, a salutogenic-based health policy brings about economic benefits, since people who enjoy good mental health and quality of life due to a good level of SOC, are sick less often and therefore suffer less from disability and retire less often due to illness. It is therefore necessary for professionals to be trained in the implementation of this type of salutogenic-based policy, alleviating in turn the difficulties of the physicians, and promoting change towards a conception of life with health, and not with disease and death(30).

The first pillar, where building of this new vision of health promotion should begin, is the education, training, and motivation of social and health sciences students in general, and nursing in particular, in the use of reflexive and critical thinking and active participation in their learning process.


5. References

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