Future Perspectives of Health

Care: Closing Remarks

26
Gørill Haugan and Monica Eriksson

Abstract demand the health care services to reorient in

a health promoting direction.
The Covid-19 pandemic has demonstrated the
The IUHPE Global Working Group on
vulnerability of our health care systems as
Salutogenesis suggests that health promotion
well as our societies. During the year of 2020,
competencies along with a reorientation of pro-
we have witnessed how whole societies glob-
fessional leadership towards salutogenesis,
ally have been in a turbulent state of transfor-
empowerment and participation are required.
mation finding strategies to manage the
More specifically, the IUHPE Group recom-
difficulties caused by the pandemic. At first
mends that the overall salutogenic model of
glance, the health promotion perspective
health and the concept of SOC should be further
might seem far away from handling the seri-
advanced and applied beyond the health sector,
ous impacts caused by the Covid-19 pan-
followed by the design of salutogenic interven-
demic. However, as health promotion is about
tions and change processes in complex systems.
enabling people to increase control over their
health and its determinants, paradoxically
Keywords
health promotion seems to be ever more
important in times of crisis and pandemics. Health promotion · Pandemics · Non-
Probably, in the future, pandemics will be a communicable diseases · Reorienting the
part of the global picture along with the non- health-care services · Salutogenesis · Salutary
communicable diseases. These facts strongly factors

G. Haugan (*)
Department of Public Health and Nursing, NTNU 26.1 Future Perspective
Norwegian University of Science and Technology,
Trondheim, Norway
The present condition gives us directions in which
Faculty of Nursing and Health Science,
Nord University, Levanger, Norway to look forward; the year of 2020 is the year of the
e-mail: [email protected], Covid-19 pandemic. Lately, entire cities, regions
[email protected] and countries have been sealed off, travelling has
M. Eriksson been banned, universities have been closed, along
Department of Health Sciences, University West, with shops, restaurants etc. all over the world. We
Trollhattan, Sweden have witnessed that economic, cultural and social
e-mail: [email protected]

© The Author(s) 2021 375

G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_26
376 G. Haugan and M. Eriksson

activities have come to a stop, resulting in big whole societies are in a turbulent state of transfor-
challenges to a great number of people around the mation in need of ways and strategies to manage.
globe. Thus, health concerns have become the To return to the health care sector, the IUHPE
prevailing concern that takes precedence over all Global Working Group on Salutogenesis states in
other issues. In the years to come, the health ser- a position article that one way is to position health
vices globally will need to collaborate on han- promotion competencies as an essential framework
dling pandemics such as the Covid-19 pandemic to reorient health care services [3] (p. 9). In addi-
ruling the world during the writing process of this tion, the professional leadership must be reoriented
book. Facing the serious impacts caused by the towards salutogenesis, empowerment and par-
Covid-19 pandemic, at first sight, this pandemic ticipation. To move forward with the concept of
and the world’s response to it might seem far salutogenesis as a sound scientific base for health
away from the health promotion perspectives. promotion, some suggestions have been given:
However, in a recently published Editorial in
Health Promotion International, Van den Broucke 1. To advance the overall salutogenic model of
[1] (p. 181) highlights the important role of health health
promotion in the time of crisis and pandemics by 2. To advance the concept of SOC
saying “…Enabling people to increase control 3. To define and design salutogenic interventions
over their health and its determinants is at the and change processes in complex systems
core of health promotion. As such, health promo- 4. To apply salutogenesis beyond the health
tion may paradoxically be more important in this sector [3]
time of crisis than ever before”. Probably, in the
future pandemics will be a part of the global pic-
ture along with the so-called non-communicable 26.1.1 Advancing the Overall
diseases (NCD) which covers chronic illnesses Salutogenic Model of Health
such as cancer, dementia, heart failure, diabetes as
well as mental health issues. In this book, we have The IUHPE Group states that the salutogenic
highlighted the need of health promotion as an model of health needs an additional positive
integrated aspect of the treatment and care of health continuum and a path of positive health
patients with various NCDs. NCD Countdown development linking resources to this new con-
2030 [2] is an independent collaboration to inform tinuum [3]. During the last decades, a broader
policies that aim to reduce the worldwide burden literature on the ease-end of the health con-
of NCDs, and to ensure accountability towards tinuum has emerged emphasizing among oth-
this aim. In 2016, an estimated 40.5 million (71%) ers the importance of developing individuals’
of the 56.9 million worldwide deaths were from personal potential and functioning, supporting
NCDs. Of these, an estimated 1.7 million (4% of people’s perception of self-fulfillment, purpose
NCD deaths) occurred in people younger than and meaning-in-life, thriving, social attractive-
30 years of age, 15.2 million (38%) in people ness and making a valuable contribution to soci-
aged between 30 years and 70 years, and 23.6 mil- ety [4–6]. Considering these developments, the
lion (58%) in people aged 70 years and older. An IUHPE group recommends the addition of a pos-
estimated 32.2 million NCD deaths (80%) were itive health continuum to Antonovsky’s original
due to cancers, cardiovascular diseases, chronic salutogenic model [3]. Furthermore, the IUHPE
respiratory diseases, and diabetes, and another 8.3 Group underscores the importance of linking
million (20%) were from other NCDs [2]. These resources to this new continuum of positive health
facts strongly demand the health care services to development; “…Resources not only immediately
reorient in a health promoting direction. As Van help people to cope better with stress (and surviv-
den Broucke [1] argued in his editorial, the pan- ing). Also, over time personal and environmental
demic has shown how vulnerable health care ser- resources can help with recovery and healing…
vices may be, and not only the health care sector; Beyond healing and recovery, resources can
26 Future Perspectives of Health Care: Closing Remarks 377

directly promote health, wellbeing and thriving— grating key elements of salutogenesis should be
even in the absence of current or previous adver- developed [3]. Antonovsky stated that SOC [9] is
sarial life situations” [3] (p. 3). Consequently, formed by three kinds of life experiences: (1)
in line with the Health Development Model [7] consistency (strengthening comprehensibility),
which proposes that pathogenesis and saluto- (2) underload–overload balance (strengthening
genesis are two complementary perspectives on manageability), and (3) participation in socially
health development, GRRs and SRRs1 are seen to valued decision making (strengthening meaning-
facilitate and nurture positive health; thus direct fulness). Accordingly, further knowledge about
paths of positive health development have been these kinds of life experiences and how they can
added to the salutogenic health model [3]. be assessed (quantitatively and qualitatively) in
different contexts as well as on different system
levels are required [3] (p. 5). To reorient health
26.1.2 Advancing the Concept care, it is important to capture factors and initia-
of SOC tives that nurses along with other health profes-
sionals consider health promoting resources in
The second point underscores a need for advanc- their everyday clinical practice. We must learn
ing the SOC concept; many translations of the from their experiences and integrate this new
Orientation to Life Questionnaire (OLQ) and the knowledge in education for health professionals.
evidence on SOC have provided confidence that
the SOC construct is measurable. However, the
substance, content, wording and dimensional- 26.1.4 Applying Salutogenesis
ity of the SOC construct have yet to be explored. Beyond Health Sector
Research on SOC utilizing other methodological
approaches than Antonovsky used accompanied Finally, applying salutogenesis and SOC to other
by a replicability of Antonovsky’s qualitative anal- fields beyond the individual health issues might be
yses and findings are highly welcome [3] (p. 4). valuable as we can learn from other fields for health
Further, there is a need of developing new ques- research. For instance, intergroup relations are vital
tionnaires for measuring salutary factors for health in peoples’ daily life at work, in leisure, in the com-
and wellbeing. Some attempts can be found, for munities and the municipalities, etc. Therefore, we
example The Salutogenic Health Indicator Scale need to more fully examine the differential benefits
(SHIS) [8]. In Sweden, an ongoing research study and potential harm of SOC on the individual, group
has developed and tested a new scale, adapted for and intergroup as well as organizational and system
nurses’ work situation and to be used in health levels [3]. In a public health perspective, such
care, The Salutogenic Survey on Sustainable knowledge seems fruitful for the development of
Working life—Nurses (SalWork-N) (www.hv.se). health promoting workplaces, health promoting
hospitals, health promoting communities, munici-
palities, schools, kinder gardens, living areas, etc.
26.1.3 Salutogenic Interventions
and Change Processes
26.2 Health Promotion Is About
Thirdly, strengthening the SOC through health Thriving and Enabling
promotion intervention is key. Purposefully People to Increase Control
designed salutogenic interventions and change over Their Health
processes are needed; therefore, explicit saluto-
genic intervention theories building on and inte- The health promotion perspective as well as the
salutogenic theory of health is based in the idea
1
GRR = Generalized Resistance Resources; SRR = Specific that every single person has a health, which var-
Resistance Resources, central concepts in salutogenesis. ies and moves along the health continuum between
378 G. Haugan and M. Eriksson

dis-ease and ease. Antonovsky [9] (p. 14) raised book with the same figure (Fig. 26.1). Some of
the question: How can we understand movement the umbrella concepts are described in this book,
of people in the direction of the health end of the whilst some remain to be explored. However, to
continuum?’—note, all people, wherever they are our knowledge this book is the first one to high-
at any given time, from the terminal patient to the light and emphasize concepts closely related to
vigorous adolescent—we cannot be content with the sense of coherence (SOC) in general, and to
an answer limited to ‘by being low on risk factors’. health care systems in particular. There is a need
A salutogenic orientation, then, as the basis for to continue exploring other salutogenic concepts
health promotion, directs both research and action to strengthen the salutogenic theory, but also to
efforts to encompass all persons, wherever they are contribute to the development of nursing and the
on the continuum, and to focus on salutary factors. health sciences. Among others, concepts such as
Beyond survival, health promotion is about thriv- empathy, humour, learned optimism and learned
ing and enabling people to increase control over hopefulness, would be interesting.
their health [10]. The salutogenic model is useful Moreover, the implementation of the concepts
for all fields of health care and therefore helpful in and the salutogenic approach to health and well-
the reorienting of the health care services. being in a systematic way is highly needed. An
integration would benefit both staff and patients.
Such an effort could begin with an education, i.e.
26.3 A reorientation of Health salus education proposed in Chap. 15, continuing
Care by Implementing with a focus on learning processes to finally end
Salutogenesis with the development of a new way of working in
health care settings, which means that salutary
We started this book showing a figure (Fig. 1.4) factors are recognized, identified and used in a
describing the salutogenic umbrella adjusted for health promoting manner. In other words, reori-
health care settings. We also choose to end the enting the health care services according to the

Fig. 26.1 The salutogenic umbrella: theoretical concepts relevant to health care. (Reproduced with permission from
Folkhälsan Research Center, Lindstrom & Eriksson) [4]
26 Future Perspectives of Health Care: Closing Remarks 379

Ottawa Charter for health promotion. Already in study among hospital nurses explored salutary
the mid-1990s Antonovsky argued the saluto- factors for a sustainable working life [17]; having
genic orientation as the theoretical basis for fun at work, being acknowledged, feeling togeth-
health promotion, directing both research and erness in the team, having varying tasks with a
action efforts particularly useful for all fields of manageable workload, good interaction between
health care [9] (p. 18). The progress of new salu- colleagues and patients, doing good work, feeling
togenic models of health has been limited. An committed to and pride in the professional role,
attempt to fill this knowledge gap can be seen in and having a balance between work and leisure
an article on “The Synergy Model of Health”, time were found to be factors that made them
which integrates salutogenesis and the assets stronger, which in turn explained why they stayed.
model in a framework of Bronfenbrenner’s eco- Similar findings have been seen in Norway [18,
logical theory of human development [11]. 19]. Further research on salutary factors is needed.
When reviewing research on SOC we have
become aware of how limited the research on
working conditions of health care personnel is. 26.4 Closing Remarks
There is a lot of research by nurses and other
health professionals on different patient groups In this book, we have highlighted the need to
including measuring the SOC. However, saluto- work to promote health in both hospitals and the
genic research on how health professionals’ municipality health care; treatment and care of
health and wellbeing can be maintained and patients with chronic diseases and the so-called
developed is scarce. The same applies to knowl- non-communicable diseases (NCD) will be fun-
edge about health professionals’ SOC. For damental in the years to come. Our point of
instance, have nurses forgotten themselves in departure has been to focus attention on health
their quest to do good for the patients? We here promotion and salutogenesis in health care set-
argue that research must also focus on the work tings. We argue the salutogenic theory of health
environment and salutary factors for developing a to be appropriate to guide health promotion in the
sustainable working life for nurses and other health services. In a lecture at the Nordic School
health professionals. However, some attempts to of Public Health (NHV) Antonovsky lectured
fill this knowledge gap can be seen. A longitudi- about salutogenesis and health [20]. He called on
nal study on the influence of a health promoting to think salutogenically and act salutogenically.
work environment [12] as well as a study on To use his own words, “the key lies in a society
work-related SOC and its longitudinal relation- and in people who care about others” [20].
ship with work engagement and job satisfaction Nurses and the other health care professions are
[13] were recently conducted in Norwegian nurs- just such people who cares!
ing homes. Correspondingly, studies focusing on
the working culture in nursing homes have shown
empowerment, participation and influence over References
the work situation to be vital aspects for care qual-
ity [14, 15]. Moreover, SOC was newly measured 1. Van den Broucke S. Why health promotion matters
to the COVID-19 pandemic, and vice versa. Health
among Swedish hospital nursing staff [16]. They Promot Int. 2020;35:181–6.
found that on a national level, nurses reported 2. NCD Countdown 2030 Collaborators. NCD
weaker SOC than the general population, but Countdown 2030: worldwide trends in non-
stronger in an international comparison of nurses. communicable disease mortality and progress towards
Sustainable Development Goal target. Lancet.
Nurses found their work difficult to manage, but 2018;22(392):1072–88.
meaningful. Many nurses want to leave their 3. Bauer GF, Roy M, Bakibinga P, Contu P, Downe S,
workplaces and even the profession, as they found Eriksson M, et al. Future directions for the concept of
the work situation too stressful for their health. salutogenesis: a position article. Health Promot Int.
2019;2019:1–9.
This is a worldwide dilemma. Another Swedish
380 G. Haugan and M. Eriksson

4. Lindström B, Eriksson M. The Hitchhiker’s guide to employees: a longitudinal study on the influence of
salutogenesis. Salutogenic pathways to health promo- a health-promoting work environment. Nurs Open.
tion. Helsinki: Folkhälsan Research Center; 2010. 2019;6(4):1414–23.
5. Commers MJ. Determinants of health: theory, under- 13. Grødal K, Innstrand ST, Haugan G, Andre B. Work-
standing, portrayal, policy. Dordrecht: Springer; related sense of coherence and longitudinal
2002. relationships with work engagement and job satis-
6. Pelikan JM. Understanding differentiation of health in faction. Scand J Work Organ Psychol. 2019;4(1):
late modernity—by use of sociological system theory. 1–11.
In: McQueen DV, Kickbusch I, Potvin L, Pelikan 14. Andre B, Sjøvold E. What characterizes the work
JM, Balbo L, Abel T, editors. Health and modernity: culture at a hospital unit that successfully implements
the role of theory in health promotion. New York: change—a correlation study. BMC Health Serv Res.
Springer Scientific Publisher; 2007. p. 74–102. 2017;17:486.
7. Bauer GF, Davies JK, Pelikan JM. The EUHPID health 15. Andre B, Sjøvold E, Rannestad T, Ringdal GI. The
development model for the classification of public impact of work culture on quality of care in nurs-
health indicators. Health Promot Int. 2006;21:153–9. ing homes—a review study. Scand J Caring Sci.
8. Bringsén Å, Andersson HI, Ejlertsson G. Development 2014;28(3):449–57.
and quality analysis of the Salutogenic Health 16. Eriksson M, Kerekes N, Brink P, Pennbrant S,
Indicator Scale (SHIS). Scand J Publ Health. Nunstedt H. The level of sense of coherence among
2009;37(1):13–9. Swedish nursing staff. J Adv Nurs. 2019;75:
9. Antonovsky A. The salutogenic model as a the- 2766–72.
ory to guide health promotion. Health Promot Int. 17. Nunstedt H, Eriksson M, Ayman O, Hillström L,
1996;11(1):11–8. Truong A, Pennbrant S. Salutary factors explaining
10. WHO. The Ottawa Charter for health promotion: an why hospital nurses remain in work and the profes-
international conference on health promotion. The sion. BMC Nurs. 2020; in review.
Move towards a New Public Health. Copenhagen; 18. Hauvik S, Haugan G. The influence of rotation work
1986. on nursing home nurses’ health and quality of life.
11. Pérez Wilson P, Marcos Marcos J, Morgan A, Eriksson Geriatr Nurs. 2016;20(2):26–35.
M, Lindström B, Alvarez Dardet C. “The synergy 19. Hauvik S, Haugan G. The importance of the turn for
model of health”—an integration of salutogenesis nurses’ work situation and quality of life in nursing
theory and health assets model. Health Promot Int. homes. Geriatr Nurs. 2017;2017(3):5–13.
2020; in press. 20. Antonovsky A. Some salutogenic words of wisdom to
12. Grødal K, Innstrand ST, Haugan G, Andre B. Affective the conferees. Lecture held at the Nordic School of
organizational commitment among nursing home Public Health (NHV), 1993. Gothenburg.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license and indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter’s Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.