A salutogenic approach: Changing the paradigm
Johnathan Hewis
Abstract
In 1992 during the World Health Organisation's (WHO) first international seminar on health promotion, Anton Antonovsky [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar] employed a river as a metaphor for life whilst presenting his salutogenesis theory and model. He suggested that curative medicine was predominantly concerned with treating individuals “drowning” in the “river of life”, whilst preventive medicine focused purely on those pushed or falling in “upstream”. Antonovsky [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar] proposed that health promotion and healthcare more broadly, should instead refocus on the actual “river”, for “each of us, by virtue of living, is in the river, and none are on the shore” [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar]. The river being full of not only risks but also resources. “We are all, always, in the dangerous river of life. The twin question is: How dangerous is our river? How well can we swim?” [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar]. More than thirty years after Antonovsky's WHO address, Western healthcare systems face unprecedented challenges from chronic staff shortages [[2]Poon Y-S. Lin Y. Griffiths P. et al.A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions.Hum Resour Health. 2022; 20: 1-18PubMed Google Scholar] to spiralling waiting times [[3]McIntyre D. Chow C. Waiting time as an indicator for health services under strain: a narrative review.J Health Care Organ Provisi Financ. 2020; 57: 1-15Google Scholar], further compounded by the ongoing effects of the COVID-19 global pandemic [[4]Arsenault C. et al.COVID-19 and resilience of healthcare systems in ten countries.Nat Med. 2022; 28: 1314-1324Crossref PubMed Scopus (69) Google Scholar] and the increasing challenges of climate change [[5]Agache I. et al.Climate change and global health: A call to more research and more action.Allergy. 2022; 77: 1389-1407Crossref PubMed Scopus (23) Google Scholar]. Ironically, as a patient; healthcare can be a threatening and dangerous experience, with potential risks of side effects or complications, contracting a healthcare acquired infection, or longer-term psychological distress [[6]Panagioti M. et al.Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.Br Med J (Clin Res Ed). 2019; 366: 14185Google Scholar]. Equally, working as a healthcare practitioner can be physically, emotionally, and psychologically demanding and can commonly lead to detrimental problems such as physical injury [[7]Mavavei D. Clark K. Occupational injuries involving medical imaging and radiation therapy.Radiol Technol. 2020; 91: 422-430PubMed Google Scholar], compassion fatigue [[8]Hegel J. et al.The relationship between present-centered awareness and attention, burnout, and compassion fatigue in oncology health professionals.Mindfulness. 2021; 12: 1224-1233Crossref PubMed Scopus (8) Google Scholar] or burnout [[9]Shields M. et al.Burnout in the disciplines of medical radiation science: a systematic review.J Med Imaging Radiat Sci. 2021; 52: 295-304Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. As practitioners, we perhaps rarely consider the philosophical assumptions that ground and shape our world view and professional practice. Traditionally, Western healthcare has been dominated by the biomedical model, directed on understanding, preventing, and treating disease [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar]. ‘Health’ in the biomedical context can be defined as the absence of biophysical signs of disease where humans are dualistically (and overly simplistically) categorised “into those who have succumbed, temporarily, permanently or fatally to some disease” (‘unhealthy’ or sick) and the ‘healthy’ [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar]. Under this dualistic biomedical and pathogenic focused healthcare paradigm, our everyday lives have become increasingly medicalised, including areas such as fertility, childbirth, sleeping and ageing [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar]. Medicalisation is a reductionist tendency of healthcare to increasingly define and treat all aspects of our life as a medical issue viewed through a biomedical lens and framed in pathological terms [[11]Ballard K. Elston M. Medicalisation: a multi-dimensional concept.Soc Theory Health. 2005; 3: 228-241Crossref Scopus (120) Google Scholar]. Biomedical healthcare provision is typically fragmented and compartmentalised with a focus often on singular diseases and mirrored through medical specialisation and broader healthcare structures. Biomedical shaped healthcare is often highly mechanistic in nature, where the individual is studied and treated as isolated parts like components of a car being repaired in a garage. This mechanistic approach has been heavily influenced by the philosophical writing of Descartes who proposed the separation of mind and body (mind-body dualism) that went on to significantly shape the natural sciences in fields like psychology and medicine [[12]Cottingham J. Cambridge Texts in the History of Philosophy: Descartes: Meditations on First Philosophy: With Selections from the Objections and Replies.2nd ed. Cambridge University Press, 2017Google Scholar]. However, such dualistic thinking limits our ability to see the individual holistically [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar]. The patient journey through biomedical shaped healthcare is often one of navigation from one specialist to another, being treated in fragments or as a disease (or “diseased”) rather than as a person, and one where the individual can too often fall through gaps between specialisms or services. This fragmented and mechanistic model leads to objectification and dehumanisation of the individual [[13]Haque O. Waytz A. Dehumanization in medicine: causes, solutions, and functions.Perspect Psycholog Sci. 2012; 7: 176-186Crossref PubMed Scopus (236) Google Scholar]. The traditional patient role is often passive [[14]Diniz E. Bernardes S. Castrom P. Self- and other-dehumanization processes in health-related contexts: a critical review of the literature.Rev Gen Psychol. 2019; 23: 475-495Crossref Scopus (19) Google Scholar] with reduced or loss of agency [[13]Haque O. Waytz A. Dehumanization in medicine: causes, solutions, and functions.Perspect Psycholog Sci. 2012; 7: 176-186Crossref PubMed Scopus (236) Google Scholar]. Within MRS we are not immune to this dominating biomedical paradigm, it is transparent within our culture, function, organization, research, and education [[15]Ferris C Specialism in radiography – a contemporary history of radiography.Radiography. 2009; 15: 78-84Abstract Full Text Full Text PDF Scopus (9) Google Scholar,[16]Tornroos S. Leino-Kilpi H. Metsala E. Phenomena of radiography science – a scoping review.Radiography. 2021; 27: 1231-1240Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar. Our specialisations are highly technology focused and we are frequently guilty of using body parts or disease when referring to our patients or when organising our workload. The reality of being practitioners within this paradigm is that the biomedical model demands that we must actively attend and work on our empathy, compassion, and a holistic person-centred approach [[17]Taylor A. Bleiker J. Hodgson D. Compassionate communication: keeping patients at the heart of practice in an advancing radiographic workforce.Radiography. 2021; 27: 43-49Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,[18]Robertson S. England A. Khodabakshi D. Compassion fatigue and the effectiveness of support structures for diagnostic radiographers in oncology.J Med Imag Radiat Sci. 2020; 52: 22-28Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar. More broadly, health policy and research are dominated toward risk factors [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar,[19]Mittelmark M. Bauer G. et al.Salutogenesis as a theory, as an orientation and as the sense of coherence.in: Mittelmark M. The Handbook of Salutogenesis. 2nd Edition. Springer Open, 2022Crossref Scopus (14) Google Scholar, where the individual is held accountable for their health status and where medical interventions are targeted at individual behaviour [[1]Antonovsky A. The salutogenic model as a theory to guide health promotion.Health Promot Int. 1996; 11: 11-18Crossref Scopus (1375) Google Scholar]. The biomedical model has been criticised at times for seeking “magic bullet” solutions with a “one disease, one cure” approach [[20]Antonovsky A. Health, Stress and Coping.1979Google Scholar,[21]Fries C. Health health care: from sick care towards salutogenic healing systems.Soc Theory Health. 2020; 18: 16-32Crossref PubMed Scopus (13) Google Scholar where standardised treatments may be less effective in complex cases or do not account for individual variation and need [[21]Fries C. Health health care: from sick care towards salutogenic healing systems.Soc Theory Health. 2020; 18: 16-32Crossref PubMed Scopus (13) Google Scholar]. The pathogenic paradigm has in part contributed to a more business-like healthcare model with increasing focus on time and cost efficiencies [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar,[21]Fries C. Health health care: from sick care towards salutogenic healing systems.Soc Theory Health. 2020; 18: 16-32Crossref PubMed Scopus (13) Google Scholar. It is important to strongly reinforce that the biomedical healthcare paradigm has been enormously successful in transforming and improving health and that a pathogenic and risk factor-orientation is critical to the understanding of and treatment of disease. However, Western healthcare is undergoing a slow paradigm shift as we grapple with the challenge of a growing ageing population who live longer with increasingly chronic complex health needs [[2]Poon Y-S. Lin Y. Griffiths P. et al.A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions.Hum Resour Health. 2022; 20: 1-18PubMed Google Scholar,[4]Arsenault C. et al.COVID-19 and resilience of healthcare systems in ten countries.Nat Med. 2022; 28: 1314-1324Crossref PubMed Scopus (69) Google Scholar,[22]Hudson K. Salutogenesis: The origin of health.Evid Based Nurs. 2013; 11: 12-13Google Scholar. The traditional biomedical and pathogenic paradigm has proved to be less effective for individuals who present with chronic multidimensional conditions such as diabetes, obesity, and cardiovascular disease [[23]Suominen S. Lindstrom J Health. PubMed Scopus Google G. Moksnes U. Haugan G. The concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Scopus Google Scholar. ‘Health’ is a complex and highly is factors broader than the individual and the traditional of the healthcare The World Health (WHO) has the need to health care towards a paradigm for in the G. Moksnes U. Haugan G. The concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Scopus Google Scholar]. The WHO Promotion of World Health Scholar] health as of and and not the absence of disease or the of a more holistic approach to individual and health and is a health theory, a model of health and an orientation a paradigm of health [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar,[19]Mittelmark M. Bauer G. et al.Salutogenesis as a theory, as an orientation and as the sense of coherence.in: Mittelmark M. The Handbook of Salutogenesis. 2nd Edition. Springer Open, 2022Crossref Scopus (14) Google et interventions and health a scoping review of the 2021; PubMed Scopus (13) Google Scholar. The salutogenesis was by medical Antonovsky who his model of health as the for health promotion [[10]Espnes G. Moksnes U. Haugan G. The overaching concept of salutogenesis in the context of health care.in: Haugan G. Eriksson M. Health Promotion in Health Care – Vital Theories and Research. Springer, Cham2021Crossref Google Scholar,[19]Mittelmark M. Bauer G. et al.Salutogenesis as a theory, as an orientation and as the sense of coherence.in: Mittelmark M. The Handbook of Salutogenesis. 2nd Edition. Springer Open, 2022Crossref Scopus (14) Google A. Health, Stress and Coping.1979Google Scholar. The salutogenesis to the of [[20]Antonovsky A. Health, Stress and Coping.1979Google Scholar], Antonovsky from the and the M. Bauer G. et al.Salutogenesis as a theory, as an orientation and as the sense of coherence.in: Mittelmark M. The Handbook of Salutogenesis. 2nd Edition. Springer Open, 2022Crossref Scopus (14) Google Scholar]. The salutogenic to and support that the effective of individual and to health and et interventions and health a scoping review of the 2021; PubMed Scopus (13) Google Scholar]. The salutogenic model of health that life and an individual their life or their Health can be to a M. 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