REVIEW ARTICLE

The salutogenesis in health research: an integrative review

Cláudia Cossentino Bruck Marçal^I; Ivonete Teresinha Schülter Buss Heidemann^II; Gisele Cristina Manfrini Fernandes^III; Pamela Camila Fernandes Rumor^IV; Lays Souza de Oliveira^V

^I Speech Therapist. PhD. Florianópolis, Santa Catarina, Brazil. E-mail: cláudiabruck@gmail.com
^II Nurse. PhD. Professor of the Nursing Department, Federal University of Santa Catarina. Brazil. E-mail: ivonete.heidemann@ufsc.br
^III Nurse. PhD. Adjunct Professor I of the Nursing Department, Federal University of Santa Catarina. Brazil. E-mail: gisele.manfrini@ufsc.br
^IV Nurse. PhD Nursing student at the Federal University of Santa Catarina. Brazil. E-mail: pamrumor@hotmail.com
^V Undergraduate Nursing Student at the Federal University of Santa Catarina. Brazil. E-mail: lays.souza@grad.ufsc.br

DOI: http://dx.doi.org/10.12957/reuerj.2018.37954

ABSTRACT

Objective: to identify sense of coherence and salutogenic resources to promote people's health, in national and international scientific productions, from 2008 to 2017. Method: in this qualitative, integrative literature review, five databases were searched and studies were read and critically analyzed so as to discover salutogenic resources to promote health. Results: the 23 articles that emerged indicated that sense of coherence is a positive resource for promoting people's quality of life. It is important to include the expanded concept of health and its social determinants, with a view to developing personal skills, autonomy and empowerment, as salutogenic resources for people to keep themselves healthy and contribute to their own well-being. Conclusion: it was found that, in most of the studies, people reported that they have a high sense of coherence and seek to maintain and improve their health by focusing on positive resourc.

Descriptors: Health; health promotion; sense of coherence; quality of life.

INTRODUCTION

The Salutogenic Theory, proposed by Aaron Antonovsky, is considered in the health literature as a new approach to health promotion. It seeks to understand what generates people's health, given that there are people who remain well and are able to manage their lives despite adverse conditions.¹

The explanation about the factors that promote health, part of concepts that are structured according to the individual historical-cultural context, expressing itself as a predictor in this field, what is called a sense of coherence.²

The sense of coherence, considered the central aspect of the answer to the salutogenic question of maintaining health, is theoretically composed of three variables that act together, allowing the individual to face the stressors present in everyday life: comprehensibility (ability to understand an event), maneuverability (perception of the potential to manipulate or solve it), and significance (meaning given to that event). ³ Seeing the world as understandable, manageable and meaningful would facilitate the selection of resources and behaviors that are effective and culturally appropriate for coping with adverse situations. ^2,3 These concepts try to explain how people can manage their lives despite adverse living conditions, providing us with instruments for actions to promote health.²

In view of the above, looking for a new way to understand health and broadening the perception about the health-disease process, it is questioned how people identify the sense of coherence and the salutogenic resources to promote health from national scientific publications and countries. Therefore, the aim is to identify the sense of coherence and the salutogenic resources to promote people's health, in scientific publications, between the periods of 2008 to 2017.

METHODOLOGY

This is an integrative review of the literature of a qualitative nature, which provides a synthesis of the information on a certain subject, which may point to gaps and infer general conclusions about a particular area of study contributing to the development of knowledge on the theme with the application of explicit and systematized methods of searching, critical appreciation and synthesis of the selected information and studies of the practice.^4,5

The initial search resulted in 457 articles, and from the reading of the abstracts, the articles were evaluated and those that met the inclusion and exclusion criteria were systematized in tables. Subsequently, a careful reading of the 65 selected articles was carried out and, in compliance with the exclusion criteria, 11 articles were excluded because they did not contemplate the subject, and eight because they were literature review articles; after refinement, it resulted in 23 articles.⁴

In order to operationalize it, the methodological steps of Whittemore & Knafl were followed: identification of the study problem; literature survey; critical evaluation of the studies; data analysis; presentation, which provided a methodological organization and rigor to the study.

The data were collected from September to December 2017 in the following databases: Medical Literature Analysis and Retrieval System Online (Medline) and Latin American and Caribbean Literature in Health Sciences (LILACS) and in the Scientific Electronic Library Online (SciELO). The choice for these databases is justified, since it is understood that, while the latter two make it possible to direct access to Brazilian scientific journals, Medline allows wide access to publications in international journals and, in addition, reaches the literature published in periodical journals of the health area.

For the search of the articles, it was used the crossing of the keywords: salutogenic e salutogenisis and as boolean operator it was used or between the keywords. Original articles that were available in the online format were included, in full (fulltext) and published in the period from 2008 to 2017.

It has been excluded from this selection the articles published in other modalities than in scientific journals , repeated studies in the databases, guidelines, letters, reviews, forum, editorials, opinion articles, essays, previous notes, special collaboration, comments, yearbooks, books, book chapters, government publications, newsletters, complete theses, dissertations, monographs and course completion papers (except those whose results are published in journals), manuals, reviews and studies that do not respond to the scope of the research.

Finally, a critical analysis of the studies was carried out in order to know the practices of sense of coherence and salutogenesis. This step followed the steps of Whittemore & Knafl, data reduction: determination of a general classification system, to facilitate the analysis.⁶ At that moment, it was used the chronological order of the publications; visualization of the data: display of the general classification, used in the previous step, in a visual form, that is, data collection table; comparison of the data: examining the data in order to identify the patterns and differences between the studies, determining categories in which similar variables are grouped. The categorization of this review occurred according to the analysis of the Salutogenic Theory. Outline of the conclusion and verification: interpretation of the data, from the description of the patterns and relations of similarities and differences identified in the studies and its discussion with the pertinent literature.

After analyzing each category, each subject was highlighted, in order to reveal relevant data in the review. The appreciation of the subjects critically made possible reflections and interpretations of the data found based on the available literature.

RESULTS AND DISCUSSION

Of the total number of studies selected, in relation to the publication period, five articles were verified in 2016, followed by the years 2014 with six articles and five articles in 2012. There were two articles from the years of 2015 and 2008 and only one article referring to the years of 2009, 2011 and 2013.

The sample of the selected studies represents the expressiveness of the publications on the Salutogenic Theory in the field of health, especially in the last two decades. It is observed that the distribution of the studies over the years is ascending, which corroborates studies that also analyzed aspects of the salutogenesis thematic.^7,8

Another bibliometric aspect analyzed among the selected studies was the methodological design of the research, where a predominance of quantitative research (n = 15), five articles of qualitative research and three articles of mixed method were identified. Among the quantitative, the transversal, cohort and case types methods should be highlighted. The qualitative studies were represented by the phenomenological type.

Cross-sectional studies are considered to be a very useful tool for the description of population characteristics, identification of risk groups, and health action and planning, however, the measurements are made in a single moment and reveal only the associations between the variables, not investigating the causal relationship.⁷

As it was possible to identify in the studies, the use of questionnaires for data collection, such as the coherence sense questionnaire, quality of life and health questionnaire, other instruments that evaluate resilience strategies and coping. Specifically regarding the Salutogenic Theory, researches have turned to the construct of the Coherence Sense, in an attempt to find new ways that contribute to the understanding of the health-disease process.^9,10 The 23 articles examined^11-33 are shown in Figure 1, being highlighted the authors, titles and year of publication.

FIGURE 1: Presentation of the synthesis of the articles used in the integrative review.

Regarding the geographical distribution, most of the studies originated in the European Continent and from a smaller part in the Asian Continent. It is believed that this relationship is related to the origin of the Salutogenic Theory, which began in Europe by Aoran Antonowsky. Considering the adopted criteria, there were no studies coming from the American Continent.^17,31

Salutogenic resources for health promotion

From the interpretative and in-depth reading of the selected articles, different approaches of the salutogenesis were identified, having as focus of analysis the health promotion. In this review, health promotion is understood as the process of training individuals and communities to act in the improvement of the quality of life and health.³⁴ When considering the health promotion, it was observed that the content of the studies addressed the development of personal skills, with emphasis on health education.^{11,12,14,21,26} In these, the Salutogenic Theory seeks to understand the potential of people to stay healthy. This perspective meets the lines of action proposed in the Ottawa Letter, ³⁴ in which health should be used as a resource for life.

Other studies mention that the practices of health promotion inserted in the work process of Primary Health Care teams offer new forms of care through salutogenic actions.^17,19,35 In this sense, salutogenesis is understood as a process that enables people to live life as they want to live it, which promotes the ability to overcome, to recover from adversities, establishing as main focus the promotion of positive health.³⁶

The empowerment approach has also been identified in the studies,^20,29,30,37 being highlighted the social support and self-esteem as a psychological empowerment for positive health behaviors. Empowerment has been considered essential in the Salutogenic Theory, considering that salutogenesis is focused on the development of competences so that all the people can effectively deal with the demands and challenges of everyday life.^10,37,38 It is necessary to empower to promote health through individual and collective actions of health education that bring effective results, evidencing this referential as a tool of psychological empowerment that rescues the individual potentialities so that the person can make choices that they consider most important for their lives.^11,39

Alternative therapies appear as a holistic approach to health promotion,^17,30 focusing on therapeutic acupuncture, Ayurveda medicine and the salutogenic dialogue as possibilities to promote health and changes in lifestyle and quality of life. Alternative therapies are designed to treat body, mind and spirit. They are holistic health interventions that can offer insights on how to change the experience.⁴⁰ Holistic medical systems, by considering the individual in their social context, can offer clues on how to better understand behaviors that generate health, in order to make them more effective and increase adherence to salutogenic actions for health promotion.¹⁷

In the theoretical approach to salutogenesis, thinking about health in a broader context means recognizing that it results from the adaptive capacity of the human being to the adverse situations of life. For this, the autonomy and ability of individuals to manage their lives and make conscious choices are key factors in maintaining health.

The sense of coherence in health promotion

Some studies have addressed the sense of coherence in the health-disease process related to diseases such as heart disease, Parkinson's disease, osteoarthritis and health status of health workers, oral health, teacher's health, mental health, health in prison, elderly's health, health in the workplace and general health behaviors.

In the salutogenic approach, one of the factors that are structured from the individual historical-cultural context and that has been seen as a strong predictor of health in general is the so-called sense of coherence. ^2,23 The sense of coherence is related to how individuals give meaning to the world, use the resources required to respond to a demand, and feel that these responses are meaningful.^9-10,25

In relation to the sense of coherence and the generalized resources of resistance, eight publications^{11,13,15,18,21,23,26,28} describe that such resources serve to reinforce this sense and mobilize individuals in the process of coping with adversity, which may imply more favorable outcomes in terms of health. In addition, widespread resources contribute to improving people's lifestyles and quality of life.^14,16,19

General resistance resources, in turn, reinforce the salutogenic approach to lifestyle changes by being both individual and social determinants to promote psychosocial health and increase health potential in the primary care practice and overall health.^19,24,27,33

It is perceived that salutogenic resources support the conception of quality of life as the individual's perception of their position in life, in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concerns.¹⁰ It should be highlighted that the social determinants of salutogenesis are key to emphasize the sense of occurrence and promote health and quality of life through healthy attitudes and habits.^10,19,24 These concepts of the Salutogenic Theory share the proposals for formulating the National Policy for Health Promotion, closely related to the person's lifestyle, with a direct influence on their health and quality of life.³⁹

The sense of coherence expresses how the individual perceives life and their capacity to deal with stressful stimuli, according to some studies^{17,18,22,23,25,29-31} that show integrative and complementary practice therapies and management as the most important components in coping with stress, depression, and anxiety. A strong sense of consistency can be considered predictive for stress and positive mental health analysis.

Individuals who have high coherence scores regard the stressors as predictable and explainable agents, showing self-confidence in their ability to face and overcome them.^17,18,23,31 Diseases do not arise as a result of stress, but due to the inability to manage it, whose stressors can also be perceived as positive factors, since the individual has the competence to identify and understand them, providing the resources and the motivation to give a new meaning to life.^2,31,32

In the Theory of Salutogenesis the sense of coherence is defined as a resource that promotes and potentiates the development of a good subjective state of health and that the higher the sense of coherence the better the perception of general health, which is manifested in large populations, regardless of factors such as age, ethnicity, gender and nationality, which is why this construct constitutes a good predictor of health.^2,10,31

CONCLUSION

Rescuing the objective of this review, it is concluded that the salutogenesis reveals the positive resources for health and the strategies adopted for people to stay healthy, contributing to the well-being, quality of life and individual empowerment, which are essential for health promotion. Thus, the approach of salutogenesis allows people to live a productive active life, in the control of personal adversities and their environment.

Individuals with a high sense of consistency are better able to understand, manage, and find meaning for their world. This makes them more empowered to maintain and improve their health and well-being potential, having greater motivation to make choices and adopt healthy behaviors, even in adverse health situations.

Although not well known in Brazil and Latin America, the approach to salutogenesis represents a new possibility to modify and expand the health construction, using resources that increase the capacity of individuals, communities and peoples to maintain health and well-being, with a primary focus on health promotion.

REFERENCES