Health promotion

As advocated by the World Health Organisation (1986), health promotion is viewed as a process that empowers people to control their health, in order to better enjoy active, productive, lives. The health promotion era can be viewed as emerging at the same time as salutogenesis (Lindström and Eriksson 2006). Post World War II; there was a focus on the creation of conditions to support societal welfare, secured by the United Nations. One of the central concerns identified being the protection of human rights and freedoms, thus, within the domain of public health, the World Health Organisation was established. This establishment of WHO also encompassed a new definition of wellbeing, described as being a state of complete physical, mental and social well-being, not merely the absence of disease (WHO 2006). This definition reflects the growing awareness that wellbeing is not simply the absence of mental or physical illness (Deci and Ryan 2001). Furthermore, researchers agree that health promotion needs a greater focus on health as opposed to disease (Morgan and Ziglio 2007; Kickbusch 2006). The new definition further broadens the conceptual understanding of the individual determinants of health being a facet of the physical (body fitness), mental (sense of coherence) and social dimension (accessing social support) (Bauer et al. 2006).The Ottawa Charter is recognised as being a central document to the conceptualisation of health promotion (WHO 1986). It views health as a process that enables people to develop through their resources, thereby allowing them to have a good life (Eriksson and Lindström 2008). Additionally, the Ottawa Charter views health promotion as a process that enables a person to have greater control over, their health improvements (Antonovsky 1996). The

Charter highlights the significance of communities being responsible for controlling their future (Davies et al. 2014; Hanlon et al. 2011).

One of the main challenges to health promotion is in the fact that much health theory has been related primarily to health-related behaviours (Dean 1996) yet health promotion is concerned with societal organisations and the underpinning theories and philosophies (Nutbeam and Harris 2004). As such, the general lack of theory has concerned many researchers (KickBusch 2006; Nutbeam and Harris 2004). The Healthy Cities Movement and the salutogenic approach are examples of societal level health promotion that are underpinned by theoretical constructs.

Healthy cities movement (HCM)

The Healthy Cities Movement (HCM) is an international movement that began in 1986 and represents a new view of health promotion (O’Neil and Simard 2006). The HCM is aimed at determining means to implement the Ottawa Charter for Health Promotion (WHO 1986). In addition, it is noted that the concept of healthy cities seeks to capture the need for liveable communities in the global context (Kegler et al. 2000).

The reorganisation of public health in the UK endorses the World Health Organisation's (WHO) Healthy Cities initiative which seeks to involve local governments in health development through processes of political commitment, institutional change, capacity- building, partnership-based planning and innovative projects (WHO 2012). Currently, there are 14 UK cities participating with an exponential increase expected with the widespread acceptance of the public health agenda (Hartwell et al. 2013). For participating cities, the main goal is to elevate health as a priority in local-level decision- making (Hancock 1993). The HCM initiative is recognised as being a highly political task requiring negotiation between various stakeholders. One of the issues frequently called into question is whether universal indicators are effective (O’Neil and Simard 2006).

Salutogenic approach

The word salutogenic emerges from the combination of words ‘salus’ which means health, and ‘genesis’ within refers to giving birth, thus literally meaning that which gives birth to health (Judd et al. 2001). In the past, the public health approach has been guided by a pathogenic perspective with a focus on disease or illness prevention. Cowley and Billings (1999) contend that the adoption of a salutogenic approach underscores the fundamental consideration of how health is created and maintained through health promotion. Additionally, Labonte (1996) suggests that the salutogenic approach to health promotion questions past policies influenced by economic rationalism

The salutogenic model of health promotion as proposed by Antonovsky (1996) offers an additional approach to pathogenesis (Antonovsky 1984). From this perspective ill health refers to disease, objective and subjective disorders (Bauer et al. 2006). Salutogenesis however, assesses a person’s resources that contribute to positive health encompassing subjective wellbeing, objective fitness, optimal functioning and a meaningful life (Raphael et al. 1996). It is contended that in practice these two approaches operate in a complementary interaction, where humans are constantly using their resources to guard against health risk factors. Furthermore, it is acknowledged that humans can experience positive and negative health at the same time (Bauer et al. 2006). In the past, the majority of studies have focused on ill health and the pathogenic paradigm (Tones and Green 2004). That said this study will primarily focus on the frame of salutogenesis as it is connected to wellbeing theory and a potential means to promote long-term sustainable health.

One of the key shifts in approaches is in the focus on prevention rather than cure. A salutogenic or health-creation focus within public health, emphasizes factors that promote wellbeing rather than merely preventing disease (Lindstom and Ericsson 2006). The fundamental question underpinning salutogenesis is what creates health, as opposed to the pathogenic need to determine the cause of disease (Antonovsky 1979). This salutogenic orientation as proposed by Antonovsky (1987) is a model for health promotion which focuses on salutary factors.

Salutogenesis is guided by three main aspects. The first is the focus on problem solving and finding solutions. Secondly, it reveals Greater Resistance Resources (GRRs) that assist people in moving towards positive health. Thirdly, it recognises that social systems within society serve as the means for building capacity, a Sense of Coherence (SOC) (Lindstrom and Eriksson 2006). Salutogenesis is comprised of three primary components: the health continuum; the story of the person; and health-promoting, salutary factors (Antonovsky 1987; Langeland et al. 2007). From this perspective, opposed to traditional pathogenic orientation, health is conceptualised as a continuum, which strives to understand what encourages a person to move towards the healthy end of the continuum. Thus, the story of the person becomes instrumental rather than the diagnosis and is seen as an open system in a dynamic relationship with external and internal conditions. Raeburn and Rootman (1998) indicate that the salutogenic view of health promotion is people-centred.

Salutogenesis focuses on the necessary resources for health and health-promoting processes. Antonovsky (1979) introduced the Sense of Coherence (SOC) as a result of his inquiry into why some people were able to stay healthy in stressful situations and others were not. Eriksson and Lindström (2008), indicate that the philosophy behind

salutogenic theory corresponds with the core of the Ottawa Charter. It is noted, however, that despite this fit, the salutogenic approach has been underutilised. It is moreover suggested that salutogenesis represents the main components of health promotion further leading to greater levels of wellbeing (Lindstrom 1994). Research suggests that salutogenesis is connected to building capacity for engagement and activities that enhance individual and community wellbeing (Judd et al. 2001).

Generalised resistance resources (GRR)

Research acknowledges the impact of the salutogenic model on the health promotion discussion and debate (Eriksson and Lindstrom 2008). Within the salutogenic model, generalised resistance resources explain how people move towards the healthy end of the health continuum. GRRs are individual property, collectives, or situations which promote successful coping from life stressors (Antonovsky 1996). The suggested significance of the GRRs is that they all assist a person to see the world cognitively, instrumentally and emotionally make sense (Antonovsky 1996). From this viewpoint, the sense of coherence (SOC) construct is said to have emerged.

Sense of coherence (SOC)

The Sense of Coherence scale was developed from interview narratives collected from Holocaust survivors. The SOC construct is grounded in the assumption that the manner in which people view their life will positively affect their health. This construct refers to a resilient attitude which assesses how people use their GRRs to cope with stressful situations (Eriksson and Lindström 2007). The Sense of Coherence is comprised of three dimensions, namely comprehension (cognitive component), manageability (the instrumental component) and meaningfulness (the motivational component) as it is connected to the interactions between an individual and their environment (Eriksson and Lindström 2008). It is proposed that a strong sense of coherence will help to both identify and use necessary resources for problem solving (Eriksson and Lindström 2008). The SOC scale is argued to be a reliable means to measure health and the quality of life (Eriksson 2007). That said, a noted challenge for future health promotion research is in the full realisation of the salutogenic approach being embedded within health policies and further building salutogenic societies.

Past research outlines the connection between salutogenic thinking and the theoretical model of flow (Lindstrom and Eriksson 2006). Figure 5, illustrates the connections between public health promotion, salutogenesis and flow theory, as it is framed as an integrated wellbeing theory; blending hedonic and eudaimonic components. Figure 4,

also summarises upstream and downstream approaches to public health and theoretical links to the integrated wellbeing theory of flow.

Figure 5: Approaches to health promotion – situating salutogenesis and wellbeing theory (Adapted from Antonovsky 1996)

Figure 5 depicts the main approaches that have been employed in health promotion, namely pathogenesis and salutogenesis, using the metaphor of a river. From this perspective, Antonovsky (1996) suggests that curative medicine focuses on those who are already drowning in the river whereas; preventive medicine is focused on those individuals that are in danger of being pushed into the river, upstream. In terms of upstream approaches to health promotion, the Ottawa Charter underscores the significance of health promotion and treating people holistically (Baum 1993). It is further indicated that holistic wellbeing is unlikely to be achieved within a system that is driven by market forces (Baum 1993). This type of system is suggested to have a downstream focus, with an interest in curing ill people, as opposed to an upstream focus with the potential to prevent injury and promote health. Upstream thinking is noted to be more possible in a publically funded institution, where profit is not the primary driver (Baum 1993).

The river metaphor, seeks to juxtapose upstream-salutogenic and downstream- pathogenic approaches to public health. In this vein, pathogenesis focuses on ill-health, disease, objective and subjective disorders (Bauer et al. 2006) and salutogenesis evaluates a person’s resources which promote positive health incorporating objective fitness, subjective wellbeing, optimal functioning and a meaningful life (Raphael et al. 1996). The contention is that these two approaches are constantly interacting in a complementary fashion, where a person uses their resources to guard against risk factors.

Lindström and Erikkson (2006) reveal the connection between salutogenesis and flow theory, which is framed within this study as an integrated wellbeing theory, containing both hedonic and eudaimonic components. The SOC components, of manageability and meaningfulness can be viewed as having a parallel focus to that of flow theory. Manageability can be seen as being both the challenge skill balance and sense of control within the theoretical construct of flow (Csikszentmihalyi 1990). As well, SOC’s meaningfulness can be viewed to run parallel to the autotelic experience within flow theory, which refers to an activity having purpose and meaning within itself.

To frame the potential connections between wellbeing, public health and tourism, past destination management research examines the ways in which tourism can contribute to tourists’ wellbeing, community wellbeing and destination wellbeing. Alternative activity pathways and tourism typology examples are suggested as ways to promote eudaimonic wellbeing which may co-locate public health and tourism agendas.