Keywords

Introduction

This chapter focuses on Swiss salutogenesis publications in German. English publications by Swiss-German authors are mentioned but not systematically included in this overview. The identification of relevant research was done using national databases of ongoing or completed research projects (e.g., FORS, ARAMIS, and Swiss National Science Foundation), a project-database held by different Universities of Switzerland (http://www.forschungsportal.ch), as well as publication databases (e.g., PsychInfo and Medline), and several university databases and public libraries (e.g., Swissbib).

Salutogenesis as a Research Field in the German-Speaking Part of Switzerland

Like Swiss health research in general, research on salutogenesis is broad and wide-ranging, and characterized by a lack of coordination and cooperation. Salutogenic research is undertaken at the initiative of individual researchers, and there seem to be no organizational units that focus on salutogenesis. No conferences on salutogenesis or applied research in this field have been held, although some conferences include a salutogenic orientation (GAIMH, 2000; Hochschule Luzern, 2012; White, Schouten, Berg, & Meier Magistretti, 2014). The Swiss National Science Foundation has thus far not funded a national program on salutogenesis, but several research projects addressing salutogenesis have received financial support (Götzmann et al., 2012; Gutzwiller & Wydler, 2005; Rimann & Udris, 1997). In contrast to other areas of health research (e.g., gender health and occupational health) there is no network for salutogenic research. Instead, several networks on various topics such as wellness or self-healing programs claim to have a salutogenic orientation or refer to Aron Antonovsky’s work (not always accurately).

Yet, salutogenesis is indeed of academic interest in German-speaking Switzerland, with the more than 80 publications published over the last years spanning four themes:

  • Theory development

  • Texts about the application of salutogenesis in public health

  • Research having a salutogenic orientation in a general sense

  • Research having a salutogenic orientation with a specific focus on the sense of coherence

The first—even though the smallest—group of researchers is involved with salutogenic theory itself, developing salutogenic thinking, integrating new concepts, or adopting salutogenic theory to new fields. Abel and colleagues combined salutogenesis with concepts of Nussbaum and Sen’s capability approach (Nussbaum & Sen, 1993) showing how a salutogenic capability approach could contribute to increase equality in health (Abel, Abraham, & Sommerhalder, 2009; Abel & Frohlich, 2012; Abel, Fuhr, & Spörri, 2007; Abel & Schori, 2009). Other authors link salutogenesis to sustainable development (Anliker, 2013) or apply it to practical fields of health promotion and addiction (Wettstein, 2008, 2009, 2014), with the considerable effect that National Policy Papers on health promotion (Mattig, 2014) and migrant health (BAG, 2007) are partly or entirely and explicitly based on salutogenic theory.

The second group of publications consists of entire text books, chapters in text books, and journal articles explaining salutogenic theory to specific groups of professionals in public health (Egger & Razum, 2014; Wydler, Kolip, & Abel, 2000; Zeyer, 1997), nursing (Pielot, 2009), midwifery and early life care (Hungerbühler-Räber & Keller-Schuhmacher, 2003; Keller-Schuhmacher, 2004; Meier Magistretti & Luyben, 2012), psychotherapy (Fäh, 2004; Schlegel, 2004), or providing professional tools for salutogenic practice for teachers (Brägger & Posse, 2007; Märki et al., 2005).

A third group represents research projects taking the salutogenic perspective. Their authors refer either generally to Antonovsky’s salutogenic model (Fabian, 2012), use salutogenesis as a theoretical framework for their research (Süss et al., 2002).

The last and largest group of researchers uses the sense of coherence scale in projects with a general salutogenic orientation (e.g., Buddeberg-Fischer, Klaghofer, Leuthold, & Buddeberg, 2000; Gutzwiller & Wydler, 2005).

As illustrated in Fig. 41.1, salutogenic research is mostly focused on the health of groups and individuals, as well as some methodological research, but the salutogenic perspective is not yet applied to health system research.

Fig. 41.1
figure 1

Research activities in health fields generally and with an explicit salutogenic focus (based on the schema of Bänziger et al., 2011 and on the research presented in this chapter)

Full size image

Occupational Health

There has been a clear focus on salutogenesis in the field of occupational health at ETH Zurich —partly in cooperation with the Universities of Zurich and Berne. Starting in the early 1990s with a large research program named SALUTE, Yvan Udris and his colleagues followed the salutogenic approach and Aaron Antonovsky’s health theory integrating the tradition of personality and health promoting humane job design with the tradition of salutogenesis (Udris, 1990, 1993, 2006; Udris, Kraft, Muheim, Mussmann, & Rimann, 1992; Udris, Kraft, Muheim, & Mussmann, 1992; Udris, Rimann, & Thalmann, 1994). A Salutogenic Subjective Job-Analysis questionnaire—SALSA —was developed based on qualitative research of factors contributing to the health of healthy workers (Kraft, Udris, Mussmann, & Muheim, 1994; Rimann & Udris, 1997; Udris & Rimann, 1999).

The SALSA questionnaire has been widely used in various contexts of occupational health and health promotion. Related publications cover a broad range including national survey reports on occupational health (Hämmig et al., 2005), healthy working conditions in universities (Zölch et al., 2005), and health promotion programs of national insurance companies (Udris & Rimann, 1999). The SALSA questionnaire has been adopted by labels for health promoting companies. These labels can be applied for by companies in Switzerland who gain in compensation the title “friendly work space” that allows them an advantage on the labor market as well as an image gain for their companies (Arbeitsgruppe BGM-Kriterien, 2012). SALSA has been adopted also in public administration and in many smaller organizations (e.g., Schwendimann, 2013).

A special issue of the National Journal on Business Psychology (Wehner & Richter, 2006) provided an overview of the SALUTE and of related studies (e.g., Reuter, 2006 on salutogenesis and participation and Semmer, Jacobshagen, & Meier, 2006 on sense of coherence and stress, Bauer & Schmid, 2006 on salutogenic interventions in organizations). A salutogenic orientation in occupational health research has been taken in other contexts, such as teacher’s health and well-being (Herzog, 2007), and national surveys on psychological and occupational health (Moreau-Gruet, 2013).

Salutogenic occupational health research experienced a new and strong emphasis through the work of Georg Bauer and his group at the University of Zurich. Although the main volume as well as following publications were published in English (Bauer & Jenny, 2013), his salutogenic approach, focusing on resources and positive outcomes of health-oriented organizational change processes, considerably influenced occupational health research as well as education in the German-speaking part of Switzerland. The group developed a work-related sense of coherence questionnaire (Work-SOC) measuring the perceived comprehensibility, manageability, and meaningfulness of an individual’s current work situation on a nine items scale (Vogt, Jenny, & Bauer, 2013; Bauer, Vogt, Inauen, & Jenny, 2015). The concept and the instrument of work sense of coherence are currently applied in a longitudinal study that is systematically testing the different roles of the sense of coherence in the motivational process of the job demands-resources model in a national program for stress prevention and stress management at work (Jenny et al., 2011).

Salutogenesis in Medical Research

Medical research has traditionally been oriented toward pathology and risk avoidance in Switzerland as well as in many other countries. However, there is an ongoing tradition of salutogenic perspectives in medical research, focusing mainly on topics of coping with injuries, trauma, and surgery. At the University Hospital of Zurich, Schnyder and his group conducted a longitudinal study on psychosocial coping with posttraumatic stress disorder in patients experiencing severe injuries. They adopted a general salutogenic orientation and used the sense of coherence scale as an outcome measure (Schnyder 2000). Posttraumatic stress symptoms did not correlate with injury severity but with pretraumatic stressors, the patients’ subjective appraisal of the accident, their current coping pattern, and with their sense of coherence. The authors also found that traumatic events such as life-threatening accidents may change a person’s sense of coherence, even if psychiatric symptoms abate (Schnyder, Moergeli, Klaghofer, & Buddeberg, 2001; Schnyder, Moergeli, Trentz, Klaghofer, & Buddeberg, 2001; Schnyder, Moergeli, Klaghofer, Sensky, & Buchi, 2003), but that sense of coherence has no predicting value for the development of posttraumatic stress disorders after severe injuries (Hepp, Moergeli, Buchi, Wittmann, & Schnyder, 2005; Wittmann, Moergeli, Martin-Soelch, Znoj, & Schnyder, 2008). The relationship of sense of coherence to the psychosocial effects of health problems was confirmed by the same group of authors in patients with rheumatic rheumatoid arthritis (Schnyder, Büchi, Mörgeli, Sensky, & Klaghofer, 1999). Recently, members of this group focused on the role of the sense of meaningfulness in coping processes with trauma after the 2004 Tsunami (Kraemer, Wittmann, Jenewein, Maier, & Schnyder, 2009).

In parallel, research at the University of Berne used the sense of coherence scale in research on coping strategies and environmental resources in patients adjusting to spinal cord injury (Znoj & Lude, 2002). Also investigating sense of coherence and trauma, but focusing on a healthy population group, Sommer and colleagues concluded to the contrary to Znoj’s results that in their sample of Swiss mountain guides, sense of coherence did not predict, but seemed rather to be a marker for psychological health (Sommer & Ehlert, 2004).

The sense of coherence scale has also been used in studies of transplant patients , showing a strong positive correlation of strong sense of coherence with patients’ positive attitudes toward their medication, their perceived self, and their fate (Götzmann, 2008). A comparable picture was found with the patients’ spouses, except for a negative correlation between the sense of coherence and the attitude toward the transplantation in terms of stress and anxiety (Götzmann et al., 2012).

A study conducted on patients with morbid adiposities undergoing a gastric banding operation showed a weak sense of coherence in patients both with and without an additional psychiatric diagnosis, but no predictive power of the sense of coherence on the quality of life and eating behavior after surgery (Lang, Hauser, Schlump, Klaghofer, & Buddeber, 2000).

In studies on patients with somatoform disorders and on the elderly, the sense of coherence was measured, but no results were reported (Buddeberg, Klaghofer, Nigg, & Steurer, 2001).

A general salutogenic orientation underpinned studies on nonspecific low back pain. Rolli-Salathé & Elfering described these patients’ resources regarding life management, working ability, and pain control (Rolli-Salathé & Elfering, 2013) and Tamcan and colleagues developed and tested a 12-item scale based on the three dimensions of the sense of coherence (Tamcan, Bantli, Abel, & Barth, 2010). The scale serves as an assessment tool of patients’ resources in clinical practice.

A last branch of salutogenic research in medicine addresses the role of medical doctors, their working conditions, and health. Buddeberg-Fischer, Klaghofer, Abel, and Buddeberg (2006) addressed the question whether the sense of coherence was associated with the specializations young doctors chose. They found that although sense of coherence varies among different medical disciplines, gender is—at least in Switzerland—the decisive determinant for professional careers of young doctors (ibid). A prospective cohort study conducted by the same authors confirmed the stress-buffering effect of a strong sense of coherence among medical students and young doctors in their early professional career (Buddeberg-Fischer et al., 2008, 2009; Buddeberg-Fischer, Stamm, Buddeberg, & Klaghofer, 2009).

Salutogenesis in Research on Health Promotion

Health and health promotion over the life span are among the main areas of health research in German-speaking Switzerland (Meyer, 2009). The practical implications of a general salutogenic orientation have been discussed in terms of Antonovsky’s theory for more than 10 years (Hungerbühler-Räber & Keller-Schuhmacher, 2003; Keller-Schumacher, 2004; 2005; Hafen, 2012). Though, in maternity care as well as in early life support and education of children, salutogenesis has just started to be an explicit focus in research (Meier Magistretti & Luyben, 2012). A salutogenic orientation has been fostered in the Swiss public health position paper on early childhood health (Public Health Schweiz, 2012). But research in this area has not gone beyond a general health orientation in the sense that resources and positive health outcomes became research interests.

For school-age children, salutogenic research was more extensive in the 1990s, when the group of Buddeberg-Fischer investigated the associations among body image, sense of coherence and well-being among more than 500 high school students. They found strong correlations between the sense of coherence, well-being, body image, and concerns about eating behavior and bodily self (Buddeberg-Fischer et al., 2001). This research group has also observed a significant influence of high school climate on sense of coherence and other indicators of students’ health and well-being (Buddeberg-Fischer, 2000; Buddeberg-Fischer et al., 2000). Bolliger-Salzmann (1997) adopted the sense of coherence scale in a study showing that a school-based health-promoting program reached and benefitted the teenagers most in need—the ones with the weakest sense of coherence.

Later, sense of coherence and selected general resistance resources were used as indicators evaluating the school-based health promotion program entitled “fit and stong” (Jurt & Niewenboom, 2004). Next, Gutzwiller and his group conducted a large retrospective comparative study on 20,000 adolescents. They observed that favorable styles of parental education were associated with stronger adolescent sense of coherence (Gutzwiller & Wydler, 2005; Wydler et al, 2007). In the last few years, the salutogenic orientation in school-based health research has been reduced to a few general statements indicating that research projects should follow a salutogenic view, without explicitly adopting salutogenic theory (Fäh, 2009; Dubowicz et al., 2013).

As described above, salutogenic research on adulthood has been focusing mostly on issues related to work place health and medical studies. Research on the elderly has been selectively undertaken in the past 10 years. There, a similar pattern is noted: a salutogenic view is promulgated (Duetz & Bähler, 2006; Herrmann, 2007; Stamm et al., 2014), but not clearly put into methodological practice. An exception was found in a study of spiritual needs as one dimension of the sense of meaningfulness (Zwinggi et al., 2006). However, the study investigated the professionals’ spiritual needs and competences in a home for the elderly and not the needs of the elderly themselves.

Salutogenic Research in Psychiatry and Psychotherapy

A small number of projects with a salutogenic orientation have been published in the area of psychotherapy and psychiatry. A study conducted with children of parents with a psychiatric disorder used the sense of coherence scale as one of several elements to describe identity formation of children in these families (Sollberger et al., 2007). Meister and Haug (2004) used the sense of coherence scale as a control to validate a questionnaire measuring health in schizophrenic patients. Schlegel (2004) described parallels of Antonovsky’s sense of meaningfulness and the dimensions of sense and meaning in Jungian psychotherapy. One study included the sense of coherence in a longitudinal study on the effectiveness of systemic psychotherapy in patients suffering from anorexia nervosa and showed that the level of sense of coherence significantly increased over the relatively short time of 19 therapy sessions (Grünwald et al., 2013).

Future Perspective

The number of studies adopting the sense of coherence or other relevant aspects of salutogenic theory was surprising, considering that salutogenesis is virtually nonexistent in both the public academic discussion on health and the basic education of academic staff (outside of the professions very closely linked to the healthcare system). Additionally, there seem to be even more Master and Bachelor’s theses related to salutogenic theory than research projects. This suggests that the interest of the coming academic generation in salutogenesis is strong—stronger perhaps than the responses the young researchers might find in the academic system. Switzerland—or at least the German-speaking part of it—would be well advised to foster this interest and to support these rising initiatives by adequate models of networking, mentoring and coaching.