Health can be examined in many ways. Many multi-level examination models exist to approach health issues such as Social-Ecological, Biopsychosocial, and Community Involvement, among others. This post focuses on the Salutogenic model as it relates to Type 2 diabetes mellitus (T2DM) development and treatment.
Aaron Antonovsky developed the Salutogenic model in 1981 (Bhattacharya et al., 2020). This theory argues that by identifying how one employs coping strategies and understands their capabilities, we can address biopsychosocial health and resiliency as influenced by individual determinants of health in a way that the individual is empowered to be their greatest influencer (Bhattacharya et al., 2020). This assignment begs us to review and discuss the different levels influencing T2DM diagnosis and prognosis through a salutogenic lens.
It is widely known that positive and supportive language makes people feel validated in their experiences, thus improving their self-efficacy. This is why I chose to examine the Salutogenic theory through a biopsychosocial lens for simplicity in this analysis. The Salutogenic theory “uses a positive thought process to describe health by focusing on factors that support well-being rather than those that cause disease. It describes the relationship between stress, coping, and health” (Kalra et al., p. 170) which empowers the patient to exercise whatever degree of self-esteem is available to them in each stage of their lives.
Please refer to this video for Figure 1: an AV presentation on Salutogenesis.
Figure 1
Salutogenesis - River of life
The Salutogenic model has the greatest influence proximally when we look at the individual’s health, and the influence decreases as we travel distally. This is best represented in Figure 2. Individual factors contribute to the patient’s understanding of themselves and their surrounding environment. Individual behaviours that influence one’s health condition would be viewed through a positive lens over the traditional biomedical lens. For example, in a population with T2DM, we often hear both colloquially and medically that diabetics are overweight, live a sedentary lifestyle, and eat too much sugar. These statements have been shown over time to greatly influence diabetic diagnosis and prognosis (Polhuis et al., 2020). When reviewing these individual behaviours from a social determinants of health standpoint, one might say: “Diabetic patients cannot afford to consume nutritious food and are under too much socioeconomic stress to make healthier food choices or exercise optimally. They are not educated enough to understand carbohydrate ratios or macro-bundling”. However, if we use a Salutogenic biopsychosocial approach, one might say: “By encouraging our patients to develop a firm social network of people in similar situations who understand their struggles and are willing to help them advance, they will collectively support each other’s stress management”. This support system might help individuals understand how nutritional challenges can be altered to fit their lifestyle and understanding. Learned coping skills will allow them to avoid psychiatric comorbidities that could commonly develop in patients who experience chronic conditions. Greater self-esteem will naturally allow for increased physical activity and nutritional moderation.” Using this positive language alongside positive self-talk by the patient, such as “I am not addicted to carbs, I am intelligent, I am worthy of a healthful body, etc.” will improve patient outcomes. The study published by Kalra et al. (2018) determined that Salutogenic recommendations and approaches resulted in lower blood glucose, metabolic modulation, delayed microvascular outcomes, reduced distress and incidence of psychiatric comorbidity through self-management skills and drug therapy (Kalra et al., 2018).
Figure 2
Determinants of health
Viewing community initiatives by public health units that focus their social marketing campaigns for diabetes prevention and management by using optimistic verbiage must be structured empathetically, emphasizing that an experience of disease is not one’s fault; policies are developed to encourage affordable healthy eating, and free nutritional counselling for all, etc. Conversely, a social determinants of health approach tries to help low-income people who cannot afford nourishing food by advocating for policy change; a biomedical approach in social marketing shares grim statistics about the prevalence of ‘diseased people’ and negatively categorizes our T2DM patients, insinuating they should be doing better by eating better and exercising, in order to slow disease progression (Voseckova et al., 2017). Salutogenic-oriented social marketing campaigns acknowledge that each person’s experience of their health is different and offers small solutions that nearly everyone in that population could employ. Salutogenesis mainly focuses on the lower-risk population and encourages positive change. There is a significant area of statistical overlap between the pathogenic and Salutogenic models, as seen in Figure 3.
Figure 3
Shifting to low-risk
Salutogenesis encourages the use of resources available to individuals and determines if these individuals are resilient enough to use and reuse their resources (Antonovsky, 1996). This includes clothing, housing, and other social determinants like income and influence. We also examine interpersonal relationships and emotional well-being. By building resilience and empowering people to use and reuse their available resources, providers can encourage better health which will be more helpful in the long term (Bhattacharya et al., 2020). The government and health policy need to play a role in building this resilience by positively influencing access to care, even when creative ways are required. Government initiatives or advocacy groups such as Quebec’s ‘oeuf-lait-orange’ and Gizhewaadiziwin Health Access Centre’s ‘Healthy Living Food Box’ programs aim to reduce barriers to accessing healthy foods by providing low-cost or subsidized fruits and vegetables, along with recipes to try using ingredients in the boxes, to promote a user-friendly option to encourage healthy eating for all (Gizhewaadiziwin Health Access Centre, n.d.; Picard, 2013).
Now that we have analyzed how to treat T2DM through Salutogenic approaches at the individual, community, and governmental levels, we must also examine how people come to be affected by T2DM. While T2DM is a metabolic disease where insulin production by pancreatic islet beta-cells becomes impaired and insulin-sensitive tissues have an impaired ability to respond to secreted insulin to maintain healthy blood glucose levels, the pathophysiology barely scratches the surface in our quest to answer ‘why’ (Galicia-Garcia et al., 2020).
To properly analyze this, we look to the determinants of health: income, rurality, race, education, childhood nutrition, food, and employment security, among others (Raphael, 2010). T2DM diagnosis might be influenced by times throughout life when individual lifestyle choices are determined by social circumstances (Kalra, 2018; Raphael, 2010). In a Salutogenic approach, we acknowledge that a person’s race determines their likelihood to obtain a T2DM diagnosis, something that might feel hopeless to the diagnosed person and their family (Voseckova, 2017). To encourage positive ideas, clinicians would explain to this person that while race plays a role, knowing that role and how to minimize any risks early can help to slow the disease process.
The Salutogenic theory considers that the person’s culture helps determine which resources are appropriate for use and reuse. Some cultures cultivate a stronger sense of coherence for coping with stressors (Antonovsky, 1996; Braun-Lewensohn & Sagy, 2011). Antonovsky (1987) considered culture to contribute to developing a strong sense of coherence, particularly those with historical roots but part of the modern world; those who live in stable religious societies interpret the world as cohesive, predictable, and stable. Social supports provided by these societies enhance feelings of consistency, meaningfulness and balance, thus strengthening their resiliency (Braun-Lewensohn & Sagy, 2011; Voseckova et al., 2017). Social support is an important determinant of disease development, and as such positive relationships with one’s culture or religion could reduce the likelihood of developing T2DM.
In summary, positive approaches and the use of cognizant language which does not carry negative associations with the disease are helpful to improve biometric markers to reduce the likelihood of diagnosis and improve prognosis among people living with chronic conditions like T2DM and could contribute to a reduced likelihood to develop T2DM.
References
Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 11(1), 11–18. https://doi.org/10.1093/heapro/11.1.11
Bhattacharya, S., Pradhan, K. B., Bashar, M. A., Tripathi, S., Thiyagarajan, A., Srivastava, A., & Singh, A. (2020). Salutogenesis: A bona fide guide towards health preservation. Journal of Family Medicine and Primary Care, 9(1), 16. https://doi.org/10.4103/jfmpc.jfmpc_260_19
Braun-Lewensohn, O., & Sagy, S. (2011). Salutogenesis and culture: Personal and community sense of coherence among adolescents belonging to three different cultural groups. International Review of Psychiatry, 23(6), 533–541. https://doi.org/10.3109/09540261.2011.637905
Community Development and Health Network. (n.d.). Models of health. https://www.cdhn.org/sites/default/files/downloads/FACTSHEETS%201_Screen%20View%281%29.pdf
Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of type 2 diabetes mellitus. International Journal of Molecular Sciences, 21(17), 6275. https://doi.org/10.3390/ijms21176275 Gizhewaadiziwin Health Access Centre. (n.d.). Gizhewaadiziwin Health Access Centre website. Retrieved January 30, 2022, from https://www.gizhac.com
Kalra, S., Baruah, M. P., & Sahay, R. (2018). Salutogenesis in type 2 diabetes care: A biopsychosocial perspective. Indian Journal of Endocrinology and Metabolism, 22(1), 169–171. https://doi.org/10.4103/ijem.ijem_224_17
Picard, A. (2013, November 12). Wealth begets health: Why universal medical care only goes so far. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/news/national/time-to-lead/wealth-begets-health-why-universal-medical-care-only-goes-so-far/article15385519/
Polhuis, C. M., Bouwman, L. I., Vaandrager, L., Soedamah-Muthu, S. S., & Koelen, M. A. (2020). Systematic review of salutogenic-oriented lifestyle randomised controlled trials for adults with type 2 diabetes mellitus. Patient Education and Counseling, 103(4), 764–776. https://doi.org/10.1016/j.pec.2019.10.017
Raphael, D. (2010). Health and illness. Fernwood Publishing.
Sandén-Eriksson, B. (2000). Coping with type-2 diabetes: The role of sense of coherence compared with active management. Journal of Advanced Nursing, 31(6), 1393–1397. https://doi.org/10.1046/j.1365-2648.2000.01410.x
Voseckova, A., Truhlarova, Z., Levicka, J., Klimova, B., & Kuca, K. (2017). Application of salutogenic concepts in social work with diabetic patients. Social Work in Health Care, 56(4), 244–259. https://doi.org/10.1080/00981389.2016.1265635
Yang, S. (2018, August 23). Salutogenesis-River of Life UQ [Video]. YouTube. https://www.youtube.com/watch?v=crLs7_fNKeI
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