To the Editor:
I enjoyed reading Dr. Steinberg's editorial "Wellness in Every Stage of Life: A New
Paradigm for Public Health Programs" (1) and the related articles in the January 2007
issue. We face many challenges in conceptualizing wellness because the term has different
meanings for different people. To reach a common understanding of wellness, we could
begin by using Antonovsky's salutogenesis work (2-4) as a basis for discussion. Using
salutogenesis (origins of health) as a model for public health practice rather than
pathogenesis (origins of disease) allows us to focus on factors that support and increase
well-being rather than on factors that merely prevent disease. Antonovsky suggests
that people feel a sense of coherence if their lives are meaningful, manageable, and
comprehensible, which suggests that an orderly and consistent life is more desirable
than a chaotic, random, and unpredictable life. Therefore, when deciding how to bring
about beneficial behavior change, we must consider genetic, constitutional, and psychosocial
factors such as people's level of knowledge and intelligence as well as their ego
identity, coping strategy, social support system, religion, philosophy, and attitude
toward health maintenance.
When we look at people from a multilevel perspective, as encouraged by the Institute
of Medicine's report Who Will Keep the Public Healthy? (5), we find that interpersonal
factors, sociocultural factors, public policies, and physical environment (6) all
affect how people perceive their lives and use the resources available to them. We
must consider each individual's perception of the world when we design programs to
improve well-being. However, in public health practice, we cannot design programs
for specific individuals. We work to improve the well-being of populations and must
therefore rely on data to give us an understanding of the populations for whom we
intend to create programs. When we learn about the population's most common perceptions,
passions, knowledge, attitudes, and behaviors, we can create products and offer services
that will improve people's sense of coherence.
Public health can work well from a salutogenesis perspective, although the underlying
philosophy of salutogenesis is different from the usual disease-prevention and risk-avoidance
practices in use. Research methods, planning, and evaluation are similar for many
behavior-change strategies, but the thought processes involved in strategizing from
a salutogenesis perspective are different from those involved in strategizing from
a pathogenesis perspective. Not better or worse, just different. A salutogenic focus
changes how we see issues related to health and well-being. Instead of developing
solutions based on decreasing health-related risks, we find ways to promote healthful
behaviors that increase people's sense of well-being, their sense of coherence.
So, what does all of this mean? It means we must listen to people in the communities
we want to serve to learn about their areas of concern, and we must recognize that
people's life experience is an important factor in whether they are willing to change
and what will inspire them to do so. More than likely, interventions taking a salutogenic
approach will
Limit emphasis on clinical health risks (e.g., hypertension, elevated cholesterol).
Focus initially on improving morale within communities and developing meaningful relationships
between community members and public health practitioners.
Emphasize personal changes (e.g., increasing activity levels, controlling body weight,
decreasing stress and anxiety) and community changes (e.g., creating parks and bike
paths, adopting no-smoking policies) to increase people's opportunities to lead healthful
lifestyles.
Include mental health as a key factor in improving people's well-being, with an emphasis
on changing attitudes, increasing self-knowledge, becoming responsible, and being
empowered.
Emphasize programs that are fun rather than competitive or difficult (e.g., non-competitive
games, fun runs, walking programs, nutritional potlucks).
We must expand current practices associated with health care delivery, disease control
and prevention, risk reduction, and health promotion to include wellness management.
Doing so will expand the opportunities available to us as we work together to improve
the health of our nation. I am excited that CDC is embracing wellness as part of public
health practice.