Understanding Public Health

Productive Processing of Internal and External Reality

Klaus Hurrelmann, Matthias Richter

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781000760897
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This book develops a new model of the genesis of health, on the basis of the interplay between genetic and environmental factors. Hurrelmann and Richter build upon the basic theories of health and the popular model of salutogenesis to offer a comprehensive interdisciplinary theory of health genesis and success: Productive Processing of Reality (PPR).

The authors show that health is the lifelong dynamic process of dealing with the internal reality of physical and psychological impulses and the external reality of social and material impulses. To demonstrate this, the book is split into three interconnected parts. Part A analyses the determinants of health, providing an overview of the insights of current research and the impact of socioeconomic influences and gender on health. Part B covers public health, social, learning and coping theories, all of which understand health as an interaction between people and their environment. Part C draws on these four theories to outline PPR, stressing the interrelation between physical and mental constitution and the demands of the social and mental environment, and suggesting strategies for coping with these demands during the life course.

Understanding Public Health: Productive Processing of Internal and External Reality will be valuable reading for students and researchers in psychology, sociology, educational science, public health and medical science, and for policymakers in public health.

PART C
Understanding public health

Part C combines the basic theories presented in the preceding chapters. On the basis of their core statements, we develop a dynamic model of the genesis and maintenance of health, the model of Productive Processing of Reality (PPR). This model concludes from the social and public health theories that economic, social and cultural environmental conditions provide numerous possibilities for individual development processes throughout a person’s entire life course, which creates a certain scope for health and disease dynamics. It integrates the impulses of the learning and stress theories and takes into account the development of competences with which a person tries to cope with the requirements of life.

The model of PPR is inspired by the interdisciplinary concept of salutogenesis, which is discussed further in Chapter 7. Salutogenesis means health development and was coined by Aaron Antonovsky as a programmatic counter-concept to pathogenesis (disease dynamics). Antonovsky was interested not only in how diseases arise and develop but also in the reasons why people remain healthy and are able to successfully compensate for their health disorders despite a multitude of endangering and stressful microbiological, biochemical, physical, psychological, social, cultural and ecological factors.

The model of PPR is presented in Chapter 8. It integrates the concept of salutogenesis and builds on the approaches of the basic theories of health from Part B. The model of PPR originates from interdisciplinary socialisation theory and explains how a human being, with their genetic disposition of drives and needs and their innate temperament and personality traits, becomes an independent subject with the ability to self-reflect and manages to cope with the demands of culture, economy and the environment. Socialisation is the lifelong integration of and dealing with natural dispositions, in particular the basic physical and psychological characteristics, which form the internal reality of a person, and their social and physical environments, which form the external reality of a person. If this process is successful, it provides good conditions for the further personality development at all levels and thus also positive impulses for health dynamics. If this process fails, a negative dynamic with risks for disease arises.

Finally, Chapter 9 asks how health can consistently be restored and safeguarded. To this end, we give an overview of the two central and complementary strategies to ensure and safeguard health – namely health promotion and disease prevention – and explain their significance over the entire life course.

Summary of Part C

Part C combines the three strands of basic theories presented in Part B. On the basis of their core statements, we develop a dynamic model of the genesis and success of health, the model of PPR. This model is inspired by the interdisciplinary concept of salutogenesis. “Salutogenesis” means health development and was coined by Aaron Antonovsky as a programmatic counter-concept to pathogenesis (disease dynamics). The model PPR not only incorporates the salutogenesis concept but also builds on the approaches of the basic theories of health: it integrates learning theories as well as coping theories, social structure and milieu theories, role and organisational theories, health risk and health-care systems theories and the concept of salutogenesis. In the final chapter of this part, we give an overview of the two central and complementary strategies to ensure and safeguard health – namely health promotion and disease prevention – and explain their significance over the entire life course. All in all, in Part C, we offer a comprehensive theoretical program for a differentiated and comprehensive understanding of health.

Questions

1. What are the core ideas of the concept of salutogenesis?
2. What are the core ideas of the model of PPR?
3. What are the definitions of health promotion and of disease prevention?
4. What are the challenges for prevention and promotion strategies across the life course?
5. What are five typical examples of promotion and prevention strategies?

Answers

1. The essential achievement of salutogenesis lies in the change of perspective from pathogenetic to health genetic. The concept is based on the essential elements of stress and coping and also integrates elements of learning theories, sociological theories and public health theories. The core idea can be summarised as follows: human life and personality development are permanently confronted by stressors in the psychological, social, physical and biochemical areas, which are perceived as challenges to the physical, psychological and social coping capacities. The stressors are countered by resistance resources, whose constellation determines whether the threatening effect of the stressors can be adequately processed – that is, whether the processing of stress is successful or not. After all, the decisive moderating factor is the sense of coherence (SoC). It describes a particularly favourable and successful initial constellation of resistance resources. A person with a strong SoC has the ability to mobilise those resources, which are best suited to effectively dealing with a stressor – that is, an internal or external demand on the organism and the psyche that disturbs the balance. Characteristic for a feeling of coherence is the basic attitude of experiencing the world as comprehensible, manageable and meaningful. The SoC determines which position a person finds themselves in on the health–disease continuum. Health is understood as a dynamic, gradually unfolding process, as a precarious, unstable and constantly readjusting event.
2. The model of PPR is also built on elements of the psychological, sociological and public health theories. It is inspired by the concept of salutogenesis. The model uses the term “socialisation”, which describes the process in which the human organism, with its genetic dispositions, develops into a personality capable of social interaction and, in dealing with environmental conditions, continues to develop over the entire life course. The physical and mental dispositions and characteristics constitute the internal reality, the conditions of the social and physical environment the external reality. The processing of reality is productive because a person always deals with life in an active manner and tries to cope with the developmental tasks connected with it. If this process is successful, it provides good conditions for the further personality development at all levels, and thus also positive impulses for health. If this process is unsuccessful or fails, a negative dynamic with risks for disease arises. The model of PPR supports a dynamic image of humans and society: the human being is in active exchange with his inner and outer reality and strives, through a lifelong searching and probing, to intervene in the development of their personality and that of the social and material environment to their advantage. Inspired by the concept of salutogenesis, health is defined as a fragile but temporary equilibrium between risk and protective factors. If the equilibrium breaks down – which is quite likely due to the nature of its instability – then the risk factors gain the upper hand and a more or less long period of illness can occur. This, in turn, can possibly be overcome by activating self-control and external help, and it can transition into a period of health.
3. Health promotion is a complex social and health policy approach, which explicitly encompasses both the improvement of health-related lifestyles and the improvement of health-related living conditions. Health promotion not only aims to influence an individual’s ability to live and act and enable people to improve their health but also focuses on economic, social, ecological and cultural factors and on political intervention, to influence these health-relevant factors. The complementary strategy to health promotion is disease prevention. This refers to interventions that are able to prevent the onset of a disease through preventive strategies. Disease prevention is usually directed at risk groups: people with characteristics who can, with a certain probability, be affected by health disorders, functional limitations and diseases. Both strategies are oriented towards a “health gain”: Health promotion essentially makes use of strategies which relate to changes in health conditions and which primarily aim at influencing social factors. Their objective is to strengthen the collective capabilities anchored in the community and social organisations in order to create conditions for the production of individual health through supporting networks in the social environment, in the community and in the most important social organisations. Simplified, one can also speak of setting-based prevention. In contrast, disease prevention essentially makes use of strategies which directly aim at changing health behaviour and influencing personal factors (lifestyle habits, risk behaviour, level of education and competence in disease management).
4. Each transition in the life course represents a sensitive phase in the reorganisation of lifestyle, in which all available coping competences must be activated. In this respect, each transition is a risk that the capacities available for dealing with the developmental tasks will not be sufficient to meet the actual requirements. Such risk constellations exist particularly when the physical and mental constitution is impaired, when no sufficient social and material resources are available to support individual coping and when the individual level of education is low. Because the transitions from one life stage to another today are relatively open and unstructured, meaning that only a few fixed requirements and processes can be expected, there is a danger that the temporal and social “timing” of the life course will not be consistent with the individually feasible possibilities for shaping the life course and that as a result the health–disease balance will suffer setbacks. This holds for every single stage in the life course: childhood has become short because the onset of puberty now begins earlier. Adolescence now begins early because over the past 200 years, the beginning of puberty has continuously shifted forward in the life course. Due to the earlier onset of sexual maturity in the life course, adolescence today begins earlier than it probably ever has in human history. Additionally, it is necessary to deal with openness and uncertainty, with the asynchronicity of autonomous and nonautonomous areas of life and with a succession of often unpredictable, complex developmental tasks in various areas of life. This leads to high psychological and social demands on life management and the associated production of a health–disease balance. The same challenges are typical of the life stages of adulthood and senior age.
5. There are five examples of typical strategies for health promotion and disease prevention:
   1. The development of a health-oriented design of social policy with the aim to reduce health inequalities and prevent the exclusion from full participation in economic, social and cultural life.
   2. The development of an integrative healthcare system that combines therapeutic-curative treatment centres, centres responsible for the prevention of illnesses, rehabilitation centres responsible for the temporary or permanent care of convalescents and care centres for people who are ill or disabled or whose daily activities are impaired.
   3. The development of strategies for community and family environments that provide adequate cultural and social conditions under which people live on a daily basis.
   4. The development of strategies of health promotion at the workplace with the aim to reduce the physical and mental health burdens associated with the work process and to strengthen the positive health potential of employees.
   5. The development of strategies of health education with the objective to directly influence the knowledge, attitude and disposition of individuals by providing health information and strengthening their competences and to empower the self-determination of their health behaviour.

7
THE CONCEPT OF SALUTOGENESIS

The American-Israeli sociologist Antonovsky has presented a complex concept of the genesis of health, described by the term “salutogenesis”. This term is composed of the Latin word salus (“integrity”, “salvation” and “happiness”) and the Greek word genesis (origin) (Antonovsky, 1979, 1987).

The term “salutogenesis” – which can be translated as health development or health dynamics – is used as an antonym to pathogenesis (disease dynamics). With this, Antonovsky wants to express programmatically that the central question of his theoretical concept is not how diseases come about and develop but rather why people remain healthy despite a multitude of endangering and stressful factors in the microbiological, biochemical, physical, psychological, social, cultural and ecological realms and can successfully compensate for disorders related to their health. While a pathological orientation tries to explain why people become ill, why they fall into a given disease category, a salutogenic orientation focuses on a radically different question: why are people on the positive side of the health–disease continuum, or why are they moving towards the positive pole, regardless of their current position?

7.1 Resistance resources

The concept developed by Antonovsky is based on the essential elements of stress and coping theory that have been explained in Chapter 4. According to his analysis, stressors are present in human life at all levels. Despite this high stress load, people remain healthy because they possess adequate tension-managing capacities and a sufficient number of resistance resources.

Successful or unsuccessful processing of stress

The core idea of Antonovsky’s concept of salutogenesis can be summarised as follows: human life and personality development are permanently confronted by stressors in the psychosocial, physical and biochemical areas, which are perceived as challenges to the physical, psychological and social coping capacities. They are countered in different areas by resistance resources, whose constellation determines whether the threatening effect of the stressors can be adequately processed – that is, whether the processing of stress is successful or not. After all, the decisive moderating factor is the SoC. It provides a crucial explanation a person’s position on the continuum of health and disease (see Figure 7.1).

FIGURE 7.1 Antonovsky’s concept of salutogenesis

Antonovsky’s concept has attracted much attention in theoretical and practical discussions because of its interdisciplinary nature. It combines elements already represented in stress theory and – to a certain extent – in learning theory.

The importance of resistance resources

Stressors are vital in this concept. They are not seen as something indecent that must be reduced but instead as omnipresent. In addition to this, the consequences of stressors are not assumed to be necessarily pathogenic but perhaps actually healthy – depending on the character of the stressor and the successful tension relief. According to Antonovsky, the confrontation with a stressor results in a state of tension that one must deal with. Whether the result is pathologic, neutral or healthy depends on an adequate tension management. Thereby, the examination of the factors that determine tension management is the key issue of health sciences (Antonovsky, 1987, p. 128).

Resistance resources refer to the characteristics and qualities of a human being or a group of people that enable effective tension management. Resistance resources support an individual’s capability to deal successfully with social and biological pressures for their own benefit and to promote further development (Antonovsky, 1987, p. 27). Resistance resources have a physical, biochemical, materia...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• Introduction
• PART A Determinants of health
• PART B Basic theories of health
• PART C Understanding public health
• References
• Index