From reorienting to complementing health services contributions by salutogenesis

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1 Public and Organizational Health, EBPI From reorienting to complementing health services contributions by salutogenesis Health Promotion Research - An International Forum Trondheim, September 2016 Georg F. Bauer Bauer

2 Agenda 1. Reorienting health services: state of the art 2. Complementing/completing health services: Creating partnerships & common ground 3. Contributions by salutogenesis Bauer

3 Reorienting health services? Source: Ottawa Charta WHO 1986 The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person. Bauer

4 Reorienting health services: original recommendations from Ottawa Source: Report from the sub-plenary session of the first International Conference on Health Promotion, Ottawa November 1986 (published in Health Promotion 1/4 1986) Increase citizen partnership in planning & implementing health services Strengthen information of and collaboration with citizens Increase accountability contribution to individual, family, community health outcomes (targets/indicators) Foster research on origins of health Change financial incentives to support more HP activities Change initial and continuing education of health professionals Increase the advocacy role Bauer

5 Reorienting health services: later recommendations Specific Ottawa recommendations repeated in later articles (Nutbeam 1991, Yeatman & Nove 2002, Wise & Nutbeam 2007) Study of barriers of Reorienting to more HP in health services asking health professionals (Johansson et al. 2010) Heavy workload Lack of guidelines Unclear objectives Significantly lower willingness of male vs. female health professionals Bauer

6 Diffusion of Innovation (Rogers x); Source: Theory in a nutshell, Nutbeam et al Characteristics of an innovation Compatibility with values Clarity of relative advantage Simplicity & flexibility Reversability & perceived risk Observability of results by others Bauer/2016 Page 6

7 Reorienting health services: argument of effectiveness & equity Show effectiveness of HP beneficial to invest (Nutbeam 2008) Act collectively on the deep rooted causes of poor and inequitable health (Baum et al. 2009) Leadership: Improving the equity performance of the health care system Stewardship: Working with other sectors to improve health and health equity Combine arguments of economic efficiency and contribution to health equity to justify investments in HP (Ziglio et al. 2011, EuroHealthNet 2012) Bauer

8 Reorienting health services: approach of capacity building Build HP capacities in the health services workforce (Judd & Keleher 2012) Workforce development Organisational development Resource allocation Partnerships / alliances Bauer

9 Agenda 1. Reorienting health services: state of the art 2. Complementing/completing health services: Creating partnerships & common ground Clearify type of relationship Partnership -> requires common & complementary ground 3. Contributions by salutogenesis Bauer

10 Clarify Relationship between health services & health promotion Two opposing fields? - HP re-orienting > HS would we like to be re-oriented by HS services? can we re-orient HS? Two complementary but separate fields HS + HP? Equal Partnership in exchange HS <> HP In line with HP principles strength/resources/asset orientation In line with ideal of co-production of health in health care / mutual learning requires common & complementary ground with clear profile of each field Bauer

11 Partnership/exchange: requires common ground Common evidence & value base: social determinants of health risk factors & resources E.g. Public Health = Health Services and Health Promotion goals in Austria equity at core Common approach: health promotion working principles (equitable, empowering, participatory, holistic,...) complementing medical guidelines Common & complementary ground: shared mental model of health development linking patho- & salutogenesis Bauer

12 Common & compelementary ground: health development model (Bauer,Davies, Bauer-2016 Pelikan; Health Promotion International 2006) 12

13 Agenda 1. Reorienting health services: state of the art 2. Complementing/completing health services: Creating partnerships & common ground 3. Contributions by salutogenesis Bauer

14 Contribution by salutogenesis: a matured field Sections 1. Overview and Origins of Salutogenesis 2. Salutogenesis: New Directions 3. The Salutogenic Construct of the SoC 4. The Application in Everyday Settings 5. The Application in Healthcare Settings 6. A Portal to the Non-English Literatures 7. Questions for the Future: Dialogue Bauer

15 Contribution by salutogenesis: Selected chapters The meanings of salutogenesis (Mittelmark & Bauer) Application of salutogenesis to health care (Pelikan) Application to settings (Bauer) Bauer

16 Salutogenic orientation Salutogenic model Sense of Coherence SoC The meanings of salutogenesis (Mittelmark & Bauer) Bauer

17 Salutogenic orientation (Antonovsky 1996) dichotomous classification into healthy or not > a healthy/dis-ease continuum risk factors > salutary factors that actively promote health particular pathology, disability or characteristic of a person > relating to all aspects of a person or a community of persons Bauer

18 Application of salutogenesis in health care: Salutogenic orientation (Pelikan 2016) 1. physical, mental, and social ill and healthy aspects of a person 2. possible salutary factors have to be enhanced as well in curative, preventive, protective and promotive practice. 3. take responsibility for the health of patients, staff and citizens in the catchment area policy change of the mandate, of the traditional diagnostic and therapeutic repertoire and of the clinical outlook Bauer

19 Application of salutogenesis in health care: Salutogenic practice (Pelikan 2016) develop salutogenic standards and make institutional contexts more salutogenic using the SOC concept for making health care structure and culture as far as possible consistent, underload overload balanced and participatory for patients, staff, and visitor patients and staff could be supported by health care organizations to experience their roles and tasks as comprehensible, manageable, and meaningful Dual strategy: resources / possibilities to cope successfully <-> Salutogenic environment Bauer

Primary aims: effiency & patient outcomes (safety, health, quality experience) Traditional results re employees: intensification, strain Task-related vs.

20 Primary aims: effiency & patient outcomes (safety, health, quality experience) Traditional results re employees: intensification, strain Task-related vs. relationship-related lean implementation Integrated, salutogenic approach: beneficial for patients & employees Complementary approach: Example Lean Hospitals Bauer/2016

21 Salutogenic Model for Health Promotion (Bauer 2013) (based on Antonovsky 1979, 1987; Bauer, Davies, Pelikan 2006) Triple role of health resources Demands (risk factors) Pathogenesis Negative Health Bauer Resources 2 SoC 3 Salutogenesis 21 Positive Health Sustainable Life Wellbeing Purpose in life growth Flourishing Joy, happiness contribution

22 Specifying & testing of model Data-Base: S-Tool; SWiNG Intervention Project; 8 companies; wave 1: n=1851 Brauchli R, Jenny GJ, Fu llemann D, Bauer GF (2015) Towards a Job Demands-Resources Health Model. BioMed Research International SEM: stability accross organizations, job level, gender, time PATHOGENESIS Time pressure / Work Interruption Role unclarity Job Demands.41 Negative Health Insomnia Exhaustion Qualitative overload -.36 Pain Manager support / appreciation ns Satisfaction Peer support / appreciation Control / holistic Task Job Resources.89 SALUTOGENESIS Positive Health Commitment Enthusiasm Bauer/

Quelle: Evaluationsbericht Projekt SWiNG, Jenny et al. 2011, available at www.gesundheitsfoerderung.

resources are higher than demands... 1 Tag 3 T. 5 T. 7 T.

23 Quelle: Evaluationsbericht Projekt SWiNG, Jenny et al. 2011, available at Corporate health index: relationships with outcomes Aktuelle Ausprägung im Betrieb ( ) und Benchmark ( ) Current level in organization (o) and benchmark (x) Belastungen sind stärker If resources are higher than demands... 1 Tag 3 T. 5 T. 7 T. gering mittel stark gering mittel hoch reduiziert normal hoch Demands are higher Ressourcen sind stärker Distribution of employees (%) Prozentuale Verteilung im Betrieb (% Mitarbeitende) Resources are higher... absenteeism is reduced (-3 days low/high tertiles) Bauer/ exhaustion is reduced...work engagement is improved...job performance is improved (+10% low/high tertiles) Seite 23

pathogenesis POSITIVE HEALTH [mental] [physical] [social] NEGATIVE HEALTH [mental] [physical] [social] SUSTAINABLE PERFORMANCE

24 Organisational ENVIRONMENT ORGANISATIONAL CAPACITIES [Structure] [Strategy] [Culture] salutogenesis Optimisation/ Renewal [Interventions] JOB RESOURCES [Factual processes] [Social processes] JOB DEMANDS [Factual processes] [Social processes] pathogenesis POSITIVE HEALTH [mental] [physical] [social] NEGATIVE HEALTH [mental] [physical] [social] SUSTAINABLE PERFORMANCE [Economic] [Ecologic] [Social] [Competence] [Motivation] [Identity] INDIVIDUAL CAPACITIES Individual ENVIRONMENT Bauer/ OHD-MODELL POH UZH/ETH

25 Link to key performance indicators Bauer/2016 Page 25

26 Consider whole human being: negative & positive health development Consider whole systems: relationships between different health determinants within one system / life domain Consider whole life: social determinants across life domains & levels (cell - society) Particularly relevant for health equity Application of salutogenesis in settings: Salutogenic orientation (Bauer 2016) Bauer

27 Application of salutogenesis in chronic disease: Example of multiple sclerosis Demands (risk factors) Pathogenesis Negative Health MS Symptoms Co-morbidities Medical care Other care Bauer-2016 e.g. benefit finding scale 1 Resources 2 SoC 3 Wellbeing Positive Purpose in life Health growth Flourishing Joy, happiness contribution Salutogenesis 27 Sustainable Life

28 Future of salutogenesis: discussion questions (Espnes et al. 2016) 1. Is the future work on salutogenesis in need of an explicit definition of health? 2. Is salutogenesis important to positive health developmentbeyond coping with stressful, miserable life situations? 3. Antonovsky proposed Salutogenesis as a theory for HP. Why has this not happened? How can it happen? 4. Is there salutogenesis without sense of coherence? Is there SoC without salutogenesis? IUHPE

29 Summary 1. Reorienting health services: state of the art 2. Complementing/completing health services: Creating partnerships & common ground 3. Contributions by salutogenesis Health promotion goes beyond health care (Ottawa Charter, WHO 1986) Bauer

30 Future research areas for salutogenesis in settings Positive health and path of positive health development Dynamics of ongoing development, depletion an restoration of GRR & of SoC in settings Within / across life domains Short-term/daily; long-term; life transitions Within individuals and groups (e.g. collective restoration, shared job resources) Interventions: communication & involvement as prerequisite for coherent interventions -> measure intervention-related SoC Inclusion of equity perspective: diverse sub-groups present in shared social system of setting Understanding differences in pathogenic & salutogenic processes Opportunity for inclusion & balancing inequity Bauer

31 Society Aging society Outlook: utilizing trends in health care Equity of health Health (care) as market / wealth Citizen sciences Fitness/beauty as ideal / social pressure Disease Patient groups Organization/ Collective Social movements Positive Health Personalized medicine Genomics Bauer/2016 Individualisation; self-determination & self- actualization Individual D-/E-/M-Health

32 Work related SoC as interactional construct related to job demands/resources & negative/positive health partially mediates the pathogenic and salutogenic path responsive to changes of job demands / resources Time pressure / Work Interruption Pathogenesis Insomnia Role unclarity Job Demands Negative Health Exhaustion Qualitative overload Pain Work-SoC Manager support / appreciation Satisfaction Peer support / appreciation Job Resources Positive Health Commitment Control / holistic Task Salutogenesis Enthusiasm (Bauer & Jenny 2007; Vogt, Jenny, Bauer 2013, Bauer et al. 2014) Bauer

Building Healthy Public Policy. the Salutogenic Way

Building Healthy Public Policy the Salutogenic Way Maurice B. Mittelmark Research Centre for Health Promotion University of Bergen Mittelmark MB. Building healthy public policy the salutogenic way. The