Future directions for the concept of salutogenesis: a position article.

Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOC) that helps to mobilize resources to cope with stressors and manage tension successfully (determining one's movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky's original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal's work to strengthen salutogenesis as a theory base for health promotion.

Resources for nurturing childcare practices in urban and rural settings: Findings from the Colombia 2010 Demographic and Health Survey.

BACKGROUND: The health and development potential of young children is dependent on nurturing care (NC) provided by primary caregivers. NC encompasses attention to nutrition; symptom management; early learning, attachment, and socialization; and security and safety. Despite the importance of NC to child health and development, the measurement and study of NC are neglected. This has become a point of major concern in the public health field in low- and middle-income countries (LMICs) such as Colombia where many families are hard pressed for childcare resources. The aims of this study were therefore to (a) create age-specific NC summary indexes (0-5, 6-11, and 12-23 months) suitable for research in LMICs and (2) examine the relationship of NC to maternal resources. METHODS: 2010 Colombia Demographic and Health Survey data were obtained from mothers and their children ages 0-5 months (n = 1,357); 6-11 months (n = 1,623); and 12-23 months (n = 3,006). Age-specific NC indexes were created including information on child feeding, immunization, hygiene, response to illness symptoms, and psychosocial care. Independent variables included mother's education level and household assets, and enrolment in a government child development programme. Regression analyses with NC as the outcome variable were conducted with urban and rural subsamples in the 3 age groups. RESULTS: Among rural children, NC was significantly higher with greater household assets, maternal decision latitude, and development programme participation, with variation by child age. Among urban children, higher maternal education and white-collar occupation also predicted higher NC, with some variation by age. CONCLUSION: It is feasible to measure age-specific NC in survey research, and NC is related to maternal resources. Age and urban-rural differences in how NC is related to social factors are observed. The findings support the importance of subgroup analysis in the study of NC in LMICs such as Colombia.

Setting an ethical agenda for health promotion

The Bangkok Charter for Health Promotion in a Globalized World has sparked lively dialogue. Welcomed by some as a Charter current to the times, there are others who see it as an unneeded and therefore unwelcome challenger to the Ottawa Charter for Health Promotion. Intended or not, the Bangkok Charter seems to signal a shift in discourse, from a social-ecological approach and an emphasis on individual and community capacity-building and empowerment, to an investment approach and an emphasis on globalization, macro-level factors and policy. Positively, the Bangkok Charter proclaims to build on Ottawa, and no one suggests it is meant to replace the Ottawa Charter outright. In concert with that, the dialogue today is not so much about the ascendancy of the one Charter over the other, but about the degree to which the Bangkok Charter remains true to the ethic of the Ottawa Charter. It is welcome that the Ottawa and Bangkok Charters are the subject of brisk dialogue about strategy and tactics in a rapidly changing world, and about the foundational values of health promotion. Regarding the latter, we have unfinished work in constructing an ethic for health promotion, and the present dialogue may inspire us to progress. Though we have the cornerstone of an ethic for health promotion, in the Ottawa Charter and in other principled documents that have followed, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified, and the same is true for research. Health promotion journals, conferences and organizations can and should do more to facilitate dialogue on ethics in health promotion, and the Internet provides the means for all to participate actively. (AU)

Promoting social responsibility for health: health impact assessment and healthy public policy at the community level.

The 1997 Jakarta Declaration on Health Promotion into the 21st Century called for new responses to address the emerging threats to health. The declaration placed a high priority on promoting social responsibility for health, and it identified equity-focused health impact assessment as a high priority for action. This theme was among the foci at the 2000 Fifth Global Conference on Health Promotion held in Mexico. This paper, which is an abbreviation of a technical report prepared for the Mexico conference, advances arguments for focusing on health impact assessment at the local level. Health impact assessment identifies negative health impacts that call for policy responses, and identifies and encourages practices and policies that promote health. Health impact assessment may be highly technical and require sophisticated technology and expertise. But it can also be a simple, highly practical process, accessible to ordinary people, and one that helps a community come to grips with local circumstances that need changing for better health. To illustrate the possibilities, this paper presents a case study, the People Assessing Their Health (PATH) project from Eastern Nova Scotia, Canada. It places ordinary citizens, rather than community elites, at the very heart of local decision-making. Evidence from PATH demonstrates that low technology health impact assessment, done by and for local people, can shift thinking beyond the illness problems of individuals. It can bring into consideration, instead, how programmes and policies support or weaken community health, and illuminate a community's capacity to improve local circumstances for better health. This stands in contrast to evidence that highly technological approaches to community-level health impact assessment can be self-defeating. Further development of simple, people-centred, low technology approaches to health impact assessment at the local level is called for.

Stability and change in older adults' social contact and social support: the Cardiovascular Health Study.

OBJECTIVES: The aim of this study was to examine the degree of individual change in structural indicators of social support (family network contact and close friend network contact) and functional indicators of social support (belonging, appraisal, and tangible support) during late life. METHODS: Using a large population-based sample of older adults, hierarchical linear modeling was applied to examine the extent of change in social contact and support as well as sociodemographic characteristics (age, race, gender, and education) that might explain individual variability in contact and support at baseline and over time. RESULTS: Consistent with predictions, small yet significant increases were observed in belonging support and tangible support. Contrary to predictions, no evidence was found for significant individual change in family network contact, close friend network contact, or appraisal support. Sociodemographic characteristics were more consistent predictors of variability in contact and support at baseline than variability over time. DISCUSSION: The findings of this study add to a growing literature suggesting that late life is not typically characterized by a decline in important social resources.

Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The Cardiovascular Health Study Group.

Peripheral arterial disease (PAD) in the legs, measured noninvasively by the ankle-arm index (AAI) is associated with clinically manifest cardiovascular disease (CVD) and its risk factors. To determine risk of total mortality, coronary heart disease, or stroke mortality and incident versus recurrent CVD associated with a low AAI, we examined the relationship of the AAI to subsequent CVD events in 5888 older adults with and without CVD. The AAI was measured in 5888 participants >/=65 years old at the baseline examination of the Cardiovascular Health Study. All participants had a detailed assessment of prevalent CVD and were contacted every 6 months for total mortality and CVD events (including CVD mortality, fatal and nonfatal myocardial infarction, congestive heart failure, angina, stroke, and hospitalized PAD). The crude mortality rate at 6 years was highest (32.3%) in those participants with prevalent CVD and a low AAI (P<0.9), and it was lowest in those with neither of these findings (8.7%, P<0.01). Similar patterns emerged from analysis of recurrent CVD and incident CVD. The risk for incident congestive heart failure (relative risk [RR]=1.61) and for total mortality (RR=1.62) in those without CVD at baseline but with a low AAI remained significantly elevated after adjustment for cardiovascular risk factors. Hospitalized PAD events occurred months to years after the AAI was measured, with an adjusted RR of 5.55 (95% CI, 3.08 to 9.98) in those at risk for incident events. A statistically significant decline in survival was seen at each 0.1 decrement in the AAI. An AAI of <0.9 is an independent risk factor for incident CVD, recurrent CVD, and mortality in this group of older adults in the Cardiovascular Health Study.

The psychology of social influence and healthy public policy.

Social-psychological research has led to effective health interventions based on social influence processes. For example, school-based substance abuse prevention programs using the social influences model consistently produce better results than programs emphasizing only health information. Other areas of application have been prevention of AIDS, marketing social action programs, community-wide health promotion, anti-prejudice intervention, aggression control, crime and injury prevention, and resource conservation. Yet another area for application is the emerging field of health promotion, which seeks to cross traditional boundaries to build healthy public policies in all sectors of society. A comprehensive social influences approach is needed because education alone is not likely to change fundamental ideas about where the responsibility for health rests. Current assignment of responsibility to the health sector and victim-blaming will be difficult to defeat. Positive changes at the required levels will depend on better understanding of how to instill health promotion values in policy arenas beyond the health care sector and better understanding of the dynamics of policy-making behaviors and related social influence processes. Social psychologists can and should assist the health promotion field to meet these challenges by conducting descriptive and intervention research on the psychology of social influence processes in public policy-making arenas.

Trends in tobacco use among Estonian and Russian youth in Tallinn.

Smoking behaviour and exposure to environmental tobacco smoke (ETS) were examined in three cross-sectional surveys from 1991/92, 1993/94, and 1995/96. The study population comprised 3,185 Estonian and Russian adolescents from 17 schools in Tallinn, Estonia. Prevalence of ever-smoking girls increased by 13 percentage points versus 2% among boys during the study period. Mean ages of the first experimentation with tobacco and exposure to ETS did not change significantly. Regular smoking increased significantly from 1991/92 to 1995/96. Detailed analyses for the 1995/96 survey showed that among ethnic Estonians, compared with ethnic Russians, the prevalence of ever-smokers and regular smoking were higher, mean age for the first experimentation was younger, and on average, Estonians smoked more cigarettes per week. The smoking trend among adolescents in Estonia is worsening; especially among Estonian youth. This study identifies a compelling need for national and community-wide efforts to deter adolescents from smoking and to reduce the exposure to ETS.

Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study.

CONTEXT: Multiple factors contribute to mortality in older adults, but the extent to which subclinical disease and other factors contribute independently to mortality risk is not known. OBJECTIVE: To determine the disease, functional, and personal characteristics that jointly predict mortality in community-dwelling men and women aged 65 years or older. DESIGN: Prospective population-based cohort study with 5 years of follow-up and a validation cohort of African Americans with 4.25-year follow-up. SETTING: Four US communities. PARTICIPANTS: A total of 5201 and 685 men and women aged 65 years or older in the original and African American cohorts, respectively. MAIN OUTCOME MEASURES: Five-year mortality. RESULTS: In the main cohort, 646 deaths (12%) occurred within 5 years. Using Cox proportional hazards models, 20 characteristics (of 78 assessed) were each significantly (P<.05) and independently associated with mortality: increasing age, male sex, income less than $50000 per year, low weight, lack of moderate or vigorous exercise, smoking for more than 50 pack-years, high brachial (>169 mm Hg) and low tibial (< or = 127 mm Hg) systolic blood pressure, diuretic use by those without hypertension or congestive heart failure, elevated fasting glucose level (>7.2 mmol/L [130 mg/dL]), low albumin level (< or = 37 g/L), elevated creatinine level (> or = 106 micromol/L [1.2 mg/dL]), low forced vital capacity (< or = 2.06 mL), aortic stenosis (moderate or severe) and abnormal left ventricular ejection fraction (by echocardiography), major electrocardiographic abnormality, stenosis of internal carotid artery (by ultrasound), congestive heart failure, difficulty in any instrumental activity of daily living, and low cognitive function by Digit Symbol Substitution test score. Neither high-density lipoprotein cholesterol nor low-density lipoprotein cholesterol was associated with mortality. After adjustment for other factors, the association between age and mortality diminished, but the reduction in mortality with female sex persisted. Finally, the risk of mortality was validated in the second cohort; quintiles of risk ranged from 2% to 39% and 0% to 26% for the 2 cohorts. CONCLUSIONS: Objective measures of subclinical disease and disease severity were independent and joint predictors of 5-year mortality in older adults, along with male sex, relative poverty, physical activity, smoking, indicators of frailty, and disability. Except for history of congestive heart failure, objective, quantitative measures of disease were better predictors of mortality than was clinical history of disease.

Exercise intensity and subclinical cardiovascular disease in the elderly. The Cardiovascular Health Study.

The authors assessed the cross-sectional association between intensity of exercise in later life and coronary heart disease risk factors and subclinical disease among 2,274 men and women, 65 years of age and older, who were participants in the Cardiovascular Health Study (CHS) during 1989-1990. Subjects were free of prior clinical cardiovascular disease or impairment of physical function. Exercise intensity was characterized as low, moderate, or high, based on highest intensity exercise reported over the 2 weeks prior to the CHS baseline examination. After adjustment for age, education, and postmenopausal hormone therapy (among women), there was an inverse dose-response relationship of exercise intensity with selected risk factors. By low, moderate, and high exercise intensity, respectively: fasting insulin-men, 15.6 microU/ml, 14.1 microU/ml, and 12.6 microU/ml, p for trend <0.001; women, 14.8 microU/ml, 13.8 microU/ml, and 12.0 microU/ml, p for trend = 0.01; serum fibrinogen-men, 316.2 mg/dl, 315.4 mg/dl, and 300.0 mg/dl, p for trend = 0.01; women, 327.3 mg/dl, 317.0 mg/dl, and 310.7 mg/dl, p for trend = 0.01; lower extremity arterial disease by percent with ankle-arm index <0.9-men, 18.3, 5.5, and 3.7, p for trend = 0.01; women, 10.0, 5.7, and 2.8, p for trend = 0.02; evidence of myocardial injury by cardiac infarction/injury score (CIIS)-men, 8.0, 6.0, 3.9, p for trend <0.001; women, 4.6, 3.9, and 3.6, p for trend = 0.03. Adjustment for smoking, alcohol consumption, and total kilocalories expended in exercise altered the findings only slightly. The authors conclude that intensity of exercise in later life is associated with favorable coronary disease risk factor levels and a reduced prevalence of several markers of subclinical disease.

Health effects of caregiving: the caregiver health effects study: an ancillary study of the Cardiovascular Health Study.

We propose that two related sources of variability in studies of caregiving health effects contribute to an inconsistent pattern of findings: the sampling strategy used and the definition of what constitutes caregiving. Samples are often recruited through self-referral and are typically comprised of caregivers experiencing considerable distress. In this study, we examine the health effects of caregiving in large population-based samples of spousal caregivers and controls using a wide array of objective and self-report physical and mental health outcome measures. By applying different definitions of caregiving, we show that the magnitude of health effects attributable to caregiving can vary substantially, with the largest negative health effects observed among caregivers who characterize themselves as being strained. From an epidemiological perspective, our data show that approximately 80% of persons living with a spouse with a disability provide care to their spouse, but only half of care providers report mental or physical strain associated with caregiving.

Community education for cardiovascular disease prevention. Morbidity and mortality results from the Minnesota Heart Health Program.

The Minnesota Heart Health Program was a community trial of cardiovascular disease prevention methods that was conducted from 1980 to 1990 in three Upper Midwestern communities with three matched comparison communities. A 5- to 6-year intervention program used community-wide and individual health education in an attempt to decrease population risk. A major hypothesis was that the incidence of validated fatal and nonfatal coronary heart disease and stroke in 30- to 74-year-old men and women would decline differentially in the education communities after the health promotion program was introduced. This hypothesis was investigated using mixed-model regression. The intervention effect was modeled as a series of annual departures from a linear secular trend after a 2-year lag from the start of the intervention program. In the education communities, 2,394 cases of coronary heart disease and 818 cases of stroke occurred, with 2,526 and 739 cases, respectively, being seen in the comparison communities. The overall decline in coronary heart disease incidence was 1.8 percent per year in men (p = 0.03) and 3.6 percent per year in women (p = 0.007). For stroke, there were no significant secular trends. The authors recently published findings showing minimal effects of sustained intervention on risk factor levels. In the current report, there was no evidence of a significant intervention effect on morbidity or mortality, either for coronary heart disease or for stroke.

Use of subdermal contraceptive implants in a community-based family planning program. Experience after two years.

PIP: In North Carolina, the Rutherford County Family Planning Council obtained funds from a special grant for levonorgestrel implants for women not eligible for medical assistance benefits. The Council approved the following approaches to promoting responsible sexual behavior and preventing unwanted pregnancy: creation of an interagency council to monitor the program, education in the schools on responsible sexual behavior, establishment of an information-sharing network for social service agencies, and expanded, low-cost or free family planning services. During 1992-1993, clinicians at the county health department and in private practices inserted implants in 287 women aged 13-37 living mainly in Rutherford County but also in McDowell and Polk counties. A survey was also conducted in the public high school to obtain self-assessment and information about family planning from female adolescents. Age distribution of the acceptors of the contraceptive implants was 40% for 13-19 year olds (the initiative's target group), 34% for 21-25 year olds, and 32% for 18-20 year olds (32%). The two-year insertion rate for women aged 10-19 was 17.3/1000 compared to 20.8/1000 for women aged 20-29. The implantation rate was greatest among 18-25 year olds and lowest among women aged 26 and older. The method of payment for implantation was medical assistance in 69% of cases and a philanthropic foundation for women not eligible for medical assistance in 29% of cases. 8% had the implants removed during the study period. The leading reason for removal was psychological distress (25%), followed by headaches (20.8%), desire to conceive (16.7%), bleeding (12.5%), and medical contraindication (12.5%). The interval between implantation and removal ranged from less than 3 months to more than 12 months. 2.3% of the female high school students used implants. Among the 596 students who were sexually active, 4.2% used implants, 1.85% used a diaphragm, 27.5% used condoms, and 15% used oral contraceptives. The implant acceptors attended 65% of scheduled 3-month follow-up visits.^ieng