Salutogenesis
For the most part, in Western cultures at least, when we talk about health we are actually talking about negative health experience or ‘ill-health’ rather than more positive aspects of health. This has its roots in the medical model of health. Salutogenesis turns this idea around. Salutogenesis is concerned with what creates health and ‘what factors support health’ (Svalastog et al., 2017: 432). Antonovsky was the instigator of this idea and he has challenged the ‘pathogenic’ nature of the medical model including its fixation on the elimination of disease constituting ‘health’. Antonovsky (1996) argues that the focus should be on ‘symptoms of wellness’ rather than causes of disease and at-risk groups and that, given that we are ‘organisms’ we should accept that we will, at time, have things ‘wrong’ with us. The suggestion is, therefore, that ‘none of us can be categorized as being either healthy or diseased, (instead) we are all located somewhere along a continuum’ (Sidell, 2010: 27).
The holistic model
The contrasting medical and social models are not the only way to conceptualize health. Another way of looking at health is by taking a ‘holistic’ view, which takes a more integrated approach (Chronin de Chavez et al., 2005). Essentially holistic health is ‘an expression of wholeness’ (Svalastog et al., 2017: 431). This takes into account the interaction of biological, psychological and social factors (Earle, 2007a) and also views the person as a ‘whole’ rather than a sum of their ‘parts’. Holistic notions of health may be seen as taking into account mind, body and spirit (see Patterson, 1997 – in Earle, 2007a). The difference between the social model and a holistic approach to health is that the holistic approach tends to focus on the individual rather than social structures that influence the individual (Chronin de Chavez et al., 2005 and Earle, 2007a). A holistic approach underpins many complementary (or so called ‘alternative’) approaches to health. While a strength of a holistic approach is that it takes spiritual health into consideration, one of the criticisms of holistic approaches to health is that, similarly to the medical model, it is more individualistic and does not take wider social factors into account.
The biopsychosocial model
The biopsychosocial model of health is very closely aligned to holistic views about health but is nevertheless distinguished from it in the wider literature. Engel (1977, cited in Marks et al., 2015 and Sarafino and Smith, 2016) developed the biopyschosocial model of health and illness – an expansion of the (bio)medical model that combines social, psychological and biological aspects of health and accounts for the interaction between these. Biological factors include factors like genetics and our physiological condition and systems. Psychological factors include taking into account how we behave, how and what we think and how we feel. Social factors include consideration of the fact that we are social beings who interact with others within groups, communities and societies. This is a model of health that has influenced research, theory and practice in health psychology but arguably has not had as much impact in other disciplinary areas in relation to health.
Different perspectives
Different perspectives offer different contributions to our understanding of health. In the first instance let’s consider philosophical perspectives about health. Seedhouse (2001) argues that it is important to consider philosophy when trying to answer the question ‘what is health?’, since philosophy should be employed where competing and conflicting ideas about phenomena exist – health is a very good example of this. Another perspective is offered by psychology. Stephens (2008: 19) argues that psychology views health as ‘a matter for individual minds’. Mainstream approaches to health in psychology that focus on the individual in terms of cognitive processes and behaviour are closely aligned to the individualistic medical model of health, and the idea of the body as a machine (Stephens, 2008), which challenges more holistic ideas about health, reflected in more critical psychological perspectives. (See chapter 6, which explores the contribution of psychology in more detail.) Health is also equated with happiness for many people (Cloninger and Zohar, 2011). Warwick-Booth and Cross (2018) note how happiness has gained more attention over the past few years as concerns about health move away from illness and disease and focus more on notions such as well-being. There are a number of studies that clearly demonstrate the links between health and happiness and, specifically, the role that social connections have to play in subjective experiences in this area (for example, Clark et al., 2017).
Social construction
One of the key issues when trying to define health that also impacts on perspectives about health is the idea that ‘health’ is socially constructed. This means that the way we think about health is determined by a range of factors that influence us at any given time, in any given place. As a consequence, the notion of health is seen to be organic and fluid, changing all the time. Social constructionism argues that ‘meaning’ is socially constructed. In terms of health then, we can see that the meaning we give to it, or the way that we understand it is not straightforward or uncomplex. From a social constructionist perspective the meaning of health is created (constructed) through the way that we, as social beings, interact and the language that we use. Through talking about health we draw on different discourses, creating social consensus about what health actually is. We then reproduce and reinforce ideas about health through our talk and use of different discourses. This means that ideas about health are both timebound and culture-bound – they change and vary across time and place. In addition, many different ways of talking about health (discourses) may (and do) exist at any one time.
A moral phenomenon
It is also worth considering briefly a dominant theoretical idea about health that is concerned with its moral nature. Crossley (2003) argues that, increasingly, health has become synonymous with ideas to do with being a good and responsible person. The pursuit of health is therefore seen as something virtuous and highly valued. Lupton and Peterson (1996) refer to this as the ‘imperative of health’. The extent to which this notion is prevalent is indicated by research findings that demonstrate that people prefer to claim that they are healthy (Blaxter, 2010) or at least are trying to be (Cross et al., 2010). This ties in with neo-liberalist notions about individual responsibility. The notion that individuals have a moral responsibility to look after their own health is echoed through many aspects of health promotion and health-service provision. Lawton et al. (2005) highlights the promotion of self-management and self-care in people with type 2 diabetes, for example. The morality of health is strongly linked to ideas of ‘good citizenship’ and the drive to be a fully functioning member of society – one who protects and maintains their own health rather than being a strain on society’s finite resources. In contemporary Western societies this can be seen, for example, in the way that people who are overweight or obese are judged and blamed for their size.
So far we have focused on the way that health is theorized, which has largely drawn on professional discourse about health. The next section of this chapter will explore these ideas in more detail in relation to lay understandings about health.
Lay perspectives
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