Salutogenesis is the future of medicine: Instead of fighting diseases, the focus is on promoting and preserving health. Was your last check-up at the dentist part of the primary or of the secondary prevention? Find out and familiarize yourself with the various concepts of prevention, learn about health-related behavioral models and test your knowledge with exam questions. This way, you will be perfectly prepared for your upcoming tests in medical psychology and sociology.
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Salutogenesis: a Concept by Antonovsky

The term salutogenesis (salus = health, genesis = formation) was coined by medical sociologist Aaron Antonovsky in the 1980s as a opposite term to pathogenesis (pathos = pain, sorrow). Antonovsky compared the adaptability to menopause of various ethnic groups of women and found out that even concentration camp survivors could be classified as for the most part “healthy” – despite the inhumane tortures they had had to suffer.

His focus was on the question why some people remain healthy in spite of adverse personal and environmental factors. Health is not only the reduction of diseases; it should also be actively promoted.

Health is not a condition, it is a process. Accordingly, it is also important to focus on peoples’ resources than only focusing on their risks.

The concept of salutogenesis emphasizes two main pillars to the maintenance of health:

  • Generalized Resistance Resources: All human abilities for  reducing social, psychological, and biological stress. These include the immune system, social networks, intelligence, and mental flexibility.
  • Sense of Coherence (cohaerere = to be linked): People who can connect well with the world in all its forms are more stable in their orientations, actions, and economizing of resources. A high sense of coherence is conductive to health.

Resilience: Mental Flexibility

The term resilience refers to psychological and physical factors that help the individual go through life unimpaired by crises and diseases. A high resilience is characterized by acceptance, a focus on finding solutions, and trust in improvements, instead of self-pity and resignation. High internal locus of control („I can change something“) and corresponding styles of attribution are indicators for high resilience.

Prevention: Primary, Secondary and Tertiary

The term prevention is derived from the Latin praevenire = to obviate, prevent. The definition of prevention by the German Federal Ministry of Health is:

The term prevention is an umbrella term for the time-dependent interventions for health provision. With primary prevention, the development of diseases shall be prevented. The secondary prevention or early detection wants to detect diseases at an early stage, so that therapy can be initiated as early as possible. With tertiary prevention, consequences of diseases shall be mitigated, a relapse in already incurred diseases avoided and their exacerbation prevented.

Primary prevention

Primary prevention wants to prevent diseases before they first occur and appeals to both high-risk groups as well as healthy people. Important examples of primary prevention are:

  • Vaccinations
  • General measures, training, and campaigns on nutrition, stress management, HIV
  • Prevention of drug abuse

Secondary prevention

Secondary prevention describes specific measures that allow for an early detection of diseases. Diseases with known risk factors can be examined with specific preventive check-ups and screenings and can be intercepted beforehand or in the initial stages. Important examples of secondary prevention are:

  • Colon cancer: Colonoscopy
  • Melanoma: Skin screening
  • Breast cancer: breast screening
  • Cervical carcinoma: PAP smear

Tertiary prevention

Tertiary prevention is used when the disease has already manifested itself. The target group are mostly patients with chronic diseases. The tertiary prevention aims at minimizing or preventing secondary health damages and preventing relapses. Note the fuzzy differentiation between the terms tertiary prevention and rehabilitation. Rehabilitation is primarily responsible for re-integration into the occupational and social life. Important examples for the tertiary prevention are:

  • Rehabilitation measures
  • Follow-up treatment
  • Relapse prevention

The Prevention paradox

The key message of the prevention paradox: A preventive measure that is of great benefit to society is of little benefit to the individual – and vice versa. Examples for this are vaccinations, nursing hygiene in hospitals, and invasive preventive screenings.

Health Maintenance: The Most Important Models of Health-Related Behavior

Human behavior and choices, both negative and positive, significantly affect their health. Such behavior may be a result of lack of knowledge but many times it may be influenced by beliefs and attitudes. Various models to understand human behavior and its linkages with health have been studied.

Health behavior and social factors

The value of health in Western societies is constantly increasing; often, there is already talk of a new “religion of health”. The positive appreciation of health and associated life styles is an important prerequisite for participation in primary prevention.

Next to individual factors, there are environmental factors that influence health behavior: social networks like friends, family, and the workplace contribute to the formation of opinions. Health-related behavior is also highly dependent on the social class; for instance, vegetarian/vegan diet is more readily accepted in higher classes.

Health belief model

The health belief model focusses on the individuals’ health-related beliefs. People tend to behave more preventively when diseases, associated measures, and the situation as such are perceived as follows:

  • The disease is dangerous.
  • The risk of becoming sick is high for me.
  • The preventive measures are effective.
  • I have easy access to / no great expenses for preventive actions.
Please note: Women and members of higher social classes take more preventive action.

Theory of planned behavior (Ajzen and Fishbein, 1977)

„I think a vegetarian diet is a good thing.“ This attitude towards an action may lead to behavior in accordance with this attitude (eating vegetables) but it does not have to (eating meat anyway). This correlation between the influencing variables attitude, subjective norm, and behavioral control which then lead to forming an intention and consequential behavior is summarized in the model of planned behavior:


Image: “Theory of planned behaviour” by Robert Orzanna. License: CC BY-SA 4.0

Model of social comparison processes (Rijsman, 1983)

The propensity to compare himself and the fellows with each other is present in every human, sometimes more sometimes less strongly pronounced. This comparison is the focus of the model of social comparison processes. Two examples show the positive or negative effects of comparison processes in terms of individual health behaviour:

  • „He eats well and maintains his weight and has never had a cold.“ >> promotes own preventive behaviour
  • „My friends smoke and drink all the time and no one has health problems because of it.“ >> does not contribute to preventive behaviour

Risk Factor and Disease: Risk Parameters

In a best case scenario, there is a causal relationship between risk factor and disease. However, diseases are usually not the result of a single cause but of multiple causes. In order to make the interpretation of the risk factor-disease relationship more objective, absolute risk and relative risk can be calculated.

  • Absolute risk: Probability to become ill (Example: How many non-smokers develop lung cancer?)
  • Relative risk: The risk difference between people within a risk group and people with no risk factor is called relative risk. Quotient: Morbidity of exposed persons / morbidity of unexposed persons (Example: How many smokers and how many non-smokers develop lung cancer > quotient?)
  • Absolute risk reduction: The risk difference of clinical group and control group is called absolute risk reduction. It is an important parameter in intervention studies.
  • Attributable risk: The attributable (ascribed) risk indicates to what extent the disease can be attributed to the risk factor or other factors. (e.g. smoking and lung cancer or a higher genetic risk): calculating the difference: morbidity of the exposed persons – morbidity of the non-exposed persons

Changes in Risk Behavior: The 2 Most Important Models

Cognitive dissonance theory (Festinger, 1957)

In his theory, Festinger assumed the following: people aspire to consonance regarding their attitude and their behavior. If this fails, it creates an uncomfortable tension, the so-called cognitive dissonance. Example: An alcoholic would barely assess his consumption as healthy but drinks anyway. Two solution strategies can dissolve this cognitive dissonance:

  • Weaken the attitude by selective information retrieval („XY drinks ervery day and he is 87 years old“)
  • Find positive reasons for the behavior (taste, social behavior, …)

Transtheoretical model (Prochaska, Di Clement, 1994)

The transtheoretical model describes in 6 steps the successful process of behavioral change. As a future doctor, it is important to find out which stage your patient is currently in, in order to intervene properly and be able to treat him.

1 carelessness, not ready precontemplation
2 realization, getting ready contemplation
3 ready preparation
4 modification of behavior action
5 working to prevent relapse maintenance
6 self-efficacy, no risk of relapse termination

You can read more about the transtheoretical model in the article about motivation.

Health Promotion: The Most Important Institutions

The biggest role in health education plays the family. Our way of eating, personal care, and amount of exercise are largely dependent on the persons of reference we have in our childhood and adolescence. Also the extent to which we utilize preventive measures and how we behave in case of illness (e.g. consulting the doctor with every little cold or relying on naturopathic approaches), is also dependent on our parents.

We adopt from our person of reference as much health promoting attitudes as harmful attitudes.

Forms of Health Promotion

Personal health promotion attempts to modify the behavior of a single person. Longstanding examples are campaigns for the use of condoms, drug prevention programs, and the massive restriction of cigarette advertising.

Structural health promotion changes basic structures to promote positive impacts on health and reduce negative ones. Examples are taxation of tobacco products, mandatory wearing of seat belts, and restrictions on smoking.

Screening Procedures: Sensitivity and Specificity

The impact of health promotion activities is difficult to measure (e.g., how many people in the audience will be reached by campaigns?). In order to measure the efficiency of screenings, sensitivity and specificity are measured.

  • Prevalence: number of cases of a particular disease at a particular time in a defined group
  • Sensitivity: Sensitivity specifies how many people that were identified positive by a test (e.g. breast cancer screening) are actually sick.
  • Specificity: Specificity specifies how many persons who have been identified negative by a test are actually healthy.
  • Predictive value: a measure of the reliability of tests
  • Positive predictive value: The probability that people with a positive test result are actually sick.
  • Negative predictive value: The probability that people with negative test result are actually healthy.

With the help of this four-field scheme of alternatives, the parameters can be calculated easily:

Actual status
Diagnosis Positive (ill) Negative (healthy) Total
Positive (ill) Decision true positive Decision false positive B Positive predictive value A / A + B
Negative (healthy) Decision false negative C Decision true negative D Negative predictive value D / (C + D)
Total Sensitivity A / (A + C)  Specificity D / (B + D)

Health Promotion at the Workplace: Behavioral Prevention vs. Situational Prevention

Situational prevention

As an example, the German labour protection act regulates health protection and occupational safety. The focus is especially on situational prevention. § 4 states, „risks are to be controlled at their sources”. Thus, the labour conditions are optimized first, only then follows the protection of the individual. Situational prevention creates the conditions that provide the physical and mental protection of the workers.


  • Lighting, indoor climate, workplace dimensions
  • Protection against hazardous substances
  • Protection against noise

Behavioral prevention

Also in accordance with § 4 of the German labor act, the behavioral prevention must be implemented: „Employees must be given the appropriate instructions.” Behavioral preventive measures should educate employees to behave in a health preserving way. The occupational health physician is in this case bindingly responsible for educating and consulting.


  • Training for optimal sitting positions and back exercises
  • Stress management programs
  • In-house sporting activities

Modification of Behavior

Approaches from behavioral therapy play a central role in the implementation of prevention. The cooperation between the different health professionals is crucial: The physician by himself cannot cause behavioral change!

  • Operant tutorials
  • Stress management training
  • Problem solving training
  • Assertiveness training

Excursus on Clinical Practice: Health Promotion in Practical Daily Routine

The models and approaches are not only part of exams in medical school, but also especially important for health promotion in the clinical practice. Patient information and patient education contribute significantly to what kind of attitude patients develop towards certain disease patterns and to make them willing to participate in preventive measures (e.g., stress compromises the immune system with specific examples). The doctor’s educational activity alone is not enough: Concrete solutions with the associated measures must be handed to the patient (e.g., autogenic training).

Popular Exam Questions on Health Promotion  and Preservation

Solutions can be found below the references.

1. According to Prochaska and DiClement, the transtheoretical model of behavioral changes distinguishes 6 motivational stages. Which is not part of it?

  1. actio
  2. preparation
  3. contemplation
  4. preservation
  5. maintenance

2. The American psychologist L. Festinger created the theory of cognitive dissonance. Which of the following statements summarizes this theory best?

  1. In order to reduce the cognitive dissonance, 6 stages of behavioral changes have to be completed.
  2. Between the different social classes, there are big differences with respect to health promotion and preservation.
  3. Some people stay healthy in spite of adverse environmental factors and personal misfortunes.
  4. The health damaging behavior (e.g. smoking, alcohol) usually does not correspond to the original attitude of people but is linked to social groups or places (e.g. meetings in the pub).
  5. When people realize that their behaviour is at odds with their attitude, they rather change their attitude than their behaviour.

3. The 49-year-old Mrs S. had a serious car accident. The surgeries went well, the rehabilitation also. The patient feels well taken care of at any time by doctors and nurses and receives many visits in the clinic from family, friends, and colleagues. After being discharged from rehab, her partner and the neighbors help her with many things in everyday life that are still too burdensome. Colleagues also try to take over physically strenuous work, so that Mrs S. can still rest. What concept describes the reaction of Mrs S’s environment best?

  1. High resilience
  2. Health Belief model
  3. Social support
  4. Concept of salutogenesis
  5. Internal attribution



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