Towards Relation Based Health Promotion

In times of corona crisis and climate catastrophes - as expressions of disturbed human-nature relationships - a renaissance of an (almost exclusive) pathogenetic orientation has occurred in health policy and the medical system, which also dominates everyday life. The underlying question of how health can be created, maintained and strengthened has fallen behind. Here, there is a need for counteraction at every level. We deliberately do not focus on preventing diseases (however topical; this may seem) but ask how health can be promoted in a future-oriented way. 

The following considerations are based on the conviction that future health promotion and prevention will be oriented toward the common good, solidarity and person-centred. We refer to the Ottawa Charter [1] and its accentuation of health development as a process based on our everyday life and can be promoted explicitly in different settings. These basic statements are still relevant but have only been implemented in part so far. In particular, building healthy public policy is needed. 

A future health promotion combines interrelated bottom-up initiatives and centrally coordinated interventions. It is financed independently of profit orientation and individual interests, and it combines global orientation, supra-regional networking and local action. It uses both experience-based and research-based knowledge and is based on a fundamental attitude of recognition that guides the relationship between people and their environment. The right to health is accompanied by empowerment support, especially in crises, to enable comprehensive recovery. The possibility of healthy development of each person and the population is a fundamental human right.

• The development of health and illness is a lifelong and interconnected process that aims at a sustainable and coherent shaping of the person-environment (or person- within-the-environment) relationship. Health is thus related to the lifeworld, biographically anchored and individual [2]. At the same time, following a systemic understanding, it is population-related and oriented towards maintaining and promoting the self-regulation capacity of the respective environment and co- environment [3].
• Health promotion and prevention are to be understood as an overarching perspective that, in the sense of salutogenesis, guides the various activities related to the development, education, empowerment and maintenance of health. The health promotion of the future is interdisciplinary and intersectoral.
• Prevention and health care are subordinate to the more general goal of health promotion.
• Future health promotion takes up the existing competencies and resources -starting with the citizens/people affected, their immediate living environments, and primary support systems. It taps into the resources available at the municipal level and establishes relationships with regional, national and international voluntary and professional helpers. The common goal is to help people help themselves, i.e., promote competencies for solving questions independently to shape a meaningful and successful life from the actors' perspective [4]. 

• Health education is a social and nature-related process that concerns psychological, emotional, spiritual and physical aspects in equal measure and is relationally mediated from the very beginning [5]. Health and illness are not only in but between people. Future health promotion is serious about "introducing the subject" [6] into medicine, pedagogy, social work, etc. It enables the empowerment of citizens. It enables the empowerment of citizens and authentic professional action in which the helpers can be recognised and experienced as persons. The citizens' existing personal competencies are valued, and the limited and specific resources of the helpers in research and practice.

• The promotion of health education processes also accompanies the classic activities of health care, nursing and rehabilitation and is based on a fundamental salutogenic orientation. In the future, education, further education and training of person-related activities will place equal emphasis on the continuous teaching of technical knowledge and on experiencing, training and testing the necessary salutogenic attitudes and competencies [7]. Self-experienced participation is a prerequisite for the ability to participate [8]. 

• Health education is a (re-)constructive process in which individuals' buried needs and social, experiential knowledge about health processes come to a new effect in a future-oriented way. 

• The formation of health is also a biographical process, the conscious shaping and appropriation of which takes place interactively and not least through storytelling [9]. In upheaval and crisis, personal and continuous support and tailored information are helpful. The health promotion of the future is based on a culture of recognition and tolerance.
• The health promotion of the future faces the dual task of enabling individuals (and their members) to develop the health that suits them and contribute to the promotion of the "health" of society as a whole. In particular, it is necessary to respect the momentum of the (external and internal) nature that sustains us. (10) Therefore, we need spaces for understanding and open discourse in society about how the members of society as a community understand successful living and want to create the conditions for it.

• A new Federal Ministry for the Environment, Health and Sustainable Development should guarantee the framework conditions for these communication processes in Germany nationwide. The concrete implementation starts with bottom-up approaches considering the local structures, is scientifically accompanied, and the results are continuously put up for public discussion [11,12]. 

• Analogous to refocusing the health system from a curative to a salutogenic, health-promoting approach, policymakers must adjust the financing accordingly. Thus, relational-based public health would become value-based in a double sense [13]. First, due to the expected relief in the cost-intensive curative area, health promotion through offers in health education, nutrition and exercise etc., is possible in a cost-neutral way. 

• Health promotion of the future has a socially compensatory and socially integrative effect. Where necessary, it has a walking structure and becomes active in the respective living environments of those involved. 

Postscript 

The text presented here originated from a position paper (2021) prepared by a working group of the Dachverband Salutogenese (www.dachverband-salutogenese.de) and intended as a contribution to the health policy discussion in Germany. Participants were: Pascale Dauster, Barbara Doss, Eberhard Göpel, Sandra Kunz, Anja Lietz, Rüdiger-Felix Lorenz, Helmut Rachl, Kirsten Rachl, Christina Röhrich, Michael Röslen, Maria Sailer, Ulrich Sappok, Gerhard Unterberger, Thomas Zängler and Ottomar Bahrs (coordination and editing). The author thanks all those involved for their constructive cooperation. The position paper was revised for this publication, supplemented with literature references and translated.

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