Physical activity and salutogenesis: a necessary dialogue

Abstract

This essay aims to broaden the dialogue between physical activity (PA) and health by a salutogenesis-oriented concept, which emphasizes the origins of health, as opposed to the pathogenic model, which focuses on the origin of diseases. It presents the foundations of the theory, created by Aaron Antonovsky, whose health promotion model is centered on the sense of coherence (SOC), which consists of significance, comprehensibility, and manageability. Then, it explores the relationships between PA and salutogenesis, demonstrating how this framework can be applied in various life stages and practice settings. Studies indicate that people with a strengthened SOC will likely remain physically active. However, this relationship is not instrumental and depends on contextual, cognitive, and affective factors. This essay concludes by advocating for further research in Brazil and highlighting salutogenesis as a promising perspective to guide a new understanding of PA and health.

Key words:
Exercise; Health promotion; Sense of coherence

Resumo

Este ensaio busca ampliar o diálogo entre atividade física (AF) e saúde a partir de um conceito orientado na salutogênese (origens das saúdes) que tensiona o modelo patogênico (origem das doenças). Apresentam-se os principais fundamentos da teoria, criada por Aaron Antonovsky, cujo modelo de promoção da saúde centra-se no pilar do senso de coerência (SCo), que é constituído pela significância, compreensibilidade e capacidade de gerenciamento. Depois são apresentadas as relações entre AF e salutogênese que podem ser utilizadas nos vários ciclos da vida e nos contextos de prática. São apresentados estudos que identificam que pessoas com um SCo fortalecido apresentam maiores possibilidades de se manterem fisicamente ativas, mas essa relação não é instrumental e depende de elementos contextuais, cognitivos e afetivos. Finaliza-se indicando que novos estudos sejam feitos no Brasil e que a salutogênese se mostra como uma perspectiva profícua para orientar uma nova concepção de AF e saúde.

Palavras-chave:
Exercício físico; Promoção da saúde; Senso de coerência

Resumen

Este ensayo busca ampliar el diálogo entre la actividad física (AF) y la salud a partir de un concepto orientado a la salutogénesis (origen de la salud) que tensiona el modelo patogénico (origen de las enfermedades). Se presentan los fundamentos principales de la teoría, creada por Aaron Antonovsky, cuyo modelo de promoción de la salud se centra en el pilar del sentido de coherencia (SCo), que se constituye por la significación, la comprensibilidad y la capacidad de gestión. Presentamos las relaciones entre la AF y la salutogénesis que pueden utilizarse en los distintos ciclos de la vida y contextos de práctica. Se presentan estudios que identifican que las personas con un SCo fortalecido tienen mayores posibilidades de mantenerse físicamente activas, pero que esta relación no es instrumental y depende de elementos contextuales, cognitivos y afectivos. Se concluye indicando que se realicen nuevos estudios en Brasil y que la salutogénesis se muestra como una perspectiva fructífera para orientar una nueva concepción de la AF y salud.

Palabras clave:
Ejercicio físico; Promoción de la salud; Sentido de coherencia

Introduction

In 2021, the Brazilian Physical Activity Guidelines for the Population were published¹. Fifteen years earlier, in 2006, the Brazilian National Health Promotion Policy was integrated into Bodily Practices and Physical Activities within Primary Health Care². Brazil is recognized as a global leader in physical activity (PA) and health³; this topic remains under active debate across scientific, political, and educational spheres.

However, Brazil faces significant social inequity and inequality that hinder people’s access (especially black individuals, women, besides those with low education and income) to goods, services, and rights, including opportunities for PA⁴. This context explains the paradox: despite being a leader in the field, a substantial portion of Brazilians do not meet the PA recommendations set forth by health authorities.

Beyond these factors, it is crucial to recognize that a conceptualization of any social phenomenon shapes the associated actions derived from it. Within Health Sciences, a biomedical conception rooted in the pathogenic model (i.e., which seeks the origin of the disease) predominates. This model centers on biophysiological deficits or behavioral risks, mainly focused on cure and/or prevention.

This approach, based on a dualistic view of health (i.e., one is either ill or well), carries both moral and economic imperatives. Morally, it tends to stigmatize lifestyles that deviate from socially sanctioned norms (e.g., regarding sexuality or body shape and size). Economically, the expectation is that a reduction in the appearance of diseases will lead to fewer resources being spent by the State⁵. Often reduces bodies to “functional tools” for capital production and relies on punitive discourses that blame individuals for failing to become healthy/productive.

Before proceeding, it is crucial to outline the key conceptualizations of PA. The traditional definition frames PA as energy expenditure produced by skeletal muscles above resting levels. An alternative view regards PA as the movement of people within specific cultural contexts shaped by a range of interests, emotions, instructions, and social relationships⁶. This latter concept represents a “shift” from a restricted understanding (i.e., centered on muscles, energy expenditure, the dichotomized body) to a broader perspective, that acknowledges individuals in movement, sociocultural contexts, values ​​productive capacity, also guides the interests, emotions, and ideas that permeate the experience of PA.

Although aligned with international organizations (e.g., the World Health Organization’s PA guidelines), the Brazilian Guide defines PA as “physical activity is a behavior that involves voluntary body movements with levels of energy expenditure above the levels of rest and that promotes social and environmental interactions. It may happen during leisure time, while in transport from one place to another, at work or school, and during household chores”¹. Although it acknowledges social and environmental dimensions, the definition echoes the traditional focus on self-care centered on individual responsibility for maintaining PA, regardless of the domain in which it is practiced.

The four domains of PA (leisure, transportation, work/study, household chores) are fundamentally different when considering the relationship between PA and health. In addition to the utilitarian and behavioral aspects, human development is indicated by PA performed in free time (leisure-time)⁴. This underscores the need for an expanded lens on PA’s role in health promotion. The Ottawa Charter defines health as the process of building life projects through which people learn, play, work, and love in their lives. To sum up, an expanded perspective on PA and health centers on people within specific sociocultural contexts who collectively construct their life projects amid diverse interests, ideas, emotions, and relationships^5,6.

Despite this expanded view of PA and health, a conception rooted in the biological aspects of energy deficit and risk factors still predominate. Consequently, a pathogenic orientation towards PA is often linked to a negative concept, such as: “Do PA and you won’t get sick”. It is not uncommon to see advertisements that highlight a “difference” between people who engage in PA as “healthy/happy/capable” and those who do not do PA as “sick/sad/incapable”, as if PA were the “only path to happiness” or a panacea.

A pathogenic approach to PA fails to address a true healthpromotion agenda. This compels us to seek alternative frameworks that respect people and their diverse ways of life within a democratic context. We believe salutogenesis offers a promising lens for reimagining PA and health. This approach fosters a plurality of health that empowers people to find meaning to move forward. Salutogenesis represents a significant turning point, and a paradigm shift in the field of health, as it seeks the origins of health rather than diseases^7,8. It means a paradigm shift in health, seeking the origins of health rather than disease. Accordingly, this essay presents and reflects on the potential of a salutogenesis-oriented concept of PA and health as a healthpromotion perspective.

Theory of salutogenesis

The American Israeli sociologist Aaron Antonovsky (1923-1994), whose work focused on Medical Sociology, developed the salutogenesis theory. At the same time, Antonovsky identified central elements of the salutogenic theory in his studies of coping and breakdown. While researching women who survived concentration camps, he noted that despite enduring severe stressors, they remained surprisingly healthy and happy and built robust social networks (family, work, community activities). From this observation emerged the “health mystery,” encapsulated by the question: Why do some people stay healthy or recover from illness?⁷

Antonovsky found the answer in the salutogenic model (Figure 1), shifting attention from the pathogenic axiom; he reframed health as a positive concept. At the core of the model lies the Sense of Coherence (SoC), which explains why individuals move toward the healthier pole on the health-disease continuum. A strong SoC enables a person to mobilize generalized resistance resources (what we will call health resources) encompassing sociocultural, psychological, physical, economic, and other supports, to successfully confront life’s stressors^7,8.

Figure 1
Salutogenesis theory model.

The SoC is understood as a global orientation that life, though dynamic, is comprehensible, manageable, and meaningful. Three dimensions constitute its pillars: 1) Comprehensibility (cognitive): perceiving life’s events and environments as structured, predictable, and explicable (e.g., understanding the biopsychosocial effects of PA); 2) Manageability (behavioral): recognizing that resources are available to meet life’s demands (e.g., identifying and leveraging local spaces, programs, and policies for PA in your community); 3) Meaningfulness (emotional): feeling that life’s challenges are worthy of commitment and engagement (e.g., being motivated to view PA as contextually significant for your life)⁷.

A strong SoC and the successful use of health resources lead to consistent and repeated life experiences, which facilitate movement toward health. However, Antonovsky⁸ cautions against this theoretical-conceptual conjecture when the obligation to stay healthy is placed on the individual. For the author, life experiences related to consistency, the balance between low load/overload, and participation in decision-making depend on each person’s position in the social structure and culture.

This insight aligns with the “river of life” metaphor (Figure 2). Antonovsky critiques the biomedical focus on “rescuing swimmers” downstream or preventing disease to push them upstream. These actions help us to keep the question in mind: Who or what is pushing people into the river? Thus, if we are in the river and never close to the shore, in addition to the question of how well we can swim, another question also arises: How dangerous is this river (i.e., can it have turbulent parts, rocks, etc.)? In this sense, the river represents the sociocultural elements of people’s lives. Therefore, the focus cannot be solely on the individual (the swimmer) but must also consider the sociocultural context (the river).

Figure 2
The metaphor of the river of life.

Finally, Antonovsky intended to provide a theoretical model that grants health promotion the autonomy to flourish. Internationally, salutogenesis has been applied across hospital care, primary care, mental health, education, nutrition, and other fields. In Brazil, research on salutogenesis appears mainly within nursing, dentistry, and education.

Although salutogenesis focuses on health promotion, it does not exclude the pathogenic work of curative and preventive medicine, which remains necessary at certain points in life’s river. Salutogenesis (health promotion) should be partnered with pathogenesis (disease prevention/curative care) without being dominated by it.

PA and salutogenesis

Antonovsky hoped that salutogenesis would be adopted by professionals in other fields, like physical education (PE). The physical educator in Brazil is the professional who develops activities focusing on body practices, or PA, or physical exercise. In 2020, Brazil’s Ministry of Labor introduced code 224140, “Physical Education Professional in Health,” in its national occupational classification, underscoring the need to broaden the PA-health dialogue to encompass primary care, leisure, and private sectors.

This discussion builds on existing work linking PE and salutogenesis and informs our reflection on PA and health. Researchers in the field have applied salutogenic principles to diverse life stages, health conditions, and practice contexts, including schools, primary care, hospitals, and sports clubs.

In Brazil, Amauri Oliveira⁹ published the first known text on PE and salutogenesis in 2004, examining school PE pedagogy through a salutogenic lens. He argued that salutogenesis offers a novel way to conceive and teach health in PE, helping students navigate life’s currents and reach the riverbank of well-being autonomously and safely.

Internationally, Mikael Quennerstedt stands out for his work on PE and salutogenesis. In 2008, he proposed a salutogenic approach to PE committed to a publichealth agenda. His focus on health learning aims to enrich lives, empowering people as healthy citizens and contributors to sustainable development¹⁰.

Both Oliveira and Quennerstedt challenge the pathogenic paradigm in PE. Quennerstedt is even more incisive. He highlights that a pathogenic orientation is limiting, because focusing only on the disease, it loses sight of the individual and offers “simple” and/or “reductionist” solutions to complex public health problems, as in the phrase: “Be more active and you will have good health”. These considerations seem to emphasize the normalization of behaviors, neglecting the need to transform the perverse conditions (i.e., inequities) of life faced by many.

Antonovsky⁷ posed the “health mystery”; however, we focus on the “PA and health mystery”: Why do people become or remain active despite barriers and stressors? The SoC may hold clues. People with a strong SCo would have a better chance of understanding the relationship that PA has with their health and how to access/practice it, as well as mobilizing the necessary resources to manage their access and permanence in the field of movement, since they also construct meanings to keep moving.

Supporting the statement above, studies have addressed the relationship between salutogenesis/SCo and PA/PE in various contexts. Bronikowski¹¹ showed that a 15-month follow-up multicomponent intervention program increased leisure-time PA in participants compared to the control group. Myers et al.¹² found through a cohort study that people with strengthened SCo, after surviving a myocardial infarction, presented greater engagement in leisure-time PA. Thompson et al.¹³ observed that a PA intervention in movement communities strengthened SCo, especially among those with initially lower SCo. Regarding Asian and African refugee students in Swedish schools, Cseplö et al.¹⁴ highlighted that understanding PE and health promotion can be favored with strengths-based approaches. Ericson et al.¹⁵ found that PA practiced in a stable peer group was significant, understandable, and manageable for maintaining health in active elderly women after the end of an intervention.

The studies mentioned represent a range of publications that warrant analysis in future literature review studies. For this essay, it is worth noting that, in general, the applications of Salutogenesis in the field of PE include work that aims to strengthen the SCo for the management of available health resources, mainly those linked to access to and practice of PA. In this sense, a salutogenic orientation of practices seems to contribute significantly to people becoming more physically active and taking care of their health.

Following Quennerstedt¹⁰, we assert that PA or movement contributes to developing health-promoting resources, especially through rich PA experiences. However, it is not only the rich PA experiences (in the instrumental sense: PA = health) that become health resources, but also the cognitive and affective qualities of movement (conceptual understanding, self-understanding, joy of movement, expression, aesthetic attitude, strengthening experiences). In this sense, we can consider that it is about much more than PA. Thus, we advocate for the idea that we do not work with movement, but with people who move; indeed, we need to help them have rich experiences of PA and movement oriented towards health.

Importantly, guiding a new conception of PA and health from a salutogenic perspective, although it is a first (and important) step, will not be enough to promote substantial changes in the field of PA and health. As highlighted by Antonovsky⁸, the use of salutogenesis within the neoliberal logic may imply a simplistic view: “do PA and be healthy or be healthier”. It is crucial to avoid reducing the search for health as something centered on the individual, but rather to consider the need to change the adverse living conditions to which many are subjected and which are barriers to accessing rights, such as the practice of PA, sports, and leisure.

Above all, it is significant to conduct studies that consider the relationship between PA and salutogenesis, especially in Brazil, where the theory is little known. Initially, this relationship can be investigated quantitatively, verifying the association between SCo, PA level, and the social determinants of health. In addition, exploring how people signify, manage, and understand the relationships between PA and health can offer innovative insights from qualitative approaches.

In summary, the salutogenesis theory is promising for guiding a new and expanded conception of PA and health, broadening the dialogue on the topic. In this sense, it can contribute to the implementation of actions based on the PA Guidelines for the Brazilian Population. This implies an understanding that “more than PA” is needed to enable access to the Guide’s recommendations, not least because health promotion actions, through the practice of PA, require an approach that goes beyond the pathogenic approach (i.e., centered on deficits and risk factors). This approach is especially necessary in Primary Care and leisure, since people need positive and healthy contexts for the development of life projects in which PA makes sense, is understood, and can be managed with the support of available health resources for empowerment, happiness, and the valorization of lives.

References

• ¹ Brasil. Ministério da Saúde (MS). Guia de Atividade Física para a População Brasileira. Brasília: MS; 2021.
• ² Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde - PNPS: revisão da Portaria MS/GM nº 687, de 30 de março de 2006. Brasília: Ministério da Saúde; 2015.
• ³ Hallal PC, Umpierre D. Guia de Atividade Física para a População Brasileira. Rev Bras Ativ Fis Saúde 2021; 26:e0211.
• ⁴ Programa das Nações Unidas para o Desenvolvimento (PNUD). Relatório de desenvolvimento humano nacional - movimento é vida: atividades físicas e esportivas para todas as pessoas: 2017. Brasília: PNUD; 2017.
• ⁵ Quennerstedt M. Healthying physical education - on the possibility of learning health. Phys Educ Sport Pedagogy 2019; 24(1):1-15.
• ⁶ Piggin J. What is physical activity? A holistic definition for teachers, researchers and policy makers. Front Sports Act Living 2020; 2:72.
• ⁷ Antonovsky A. Health, stress and coping. San Francisco: Jossey-Bass Publishers; 1982.
• ⁸ Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996; 11(1):11-18.
• ⁹ Oliveira AAB. O tema saúde na educação física escolar: uma visão patogenética ou salutogenética? In: Kunz E, Hildebrandt-Stramann R, organizadores. Intercâmbios científicos internacionais em educação física e esportes. Ijuí: Ed. Unijuí; 2004. p. 241-260.
• ¹⁰ Quennerstedt M. Exploring the relation between physical activity and health - a salutogenic approach to physical education. Sport Educ Soc 2008; 13(3):267-283.
• ¹¹ Bronikowski M. Is sense of coherence needed to keep youth physically active? Med Sport (Roma) 2010; 63(4):465-483.
• ¹² Myers V, Drory Y, Gerber Y. Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: a prospective cohort study. BMC Public Health 2011; 11:708.
• ¹³ Thompson K, Herens M, Ophem JV, Wagemakers A. Strengthening sense of coherence: Evidence from a physical activity intervention targeting vulnerable adults. Prev Med Rep 2021; 24:101554.
• ¹⁴ Cseplö E, Wagnsson S, Luguetti C, Spaaij R. 'The teacher makes us feel like we are a family': students from refugee backgrounds' perceptions of physical education in Swedish schools. Phys Educ Sport Pedagogy 2022; 27: 531-544.
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• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vânia de Matos Fonseca

Publication Dates

• Publication in this collection
  08 Sept 2025
• Date of issue
  Aug 2025

History

• Received
  15 Aug 2023
• Accepted
  16 July 2024
• Published
  18 July 2024