Modeling Salutogenesis as Health Culture Diplomacy: Refocusing the Compass for Healthcare Reform

Martha Mathews Libster,PhD, MSN, APRN-PMHCNS, APHN-BC, FAAN

People throughout history have challenged the leaders of their socio-cultural institutions including governments and healthcare systems to consider their unique needs as persons, families, and communities when seeking to promote community health. In healthcare, that which people are asking for is an approach often defined as person- or relationship-centered care (PRCC). A PRCC approach is often discussed as best practice for people and systems (Institute of Medicine, 2001; Libster, 2015). Yet, while some healthcare systems incorporate those requests in system designs and practice, other systems and the people who work within them have yet to address the people’s challenge. Those systems have been described as de-humanized and even profit driven. Can a de-humanized, profit-driven healthcare system be reformed?

Whether or not a societal reform, such as healthcare reform, is in fact a “reform” is measured over time. Reforms are advanced with the intention of creating meaningful change that promotes society’s goals for such things as health or peace. While “healthcare” is often commodified (Caplan, 1989) as a product to be bought and sold, it is also a cultural institution and the peoples who serve within it carriers of health beliefs and practices tied to the institution’s enduring paradigms and traditions. Those who reform or change a healthcare system also face the challenges of addressing enduring beliefs and practices rooted in the culture that answer questions, such as “What is health?” “What is the nature of illness?” and “What are the best cures and cares for any given condition or concern?”

Cultural Diplomacy as a Peacemaking Antidote

The word culturecomes from the Latin colere meaning to cultivate. Ur in Hebrew means light. A synthesis of the roots of these words suggests that culture is, in essence, the cultivation of light. Shedding light on the process of healthcare system reform and the compass for decision making within those systems is the role of the health culture diplomat whose skills are set to promote peace and resolve conflict. Health culture diplomacy differs from “global health diplomacy” and political diplomacy in which the purpose is to advocate and extend one’s own or one’s country’s beliefs, values, traditions, and resources. Both have their place. Cultural diplomacy however is defined as, “A course of actions, which are based on and utilize the exchange of ideas, values, traditions and other aspects of culture or identity, whether to strengthen relationships, enhance socio-cultural cooperation or promote national interests; Cultural diplomacy can be practiced by either the public sector, private sector or civil society” (Institute for Cultural Diplomacy, 2025). The ethic associated with cultural diplomacy is a living ethic in which healthcare providers “bracket their own values, beliefs, traditions, and practices to focus on healthcare solutions that are person-, family-, community- or nation-centered rather than what the health practitioner prescribes”(Libster, 2015) or believes. Diplomacy is a peacemaking antidote to the culture clashes that often stem from differences in health beliefs, practices, and system policies that can lead to frustration, power struggles, anger, and even violence.

In health culture diplomacy, different ways of knowing, believing, and practicing healthcare are welcomed to round table discussions. Those ways can be organized as four subcultures within healthcare as depicted in the Cultural Diplomacy Model© published by a nurse-led interdisciplinary team in 2015. (See Figure 1) Nurses have been cultural diplomats in their communities at least since the early 19th century leading healthcare reform movements (Libster, 2004) with their integrative approaches to care that include traditional health beliefs and healing practices as well as emerging scientific technologies used by a variety of disciplines.

The first subculture of healthcare culture is the biomedical. Hospital systems are the dominant structures within the biomedical culture in which there is a pervasive emphasis on pathogenesis, as the diagnosis and eradication of disease. The second subculture, traditional / indigenous healing, with its emphasis often on the practice of herbal medicine, continues to be part of the health culture of at least 80% of the worlds populations. (Farnsworth et al., 1985) The third is a subculture more recently known as complementary therapies and the fourth is self-care, which sociologists, Levin and Idler, identified in 1981 as the “Hidden Healthcare System.”(Levin & Idler, 2010)

The skills associated with health culture diplomacy all focus on promoting peace, which is associated with health, by welcoming and integrating these different ways of knowing, believing, and practicing into PRCC plans and in the design and reform of the systems where people seek care. The three major skills of the health culture diplomat defined in the Cultural Diplomacy Model© are peacemaking communication, solution-focused negotiation, and mindfulness, which refers to non-habitual thoughts and behaviors (Langer, 1989). These three specific skills are all action-oriented, behavioral skills that can be taught and measured as opposed to the more reflective, self-assessment foci, such as cultural “sensitivity,” “awareness,” “competence,” and “humility.”

Modeling Toward Complementarity

In the Cultural Diplomacy Model©, diplomacy starts with modeling, which refers to the learned process of developing an image and understanding of a client and their world and perspective (Erickson et al., 1983, p. 95). A “client” can be a person, family, community, or nation. Using peacemaking communication, such as essence listening, one of the skills in health culture diplomacy, the practitioner begins PRCC by modeling the client’s world. That world has a rich history of thoughts, beliefs, perspectives, and values that may be foreign to the practitioner’s own personal or professional culture.

Modeling “provides the structure for the development of a mental, emotional, and spiritual receptivity to better attune to the person’s unique health patterns”(Libster et al., 2015). Role-modeling is the process used in health culture diplomacy to construct a plan of care to promote health that is congruent with the client’s own model of the world and that paces with the client’s timing for the pursuit of change. Unconditional acceptance of the client, their model of the world, and their culturally-based health beliefs and practices, cultivates inclusive and integrative solutions as well as a spirit of compassion that defines health culture diplomacy. Physicist Niels Bohr refers to this as complementarity, an inclusive process that permits “mutual understanding and respect among diverse cultures to allow for the unity of human knowledge”(Grinnell et al., 2002).

Health culture diplomats actively engage resources, people, and processes that promote health. They become more skilled as they learn to bring peoples of diverse cultures (including professional healthcare cultures) to the round table for dialog who may have seemingly opposing views so that “unity of human knowledge” is even a possibility. Health culture diplomats hold the skills to be able to perceive and discuss the health patterns that emerge in their engagements with others, be adept at engaging resources that can nourish the needs of others while ultimately having the skills to diplomatically guide clients in their process of making meaning of life’s challenges and stressors. The actions of cultural diplomats, and a health culture diplomat more specifically, to create meaningful change or reform within the healthcare culture closely complement the findings of the salutogensis research by sociologist, Aaron Antonovsky (1987).

Salutogenesis and Diplomacy as Compass for Practice and Reform

Salutogenesis provides a framework for perceiving stress and reframing stressors. Rather than organizing cares around a pathology perspective, that is a focus on disease or risk factors to discover what is wrong, salutogenesis reform adjusts the cultural compass to the study of health patterns. Antonovsky writes, “Thinking salutogenically opens the way for studying the consequences of demands made on the organism to which there are no readily available or automatic adaptive responses-a generally accepted definition of a stressor-when there is good theoretical reason to predict positive health consequences”(Antonovsky, 1987, pp. 8, 13). His contribution to healthcare reform was formulating the concept of the sense of coherence (SOC) as the “core of the answer to the salutogenic question” (Antonovsky, 1987).

There are three components to SOC: comprehensibility, manageability, and meaningfulness. A high sense of comprehensibility is developed as being able to perceive internal and external stimuli as ordered and explicable. The second component manageability is “the extent to which one perceives that resources are at one’s disposal which are adequate to meet the demands posed by the stimuli that bombard one”(Antonovsky, 1987, pp. 17 – 18). The third component meaningfulness refers to the “extent to which one feels that life makes sense emotionally, that at least some of the problems and demands posed by living are worth investing energy in, are worthy of commitment and engagement, are challenges that are ‘welcome’ rather than burdens that one would much rather do without” (Antonovsky, 1987). Health culture diplomats engage all four healthcare cultures to draw upon resources that are meaningful to those with whom they are committed to bring about change. Diplomats can negotiate change to the extent where those involved have developed a SOC as individuals and as communities.

Salutogenesis and its three components of SOC complement health culture diplomacy skills. Whether practiced between individual practitioners and persons seeking help with health choices or by community leaders setting public health policy, the practice of salutogenesis as health culture diplomacy skills, in which a focus is health promotion and peace through culture, could be a compass for decisions in healthcare that can lead to significant PRCC reform. The biomedical culture with its centuries-old philosophical emphasis on “One Cause-One Cure” or pathogenesis, still in existence today has enabled physicians and the practice of university-based medicine to secure socio-cultural dominance at least since the 19th century (Libster, 2004). One contemporary American thought leader has described this as “right man syndrome”(Dossey, 1998) a practice that continues to be evident even in biomedicine’s preventive care or health promotion approaches. Health culture diplomacy is an antidote to cultural dominance in healthcare systems that seek to better demonstrate PRCC.

There are biomedical clinician-professors who have been working for years to create cultural change starting with medical education. Rakel et al. (2008) demonstrated health culture diplomacy in their call for a salutogenic focus in healthcare and within the practice of medicine as “transcending the dichotomies between complementary alternative medicine (CAM) and conventional medicine.” The authors at the time conducted a survey of educational leaders’ beliefs as to the improvements that were needed in health care delivery. Five findings or themes were identified by the survey. One theme was a need for faculty development in CAM. The other four themes mirrored the dimensions of the health Cultural Diplomacy Model©. The four themes: relationship-centered care, holism, Self-care, and collaboration to enhance communication, were identified as important to salutogenic medical education and improved health care delivery.

Through research, education, community engagement, and clinical practice it may be concluded that the future of healthcare reform that can overcome de-humanization and promote PRCC may be framed as salutogenesis practiced as health culture diplomacy. The complementarity of the two in the joining of concepts, theory, and associated skills may even demonstrate unity in knowledge. In that unity, there is hope for a meaningful refocusing of the compass for decisions in healthcare reform with a stronger-than-ever “magnetic north” pointing directly toward health.

References

Antonovsky, A. (1987). Unraveling the mystery of health : how people manage stress and stay well (1st ed.). Jossey-Bass.

Caplan, R. (1989). The Commodification of American Health Care. Social Science in Medicine, 28(11), 1139–1148.

Dossey, L. (1998). The right man syndrome: Skepticism and alternative medicine. Alternative therapies in health and medicine, 4(3), 12–19, 108–114.

Erickson, H., Tomlin, E., & Swain, M. A. (1983). Modeling and Role Modeling. Prentice-Hall.

Farnsworth, N., Akerele, O., Bingel, A., Soejarto, D., & Guo, Z. (1985). Medicinal Plants in Therapy. Bulletin of the World Health Organization, 63(6), 965–981.

Grinnell, F., Bishop, J., & McCullough, L. (2002). Bioethical pluralism and complementarity. Perspectives in Biology and Medicine, 45(3), 338–349.

Institute for Cultural Diplomacy. Definition: What is Cultural Diplomacy? Retrieved January 2025 from https://www.culturaldiplomacy.org/index.php?en_culturaldiplomacy

Institute of Medicine. (2001). Crossing the quality chasm. National Academies Press.

Langer, E. (1989). Mindfulness. Perseus Books.

Levin, L. S., & Idler, E. L. (2010). The Hidden Health Care System Golden Apple Publications.

Libster, M. (2004). Herbal Diplomats: The Contribution of Early American Nurses (1830-1860) to Nineteenth-Century Health Care Reform and the Botanical Medical Movement. Golden Apple Publications.

Libster, M. (2015). Cultural Diplomacy: Demonstrating Person-Centered Care and Coaching In M. Libster (Ed.), Perspectives on Cultural Diplomacy: Nursing (Vol. Vol. 1 ). Golden Apple Publications. http://www.GoldenApplePublications.com.

Libster, M., Phillips, S., Smith Taylor, J., Southard, M. E., & Bryant, S. (2015). The Cultural Diplomacy Model for Demonstrating Person-Centered Care and Coaching. In M. Libster (Ed.), Perspectives on Cultural Diplomacy: Nursing (Vol. Vol. 1 ). http://www.GoldenApplePublications.com.

Rakel, D. P., Guerrera, M. P., Bayles, B. P., Desai, G. J., & Ferrara, E. (2008). CAM education: promoting a salutogenic focus in health care. Journal of alternative and complementary medicine, 14(1), 87–93. https://doi.org/10.1089/acm.2007.0562