*1.1. Salutogenesis and the Health Asset Framework as Models to Cope with Stress*

Even though the formal Salutogenic Model of Health (SMH) has not received enough attention in research and practice since its origins, there is a renewed global interest in seeking for future directions for the concept. It emerges from the need for a better understanding of the theory and its implications addressing the full spectrum of the human health experience [1]. Likewise, the concept of health assets is becoming increasingly popular and it was explored in different settings and populations throughout the world [2]. Thus, health promotion from a positive health paradigm is grounded in two frameworks: Aaron Antonovsky's salutogenic theory and the Asset–based community development (ABCD) approach [3,4]. The identification of people's health resources and assets and the design of dynamization strategies for them is a paramount issue by improving the health heritage of individuals and communities as it is defended by the SMH and the Health Assets Model (HAM) [4–8].

In this sense, the salutogenic approach promotes the concept that when people can make sense of the world that surrounds them, they will also notice a correspondence between their actions and the effects these actions will have on their environment [9,10]. In this regard, there are closer connections between salutogenesis and a health asset-based model. The salutogenic assumption seeks to explore the origin and stability of health by understanding how it can be created and determines the optimum conditions for its development [11,12]. On the other side, the HAM establishes that: the more possibilities someone has to experience and accumulate positive effects of a series of assets throughout their life, the higher the chances of achieving health goals are [4]. To this effect, HAM implements community intervention's methodologies (such as social participation and action research) to develop a salutogenic health promotion strategy. This strategy is usually addressed in four phases: identification of protective factors, participatory asset mapping, connection and dynamization of health assets (HA) and finally, evaluation [13,14].

In parallel, those approaches also maintain interesting and close linkages to 'Stress and Coping' Lazarus and Folkman's theory. These authors address the existence of internal, interpersonal (conceived as social support) and external factors to individuals that buffer adverse effects of stress, allowing people to develop mechanisms to regulate emotional responses to stressful circumstances and having a high impact on well-being. Then, stress is a two-way process that involves stressors produced by the environment and the individual subjective responses to them by using primary and secondary cognitive appraisals [15,16]. Hence, these factors may be identified, equated and assimilated on many occasions to the salutogenic 'general resistant resources' (GRR) defined by Antonovsky [9,10] because they also include psychological traits, coping strategies, social and cultural factors and social support. Moreover, these factors contribute to increasing people's resilience, enabling them to solve problems adaptively, assessing stressful events as meaningful, predictable and manageable [17]. All in all, the theory posits that life experiences shape the sense of coherence (SOC)—the core element of the SMH—that helps to mobilize resources to cope with stressors and manage tension successfully [18].

In exploiting the perspective's whole meaning, the present research assumes the notion of these resistant resources consolidated as health assets. Consequently, to operationalize all these factors for health-promoting purposes, both the SMH and HAM advocate for categorizing the intrapersonal, interpersonal and extrapersonal health elements which operate as protective and promoting factors to buffer against life's stressors [19]. A health asset itself can be defined as any factor (or resource) which enhances the ability of individuals, groups, communities, populations, social systems and institutions to maintain and sustain health and well-being and to help to reduce health inequities. These assets can operate at the level of the individual (for example, abilities, competences and talents), group and community (including the role of supportive networks and population as protective or promoting factors to buffer against life's stresses) and eventually an organizational or institutional level (for example making use of external financial, physical or even environmental resources) [19]. According to the management of stress, literature advocates that all those resources not only immediately help people to cope better with stress and surviving [1]; but also, over time, personal and environmental resources can help with recovery and healing [20–23], even from early life adversities in adult populations [24].

#### *1.2. Salutogenic Active Coping and Zest for Work in Healthcare Professionals*

Advancing and empowering the SMH and HAM to understand better the ways of coping productively with stress seems to be a paramount purpose. Furthermore, this challenge must be primarily tackled in health care professionals and their prior academic and formative context. Regarding the case of CNA nursing students and their future job demands envisaged, stress is a psychosocial factor that influences the academic performance and well-being of this group [25]. Nursing students not only face academic, but also face pressure at work during their training period [26]. Like previous findings, care behaviors correlated negatively with depression, distress and emotional exhaustion and positively correlated with coping strategies and a positive attitude to one's role at work [27]. Not surprisingly, the negative consequences of not having adequate coping strategies to undertake the inherent demands of nursing degree, as well as the future professional life, have an impact on their health and mental well-being. Furthermore, this situation is also directly related to professional performance [28].

Overall, it was shown that those using a greater variety of health assets can develop a greater sense of coherence (SOC) that will also allow them to promote active and effective stress coping strategies [18]. Concretely, healthcare students and workers with strong SOC may perceive and appraise the demands of their work environment as challenging rather than threatening, according to Antonovsky's research on health-promoting factors at work [9]. In addition, active coping is a valuable asset, especially in very demanding situations that nurses have to face up every day; therefore, resilient professionals are vital to the proper functioning of a health system [29]. Given those facts, researchers and professors suggest that daring to strengthen and reinforce the salutogenic capacity of the students must be expanded as part of the professional training in healthcare professional's degrees in order to promote and maintain the engagement and the zest for healthcare work [30]. More recently, it was observed the impact of the motivational factor in job engagement mediated by a sense of calling. This calling–vocation match brings forth from introspection, sensibility and reflection, which produces a working situation that for the most part, feels deeply gratifying and meaningful to the individual, resulting in zest for work and vitality [31].

In the spirit of the whole latest reflections on the salutogenic paradigm, for a better conceptualization of salutogenic orientation, it is necessary to encourage alternative approaches, including qualitative research [1].

Conversely, the health asset literature is underdeveloped, and its sustained credibility depends on future research dealing with definitional, theoretical and evaluative issues, being, therefore, imperative accomplishing more research to deeply apprehend the health assets model in a global context [2]. Thus, the pursuit of a better understanding between the salutogenic perspective (measuring SOC) and a health–asset approach (observing reported health assets) is the primary purpose of this study, to tempt a potential and early incorporation of a salutogenic orientation in healthcare-providers' studies. To this effect, the first phase of the present study has explored the salutogenic paradigm among nursing assistant (CNA) students in a region of Spain. Based on those findings, it seems that possessing a strong SOC appears to contribute towards improved resistance to stress, which in part, may also justify the motivation for studying a career that is pleasing and obtaining high academic performance despite being a profession with high demands and marked stressors [32]. Additional analyses of this research also have confirmed that CNA students referring a good practice on self-care and the willingness to caring for others (described as an internal health asset) also display an optimal zest for work in the nursing discipline [33].

This current study faces the last phase of the research seeking the opinions of CNA students about the HA that provides opportunities for well-being and health and determines a Health–asset Map articulated by participants using mixed-methods. Subsequently, it intends to explore, thorough a quantitative approach, the relationships between those HA, the SOC, the sense of calling (vocation-motivation variable) to choose healthcare studies as a career in concert with the academic performance for this certification in public education and vocational centers (Comunitat Valenciana, Spain).

#### **2. Materials and Methods**

#### *2.1. Study Design and Sample*

Mix-method study (qualitative and quantitative study: cross-sectional, analytical and exploratory) was carried out in 2016. Participants were enrolled—at data collection time-, in the last semester of certification of nursing assistant (CNA) from the total of public upper secondary schools providing vocational education and training (VET) certifications at Comunitat Valenciana (Spain). The study was aimed at the entire student population (*n* = 1150) enrolled in the region. With an IC = 95% and an error = 5%, a minimum sample of *n* = 289 was required.

#### *2.2. Data Collection*

Sociodemographic data collected were: (a) gender (male, female), (b) age (categorized: <30, 30–45, >45), (c) employment status (employed, unemployed), (d) income level (net income of the student's household, understood as the level of income received, from among the following options: high, medium/high, medium, medium/low, low, does not know/does not answer), (e) public secondary education centers in which CNA studies are taught, (f) geographical emplacement of the center (rural, urban, large city), (g) self-reported academic performance: students were asked about their academic record at the end of the last semester—when they already knew their global marks- and the responses were: fail (<5), pass (5–5.9), good (6–6.9), remarkable (7–7.9), outstanding (8–8.9), with distinction (9–10); in Spain, the academic record is scored in a scale of 0–10, with 10 being the highest score to reach and below 5 is considered as failed), (h) motivation of choice of studies (vocational, could not be enrolled in other studies, seek for better employment option, unmotivated). Some opened questions served to identify HA (intrapersonal, interpersonal, extrapersonal), defined as things/people/places that increased their well-being. SOC levels (a global orientation of the personality that facilitates the solution of problems in an adaptive way in stressful situations to which people are subjected throughout their lives) were assessed by the orientation-to-life questionnaire—13 items (OLQ-13 or SOC-13) [34]. This 13-item questionnaire also measures the dimensions of *comprehensibility* (with 5 items), *manageability* (with 4 items) and *meaningfulness* (with 4 items). The SOC-13 scale has shown good internal consistency, with a Cronbach's alpha between 0.70 and 0.92 [34–36].

#### *2.3. Procedure*

Professors from all educative centers attending Nursing Assistant public certifications were first contacted to mail them the questionnaire. Students completed a self-administered online questionnaire (with internet protocol—IP-response restriction) during their schedule's classes collecting qualitative data: HA; and quantitative data: the sense of coherence scale (SOC), factors related (motivation to study this career and self-reported academic performance) and sociodemographic variables. The questionnaire included information about the study and the contact details of the principal investigator. There were no exclusion criteria, and permission to participate in the study and consent to use the data were required. The qualitative analysis was carried out to identify the different types of HA, categorizing them into the categories already proposed. Subsequently, additional quantitative analysis was also carried out.

#### *2.4. Data Analysis*

#### 2.4.1. Qualitative Phase

The CNA student's HA mapping was underpinned according to the fundamentals of HAM methodology [3,13,37–39]. Most of these authors propose six categories of health assets: people, agencies or organizations (with or without profit), institutions, infrastructure or physical resources, economy and culture (including traditions, identity and sense of belonging). In this study, HA were collected and categorized in four HA groups, according to recommendations and results of previous

research in this field [40]. First, the intrapersonal HA, which corresponds to an individual level; second, the interpersonal HA; third, the extrapersonal HA I—as institutions, organizations, etc.-; and finally, the extrapersonal HA II—as infrastructures, indoor/outdoor spaces, etc.-, which correspond to a community level.

In order to dump qualitative data collected from the questionnaire regarding to HA, the procedure was developed in 3 operationalization's phases and conducted by the main researcher and a different extra researcher. Phase (1) first, consisted of an information's transcription of the given responses from the open-ended asset questions, through a thematic analysis. This analysis was employed to codify information, also using the word economy, making significant groupings of the answers whenever possible, and trying to preserve the literalness of the discourse. Phase (2) was a reflection stage to prepare emerging subcategories for the four HA types that included sensitizing concepts. This means that these subcategories were aroused as a result of raising significant reference frames from the thematic analysis. Thus, a total of 30 HA's subcategories were built and identified with a subsequent numeric code: 3 subcategories for the Intrapersonal HA, 7 subcategories for the Interpersonal HA, 8 subcategories for the Extrapersonal HA I and 12 subcategories for the Extrapersonal HA II. Phase (3) was a proceeding of classifying and reconversion of each thematic content in its related HA subcategory—concretely, into its code number- with the purpose to prepare the database for the posterior statistical analysis.

In parallel and once again following the HAM methodology, the graphical students' HA map was built as a reflection of the literal qualitative data collected at the open HA questionnaire.

#### 2.4.2. Quantitative Phase

Both the population characteristics and the subcategories of the HA classification that emerged after the qualitative analysis were analyzed in this phase. Descriptive statistics were applied to obtain frequencies and percentages in case of qualitative variables or means (M) and standard deviations (SD) to describe the quantitative ones.

chi-squared test was used to analyze the relationship among the HA identified and some population characteristics. Differences in SOC scores (global and for each dimension), according to the HA subcategory, were analyzed using the nonparametric Kruskal–Wallis test. In case of finding differences in SOC scores among groups, post hoc analysis using Bonferroni correction was performed to identify between which groups these differences occur.

In all cases, statistical significance was set at *p-*value < 0.05.

#### *2.5. Ethical Considerations*

In the case of underage students, prior authorization was obtained from parents or legal guardians to participate in the study. At the time the questionnaire was administered, the following measures were taken to ensure the anonymity and protection of the study participants: the professors—who were instructed to give the relevant indications to answer questionnaire right and accurately informed students that their participation was voluntary. They were also informed that not participating in the study did not imply grievances for them. The first screen of the online questionnaire informed about the legal details of the research. Data were anonymized and processed according to the recommendations of the State Data Protection Agency based on Organic Law 15/1999 and the European Directive on Data Protection 95/46/EC. Furthermore, permissions were also requested and obtained from each educational center and the competent organism in the area of education in the region (05ED01Z/2016/406/S) Resolution of February 25th, 2016 of the Autonomous Secretariat of Education and Research of the Conselleria d'Educació, Investigació, Cultura i Esport.
