THEORY AND METHODS
Antonovsky’s sense of coherence scale and the relation with
health: a systematic review
Monica Eriksson, Bengt Lindstro ¨m
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Folkha ¨lsan Research
Centre, Health Promotion
Programme, PO Box 63,
Accepted for publication
5 December 2005
J Epidemiol Community Health 2006;60:376–381. doi: 10.1136/jech.2005.041616
Study objective: The aim of this paper is to synthesise empirical findings on the salutogenic concept sense
of coherence (SOC) and examine its capacity to explain health and its dimensions.
Design: The study is descriptive and analytical with a systematic integration of the contemporary
knowledge base on the salutogenic research published 1992–2003. The review includes 458 scientific
publications and 13 doctoral theses.
Setting: Worldwide, based on postgraduate scientific publications in eight authorised databases, doctoral
theses, and available books.
Main results: SOC is strongly related to perceived health, especially mental health. The stronger the SOC
the better the perceived health in general, at least for those with an initial high SOC. This relation is
manifested in study populations regardless of age, sex, ethnicity, nationality, and study design. SOC
seems to have a main, moderating or mediating role in the explanation of health. Furthermore, the SOC
seems to be able to predict health. SOC is an important contributor for the development and maintenance
of people’s health but does not alone explain the overall health.
Conclusion: SOC seems to be a health promoting resource, which strengthens resilience and develops a
positive subjective state of health. Salutogenesis is a valuable approach for health promotion and would be
worth to implement in practice much more than to date.
undertaken by the authors.1–4The main purpose is to provide
a more comprehensive understanding of the SOC concept
from research between 1992–2003. This is a relevant
contribution to health promotion and public health research.
It is necessary to get deeper knowledge about the interaction
between SOC and socioeconomic characteristics like age, sex,
social class, and how SOC might be related to physical and
mental health. Are there any relations and does the SOC have
an impact on health at all?
Fundamental in the salutogenic theory is to consider health
as a position on a health ease/dis-ease continuum and the
movement in the direction towards the health end.1 2The
salutogenic model of health, developed and formulated in the
framework of system theory thinking, proceed from the
assumption of the human nature as heterostatic rather than
homoeostatic.5Antonovsky was confronted with the saluto-
genic question why some people, regardless of major stressful
How do people manage the lack of control of their life? The
answer was formulated in terms of SOC and general
resistance resources (GRRs). The SOC is a resource that
enables people to manage tension, to reflect about their
external and internal resources, to identify and mobilise
them, to promote effective coping by finding solutions, and
resolve tension in a health promoting manner. The SOC scale
has proved to be psychometrically sound.3 6The theory of the
salutogenesis and the validity of the orientation to life
questionnaire (sense of coherence) is described more in detail
An extensive review is in process, processed by the authors
and by the Health Promotion Programme at the Folkha ¨lsan
Research Centre to clarify the contribution of the SOC to the
development and maintenance of health. This paper is part of
this extensive review of the research.
his paper continues to review, analyse, and synthesise
the evidence base of research on the sense of coherence
(SOC) concept in the light of 25 years of research
The aim of this paper is to synthesise findings on the
relation between the SOC and health.
This research synthesis is based on empirical studies of the
SOC scale and presents the state of knowledge on the
salutogenic concept 1992–2003.8 9The review is systematic in
the sense that all included papers (see Eriksson and
appendix, table 9–10) have been critically
examined according to a set of criteria. The papers are
analysed according to the following dimensions: (1) the
study objective, (2) the study designs and methods for
analysis and, (3) the applicability and practical use of the
results. The analysis of the papers is described more in detail
The synthesis of the findings in this paper are based on
studies where multivariate analyses were used in the study
design and simultaneously controlled for confounding vari-
ables like age, initial health status, health behaviour, leisure
time activities, income, education, marital status, and social
support.10–15Relation between variables implies more than
associations. Relation implies dependency.13The relation
between SOC and health is examined according to SOC both
as a dependent or criterion and an independent or predictor
variable for the outcome of health. Cross sectional studies
where only bivariate analysis were used are excluded from
the synthesis because of the purpose of this particular
The effect sizes of the correlation applied in this review
follows the Cohen’s understanding and recommendation for
behavioural sciences.22The effect size r=0.10 is small,
r=0.30 medium, and r=0.50 large.
Cross sectional and longitudinal studies are analysed
separately, and so are quantitative and qualitative studies.
Longitudinal studies are needed to confirm causality between
the SOC and health. To clarify what are the results of the
examined studies and what are the interpretations and
conclusions of the authors the results are presented as study
generated results and synthesis generated findings.8
Inclusion and exclusion criteria
The inclusion criteria are: (1) papers dealing with the SOC
concept and/or using some of the different versions of the
SOC questionnaire published in scientific peer reviewed
journals; (2) postgradual papers and doctoral theses; (3)
quantitative, qualitative, and intervention studies with equal
weight to the method used; (4) papers in English, Finnish,
Danish, Norwegian, and Swedish; (5) papers with a careful
description of the translation process to other languages than
English; (6) quantitative studies with an acceptable reliability
and validity (face, consensual, construct, criterion, predictive,
and responsiveness); (7) publication in the time span 1992–
2003. Completing information has been acquired from the
Excluded are: (1) papers not using Antonovsky’s life
orientation questionnaire (SOC) for measuring coherence,
(2) papers in other languages than the before mentioned
(French, German, Japanese, Polish), (3) double published
papers, (4) papers without references to Antonovsky’s SOC
concept (primary or secondary references), (5) papers
afflicted with weakness in power—that is, response rate
,50% without a careful analysis of drop outs (after request of
completing information from the authors without an
answer), (6) papers afflicted with insufficient validity of
the SOC scale (that is, dealing only with one or two
dimensions of the concept), (7) papers on master of science
level or lower. Statistical data are systematically compiled
(see Eriksson and Lindstro ¨m3appendix table 2–8). Despite
country of origin most studies are published in English.
The following search strategy has been used: (1) electronic
search in the databases PubMed (Medline), Bibsys, ISI,
Sociological abstracts, (2) search on the key words saluto-
genesis, salutogenic, sense of coherence, and the Swedish
and Finnish translations, (3) reviewing reference lists in
identified papers, (4) personal communication with the
authors and colleagues.
MATERIAL AND PROCEDURE
The description of the material is presented in a flow chart
(see Eriksson and Lindstro ¨m3appendix table 1). After
adjustment for double listing in the databases and doctoral
theses 458 hits met the inclusion criteria (as of 31 December
2003). The review is based on these articles and 13 doctoral
theses (see Eriksson and Lindstro ¨m3appendix table 9–10). In
addition some other relevant books on this topic are included.
We have been aware of the potential limitation of this
analysis—that is, papers in other languages than the before
mentioned—but we still consider the material is adequate
enough for a reasonable review.
A detailed protocol was compiled for each article or
doctoral thesis. The assessment of the included papers is
described in detail elsewhere.3It was not possible to carry out
a full meta-analysis mainly because of the diversity of the
base material and the variations in methods. The review
material includes studies of varying sizes, samples, study
design, and methods of analysis. Therefore we prefer to
present the synthesis in tables and discuss the results (see
Eriksson and Lindstro ¨m3appendix).
Study generated results
The study generated findings of how SOC might influence
health are presented as a main, a moderating, and a
mediating effect on health.10–12 14 23Furthermore, the ability
of the SOC questionnaire to predict health is described. In
addition, studies where the findings failed to support an
effect on health are presented.
The interpretation of causality is somewhat complicated.
There are no statistical tests available that can tell us whether
we have made a correct interpretation. The choice of variables
to include in a health model is dependent on the substance
and the researcher’s theoretical insights into the problem
under investigation. A correct conclusion of the study results
requires a careful step by step analysis in the study design.14
Despite this, some of the techniques still can give us a clue to
the effects on health.
By using hierarchical regression analyses a main effect on
health can be estimated. A significant increment in R2
detected in the final step of the regression model shows a
direct effect of SOC on the health outcome.12A moderator is a
variable that affects the direction and/or strength of the
relation between an independent or predictor variable and a
dependent or criterion variable.23Moderator variables always
function as independent variables, whereas mediating events
shift roles from effects to causes, depending on the focus of
the analysis. A variable functions as a mediator when it
accounts for the relation between the predictor and the
criterion variable. Mediators specify why such effect occurs.23
Structural equation modelling is considered as a technique
for estimating causality.11 24
SOC has a main, a moderating, and a mediating
effect on health
Swedish,27 28English,29Canadian populations,30–33French,34
patients with rheumatic diseases41 42or depressive disorder,43
and immigrants44support a direct or an indirect relation
between perceived good health and a strong SOC: the
stronger the SOC the lower the number of subjective
complaints and symptoms of illness. General health was
measured among others by using study specific questions of
the perceived health,25 26 28 30 33 45medical examination and
questions about medical history,27 29items from the stress
profile and the life style profile,28health and life experiences
questionnaire,29health utility index score, and items in the
national population health survey,30–32and items on work
stress from the Whitehall II study.37The SOC scale has been
examined in relation to MOS short form 36 (SF-36), a
frequently used for measuring physical as well as mental
health.46–48The relation with the physical component in the
SF-36 is much weaker than with the mental component. The
different measures used for physical and mental health as
well as for wellbeing are described more in detail elsewhere
(see Eriksson and Lindstro ¨m3appendix table 5).
The population distribution of the SOC-29 showed a range
of the means from 100.50 points (SD 28.50) to 164.50 points
(SD 17.10). The corresponding range for the SOC-13 was
35.39–77.60 points (SD 0.10–13.80). For more details on the
distribution of the SOC see table 2–4 in the appendix.3
A large study investigated factors related to mental health
on Canadians. Here a mixed results of the relation between
positive and negative outcome measures were shown.31The
data showed a consistently strong and independent associa-
tion of current stress, social support, life events, education,
and childhood traumas with both positive and negative
indicators of mental health. The number of childhood
traumas was strongly correlated to SOC, depression and
distress, and to mastery and happiness. Hood and colleagues
report findings, also on a Canadian population, confirming
that people with a high SOC tended to be in better health.30
Antonovsky’s sense of coherence scale and the relation with health377
However, here the SOC explained alone only 10% of the total
variance in health.
In a Swedish longitudinal study on high risk families for
mental illness, the Lundby study, 22 different coping
mechanisms were discriminated. SOC was here associated
to the combined coping mechanisms and explained 22% of
the variance in health. Independent of sex a relation between
low SOC scores and poor perceived health were found in the
Swedish population in the MONICA study.27Here men
scoring low on SOC had twice the risk for reporting poor
perceived health. The EPIC-Norfolk study (United Kingdom)
reports findings that a strong SOC was associated with a 30%
reduction in all cause mortality.29
There is a strong relation with factors measuring mental
health like optimism, hardiness, learned resourcefulness,
locus of control, mastery, self esteem and self efficacy,
acceptance of disability, and social skills. SOC is strongly and
negatively associated with anxiety, anger, burnout, demor-
alisation, hostility, hopelessness, depression, perceived stres-
sors, and post-traumatic stress disorder (see Eriksson and
Lindstro ¨m3appendix table 5). SOC is strongly and negatively
related to perceived depression.35 42 43 49 50 53The stronger the
SOC the less are the symptoms of perceived depression. A
strong SOC is associated to negative and positive affectivity.51
Kravetz and colleagues found a considerable overlap between
SOC and negative affectivity.52This does not necessarily mean
that SOC only measures the absence of neuroticism or
anxiety. Von Bothmer and Fridlund showed among students
that positive affect/optimism together with alienation and
hardiness had the highest relative importance for under-
standing the SOC, explaining about 60% of the variance in
SOC seems to decrease the number of circulatory health
problems in adults. People with a strong SOC had lower
diastolic blood pressure, serum triglycerides, heart rate at
rest, and higher oxygen uptake capacity. A low SOC was
related to mental and circulatory health problems.53In the
Helsinki heart study the lowest incidence of coronary hearth
disease was in the highest SOC quintile. The incidence was
25% lower than in the lowest SOC quintile.54However, the
SOC failed to have a salutogenic effect for blue collar
Among children and young people the relations between
SOC and health are the same as in the adult population.
The better the health is perceived the higher the SOC
and simultaneously the lower are the subjective health
complains. Nordic studies on school children in different
ages and their parents showed the impact of poor SOC on the
subjective health.55–57The children’s ill health was related to
the parents’ SOC and life satisfaction. The lower the parents’
SOC the more psychosomatic complaints reported by
children. Parental complaints were associated with a 1.63
(CI 1.45 to 1.83) higher odds of having poor SOC.57Among
Norwegian 15 year old school children the SOC accounted
for more than 50% of the variance in subjective health
complains.56Using the specific SOC questionnaire adjusted
for children (CSOC) Vinson found, that the higher a
child’s SOC and self esteem, the fewer general physical
symptoms in acute asthmatic episodes were reported by the
Based on confirmatory factor analysis and structural
equation modelling, findings show that SOC and mental
health are two independent but correlated constructs. SOC is
a mediator between stress and mental health.59Evidence for a
mediating effect of the SOC between hostility and health was
found among Finnish female employees.60Low SOC was here
found to be a psychological background factor partially
underlying the adverse effect of hostility on ill health. An
opposite finding of the mediating role of the SOC was
reported by Lundberg.61SOC did not mediate the effect of
childhood factors on adult health in a Swedish population.
In stressful situations SOC seems to have a moderating
effect on health. People with high SOC seem to be more
resilient under stress than people with a low SOC.45 62The
stronger the SOC the lower the level of symptoms and
distress. Albertsen and colleagues reported both a main, a
moderating, and a mediating effect on health.37In the first
large epidemiological study of the SOC concept undertaken in
a non-western culture, Thailand, there was no association
between SOC and physical health but a direct effect and a
moderating effect on mental health.63
Does SOC predict good health?
The capacity of the SOC scale to predict a future outcome—
that is, health—is expressed by the predictive validity.64
Examining the longitudinal studies the SOC questionnaire
shows a relatively high predictability, both in a short term
(some months) and a long term (some years) perspective.
Results supporting the salutogenic theory as a factor
promoting resilience and a positive health outcome were
reported in a Finnish population,65among survivors of the
m/s Estonia Disaster,66in patients with orthopaedic injuries,67
among schizophrenic patients,68in vocational rehabilitation
of unemployed with somatic disorders,69and employees.54 70–74
In a long term perspective (five years) the SOC had a very
good predictive value for disability among Finnish patients.75
A 10 year follow up of Finnish employees SOC and changes in
support from superior was the best predictors of burnout.76 77
A strong SOC was the most important determinant of the
differences between those with serious burnout and those
However, there are different results reported.3A study of
Finnish municipal employees and technical designers failed
to give support for the SOC as a salutogenic resource.
Predictive relations from health to SOC were not found. The
results showed no support for the status of SOC as a
salutogenic resource.78Only a poor SOC seemed to have
implications for health among Canadian labour force. Smith
and colleagues recommended caution of using the SOC to
represent a stable global orientation within a causal context.79
The evidence proves the salutogenic model as a health
promoting resource that improves resilience and develops a
positive subjective state of both physical and mental health,
quality of life and wellbeing. The orientation to life
questionnaire/sense of coherence scale (SOC) refers to an
enduring attitude and measures how people view life and in
stressful situations identify, use, and reuse their general
resistance resources to maintain and develop their health. It is
a valid, a reliable, and a cross culturally applicable
instrument for measuring health. The SOC scale consists of
at least three dimensions: the comprehensibility, the manage-
ability, and the meaningfulness components. In contrast with
Antonovsky’s view the structure of the scale seems to be
multidimensional rather than unidimensional. It has been
used in at least 33 languages in 32 countries with at least 15
different versions of the questionnaire on subjects from both
Western cultures and countries like Thailand, China, Japan,
and South Africa. The mean SOC seems to be independent of
the cultural context. The instrument has been examined on
healthy populations from children to older adults, in different
patients groups and professionals, within many areas of
practice like health services, social work, working environ-
ment, care of relatives, and in learning situations.
378Eriksson, Lindstro ¨m
The results from their study showed that more research is
required to define what can be considered to be a change in
the SOC measure and what factors in the external environ-
ment bring about this change. In two separate studies, one
among American Veterans in a rehabilitation unit, the other
among Swedish primary care patients, SOC did not predict a
positive outcome of health.80 81
The limitations of SOC on health
A study focusing on control of diabetes and its relation to
SOC showed no direct relation between SOC and the
treatment results, measured as glucolysed haemoglobine
(HbA1c). However, there was a positive correlation between
SOC, self assessed health, and HbA1c. The better the patients’
estimation of their health, the higher the SOC scores and the
lower HbA1c.82Similar findings were reported by Svartvik
and colleagues, the glucose tolerance was not affected by
Synthesis generated findings
Our synthesis applies a probabilistic rather than a determi-
nistic approach and is based on studies where multivariate
analysis was applied.13This means that the outcome might
include an uncertainty. ‘‘Given a particular value of the
independent variable some values of the dependent variable
are more likely to occur than others, but these values do not
necessarily occur, and other values are possible, albeit less
likely’’ (page 65). The uncertainty also means that it is never
possible to rule out all the possible alternatives to a causal
interpretation. We have to accept a result where the most
probable alternatives are eliminated and be content with a
science distinct from absolute certainty. Correlative study
design alone does not go far enough in the analysis of
relation between SOC and health. It is more beneficial for the
analysis to investigate the square of the correlation coeffi-
There seems to be different effects of the SOC on the
various dimensions of health. SOC seems to be strongly
associated to perceived good health, especially the mental
dimension, at least among persons scoring high on SOC. The
prediction for people scoring moderate or low on SOC is not
completely clear and needs further clarification. The relation
between SOC and physical health is more complex and seems
to be weaker than with mental health. Despite some
uncertainty our interpretation and conclusion of the inves-
tigation of the included studies is that SOC seems to be a
health resource promoting resilience and the development of
a positive subjective state of health. In the middle of the
1980s Antonovsky pointed out the importance of a saluto-
genic orientation for the development of people’s mental
health through the life cycle.84Today several longitudinal
studies clearly support the importance of a strong SOC for the
development and maintenance of a positive state of mental
The very strong correlation to determinants of mental
health, especially to positive emotions and opposing negative
affectivity, raises the question whether SOC is a parallel
expression of mental health. At least it means that a person
with a strong SOC can cope with stressful situations and stay
well in a better way than a person with a low SOC.
Furthermore, SOC seems to have qualities reaching beyond
only the presence of positive and the absence of negative
emotions. The strong relation with factors measuring positive
dimensions of health like optimism and hardiness and the
opposite or anxiety and depression tend to interpret the SOC
as an overlapping construct of other measures of health. Our
suggestion and conclusion is that SOC comes close to mental
health and mental wellbeing but is not the same as mental
There was one finding in the review that is quite
surprising. Very few investigators are aware of the potential
measurement error of the SOC questionnaire regarding
normal variations in the analysis of change in the SOC. A
change in SOC (mean) has usually been interpreted as a real
change. One exception is a study on Canadian labour force.79
Here the reliability of change index was used to distinguish
between measurement error and a real change. The findings
show that a high SOC protects health, but we have no clear
indication of where the cut off point is and where SOC loses
this protective effect. Is it around the mean value, median, or
somewhere else? Is it identical for all individuals, probably
not. Antonovsky talks about high and low SOC but he never
defined what could be seen as a normal SOC.1 2This
complicates the interpretation of the effect on health and
requires further research.
We here list some of the criticism that has been presented
in earlier studies on SOC. The SOC concept has been criticised
from many points of view: to be psychometrically unclear,85–89
a theory confounded with emotionality,62other concepts
available to explain health,90a theory full of contradictions,91
the results to be trivial and overrated,92only a few have
considered the concept to be worth examining,93and lack of
evidence of the stability over time.90We consider the above
mentioned statements partially as wrong and reject them
because the empirical evidence supports the theory. The
psychometric properties of the SOC concept has been
discussed elsewhere.3We agree with the critique that there
are other concepts with salutogenic elements that can explain
health, but still we want to emphasise the important
contribution and comprehensibility of the SOC concept in
The main intention of this paper was to summarise 25 years
of salutogenic research to present evidence of the relation
between SOC and health. This objective is relevant in a public
health and health promotion perspective. We agree with
Stephens et al in their conclusion that strategies that promote
resilience and other psychological resources also will con-
tribute to problem reduction and prevention. Health promo-
tion and disease prevention can perhaps, in a sense, be seen
as two sides of the same coin.31
Another intention was to make a coherent analysis of the
salutogenic concept to clarify both the strengths and the
weaknesses of the theory. Such an approach contributes to
the development of the theory.13Is SOC the same as health?
To our knowledge the answer is no. The analysis of variance
shows that SOC is strongly related to health, especially
mental health, partly explaining health. The rest of the
variance is explained or accounted for by other factors like
age, social support, and education. The interpretation could
be that SOC is not the same as health but still an important
disposition for people’s development and maintenance of
What people are at risk for developing poor health? Social
class and social conditions have an effect on the individual
health.53As a sociologist Antonovsky knew very well about
the impact of social conditions in a society on the people’s
health. The SOC concept can be understood as a concept only
for people with a high education, a good economy, a good
social support, and social integration, an elite. We do not
understand the concept in such a way, neither did
Antonovsky. In a lecture at the Nordic School of Public
Health in Gothenburg in 1993 he explicitly pointed out the
responsibility of the society to create conditions that foster
the strengths of coping—that is, SOC. It is not question about
a free choice of the person to cope well. The key lies in a
society and in people who care about others.94A salutogenic
Antonovsky’s sense of coherence scale and the relation with health 379
orientation provides no prescription for a good life in the
moral sense of the term; it can only help us understand
health/illness.95Furthermore, the potential of the salutogenic
concept lies in its implications for creating societies adopting
a healthy public policy, where the content and the structure
of the services is salutogenic, not only a healthy policy for the
health services. Here it is important to strengthen available
and create new kinds of general resistance resources to make
it possible for the citizens to identify and benefit them. An
implementation of the salutogenic construct in practice could
be the salutogenic dialogue described by Malterud.96 97In
addition, the salutogenesis could be the theoretical founda-
tion for the health promotion research.
There is a need for a further synthesis as of the relation
between the SOC and quality of life and wellbeing, health
behaviour, working life, education and learning, social
support and social integration, life events, family SOC,
development of the SOC, and other concepts with salutogenic
elements that contribute to the explanation of health.
Now having concluded the contemporary evidence base it
is remarkable the saluotgenic framework has not been used
more frequently in research and practice. One of the reasons
is probably the fact that Antonovsky died quite unexpectedly
just at the time when the concept had been accepted and
introduced to the global community of health promotion
researchers. His death created a vacuum as the field lost its
most distinguished and natural leader.
M Eriksson, Folkha ¨lsan Research Centre, Health Promotion Programme,
B Lindstro ¨m, Folkha ¨lsan Research Centre
Funding: this study was supported by grants from the European
Commission (European Masters in Health Promotion (EUMAHP) and
Folkha ¨lsan Research Centre/Health Promotion Programme.
Conflicts of interest: none declared.
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