Validity of Antonovsky’s sense of coherence scale:
a systematic review
Monica Eriksson, Bengt Lindstro ¨m
See end of article for
Dr B Lindstro ¨m, Nordic
School of Public Health,
Box 12133, S-40242
Accepted for publication
18 January 2005
J Epidemiol Community Health 2005;59:460–466. doi: 10.1136/jech.2003.018085
Study objective: The aim of this paper is to systematically review and analyse the validity and reliability of
Antonovsky’s life orientation questionnaire/sense of coherence scale (SOC).
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: The SOC questionnaire has been used in at least 33 languages in 32 countries with at least
15 different versions of the questionnaire. In 124 studies using SOC-29 the Cronbach’s a ranges from
0.70 to 0.95. The a values in 127 studies using SOC-13 range from 0.70 to 0.92, and in 60 studies using
a modified SOC scale range from 0.35 to 0.91. Test-retest correlation show stability and range from 0.69
to 0.78 (1 year), 0.64 (3 years), 0.42 to 0.45 (4 years), 0.59 to 0.67 (5 years) to 0.54 (10 years). The
means of SOC-29 range 100.50 (SD 28.50) to 164.50 (SD 17.10) points and SOC-13 from 35.39 (SD
0.10) to 77.60 (SD 13.80) points. After 10 years SOC seems to be comparatively stable, but not as stable
as Antonovsky initially assumed. SOC tends to increase with age. The factorial structure of SOC seems
rather to be multidimensional than unidimensional. SOC predicts a positive outcome in a long term
perspective, although there are divergent findings reported. The SOC scale seems to be a reliable, valid,
and cross culturally applicable instrument measuring how people manage stressful situations and stay well.
a global orientation to view the world and the individual
environment as comprehensible, manageable, and mean-
ingful, claiming that the way people view their life has a
positive influence on their health.1Over the first 10 years
after the introduction of the salutogenesis Antonovsky
developed the life orientation questionnaire, sense of
coherence scale, and examined its properties. In addition,
the theory was somewhat revised over time and made more
explicit in his second book Unraveling the Mystery of Health.2
The paradigm shift from the pathogenic focus on risk factors
for disease to the salutogenic focus on the strengths and
determinants for health was introduced. Fortigenesis, refer-
ring to the origins of one’s psychological strength in general,
attempts to broaden the SOC concept.3
Originally interviewing Israeli women about the adaptation
to menopause Antonovsky studied a group with experiences
from the concentration camps of the second world war who
despite this stayed healthy.2He was intrigued and raised the
salutogenic question why these people were able to stay
healthy. He postulated it was because of the way they viewed
their life and their essence of existence. Through research
three components emerged: the ability for people to under-
stand what happens around them, to what extent they were
able to manage the situation on their own or through
significant others in their social network, and the ability to
find meaning in the situation. These three elements,
comprehensibility (cognitive), manageability (instrumental/
behavioural), and meaningfulness (motivational), formed
the concept of sense of coherence. Another concept intro-
duced were general resistance resources (GRR),1such as
material, ego identity, knowledge, intelligence, coping strat-
egy, social support, commitment, cultural stability, magic,
ore than 20 years have passed since the American-
Israeli medical sociologist Aaron Antonovsky intro-
duced his salutogenic theory ‘‘sense of coherence’’ as
religion/philosophy, and a preventive health orientation. The
GRRs are shaped by life experiences characterised by
consistency, participation in shaping outcome, and a balance
between underload and overload.2These resources reinforce
the SOC. Persons with a strong SOC are likely to identify a
greater variety of GRRs at their disposal.4Antonovsky
emphasises that the SOC concept is a dispositional orienta-
tion rather than a personality trait/type or a coping strategy.4 5
The SOC construct reflects a person’s capacity to respond to
In 1993 Antonovsky summarised the research until 1992
reporting data from 42 studies using the life orientation
questionnaire/sense of coherence.2Thereafter, unfortunately
only a few researchers have reviewed results from studies on
the SOC concept. However, these are only based on highly
selected materials such as two Swedish reviews,5 6unpub-
lished material reviewing South-African studies,7and a
German review.8The latter is hard to evaluate as it lacks
clear inclusion criteria and a systematic methodology.
Since 2003 the Nordic School of Public Health has been
running a salutogenic project. The main objective is to
provide a more comprehensive understanding of the SOC
concept by systematically reviewing, analysing, and synthe-
sising the evidence on the salutogenic concept 1992–2003. So
far and to our knowledge, this review is the first compre-
hensive attempt to review the whole area of salutogenic
research after Antonovsky’s sudden and unexpected death.
This paper is part of a more extensive review of the
research area undertaken by the authors. The aim of this
paper is to show the validity and the reliability of
Antonovsky’s SOC scale.
Abbreviations: SOC, sense of coherence scale; GRR, general resistant
This research synthesis focuses on empirical studies of the
SOC scale and seeks to summarise, analyse, and present the
state of knowledge on the salutogenic concept 1992–2003.9 10
The study is systematic in the sense that all included papers
(see appendix, tables 9 and 10 (available on the journal web
site http://www.jech.com/supplemental)) have been critically
examined according to a defined set of criteria. In the
analysis the following dimensions have been applied: (1) the
study objective (as the exploration of how SOC may effect
health both as a dependent and an independent variable, the
examination of predicting and maintaining value of the SOC
regarding health, quality of life and wellbeing, the test of
related measures to SOC, the exploration of the relation to
different areas of life, the development of the theory base),
(2) the study designs and methods for analysis, and (3) the
applicability and practical use of the results. Studies using
interviews for gathering data and quantitative methods for
the analysis are categorised as quantitative studies.
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) postgraduate papers and doctoral thesis; (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 knowledge 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 above mentioned
(French, German, Japanese, Polish), (3) double published
papers, (4) papers without references to Antonovsky’s SOC
concept (primary or secondary references), (5) papers with
weakness in power—that is, response rate ,50% without a
careful analysis of drop outs (after our request of completing
information from the authors without an answer), (6) papers
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 appendix tables 2 to 8).
The search strategy is based on: (1) electronical search in the
following databases PubMed (Medline), Bibsys, ISI, Libris,
PsychInfo, Cinahl, Social Services Abstracts, Sociological
abstracts, (2) search on the key words salutogenesis,
salutogenic, sense of coherence, Antonovsky (also the
Swedish and Finnish translations of sense of coherence),
(3) reviewing reference lists in identified papers, (4) personal
communication with the authors and colleagues.
Material and procedure
Description of the material is presented in a flow chart (see
appendix, 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 appendix tables 9
and 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 assume the material is
adequate enough for a reasonable review.
A detailed protocol was compiled for each article or
doctoral thesis. This included details on (1) the aim (general
papers on theoretical and philosophical considerations;
validity of the SOC scale, association with health and health
behaviour, coping with stress/work conditions, life events,
disability, serious disease, association with quality of life and
wellbeing, applicability in practice, learning, and association
with social support and social network), (2) the country, (3)
the sample (randomised, consecutive/convenience, matched),
(4) the method/study design, (5) the ethical considerations,
(6) the methods for analysis, (7) the version of the SOC
questionnaire used, (8) the language of the SOC scale, (9)
statistical data such as the population size, population mean
age and sex, SOC means, standard deviation, Cronbach’s a,
response rate, SOC division (low/weak compared with high/
strong), correlation with other standardised measures, (10)
the main results and limitations of the study, (11) the
references, (12) the author’s contact data, (13) the key words
related to details in the paper, (14) the comments of the
assessment, and (15) the number related to the total
reference list of included papers in the review (appendix
table 9 and 10). The analysis is based on these protocols.
Furthermore, data were put together in tables on statistical
data using SOC-29, SOC-13, modified versions of the SOC
questionnaire (see appendix, tables 2 to 4), and on means
and standard deviations of subscales (see appendix, table 5).
In addition, SOC was compared with other standardised
measures serving as tests of criterion validity, which are used
in the different empirical studies, and categorised as follows:
(1) health, (2) generalised perceptions of self and environ-
ment, (3) perceived stressors, (4) quality of life and
wellbeing, (5) attitudes and behaviours (see appendix, table
4). Table 5 in the appendix follows the same structure and
use the same division and classification as Antonovsky in his
only review.4This makes it easier to compare the data over
It was not possible to carry out a full meta-analysis mainly
because of the great 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 findings in tables
and discuss the results. Validity is described and examined
according to the classification in face, consensual, construct,
criterion, predictive validity, and responsiveness.11Reliability
is examined through internal consistency measured by
Cronbach’s a and test-retest correlation.
The face validity of the SOC scale seems to be acceptable (see
appendix, table 2–4). The respondents do not usually find the
questionnaires difficult to complete (as an example no
evidence that 80 year old or even older people have
difficulties to complete the questionnaires.12However, there
are other experiences reported. Lee and colleagues found that
Japanese respondents reported difficulties with filling in the
scale compared with Chinese.13The Chinese more often
skipped questions. In a Swedish qualitative study on 15
Pentecostalists all the interviewees reported difficulties to
answer the questions.14The items concerning comprehensi-
bility and manageability caused the most trouble. The strong
ego-central items in the SOC questionnaire seemed to be
inappropriate for these participants. These findings were not
confirmed in another Swedish study among Pentecostalists.15
Problems with items 5, 6, 10, and 17 are reported.4 16 17
Until 1993 the SOC questionnaire had been used in at least
14 languages (Afrikaans, Czech, Flemish/Dutch, English,
Finnish, German, Hebrew, Norwegian, Rumanian, Russian,
Serbian, Spanish, Swedish, Tswana).4To date there are
Validity of Antonovsky’s sense of coherence scale461
additional translations in at least 19 languages are found:
Italian,41Japanese,13 42–46Lithuanian,47Polish,48 49Portuguese
total the SOC questionnaire has been used in 33 languages in
32 countries (Australia, Belgium, Brazil, Bulgaria, Canada,
China, Colombia, Denmark, Finland, France,
Germany, Greece, Iceland, Israel, Japan, Lithuania, New
Zealand, Netherlands, Norway, Poland, Rumania,4Russia,
Switzerland, Thailand, United Kingdom, USA) on subjects
in studies varying from large samples of the general
population covering 20 000 persons to small samples about
20 people (for details see appendix tables 2 to 4). The SOC
questionnaire has to date been used in both Western
countries and countries such as Thailand, China, Japan,
and South Africa. Therefore, the SOC scale seems to be a
cross culturally applicable instrument.
Most of the studies are cross sectional, although some
longitudinal17 53 57–74studies were found. The study designs
are either quantitative, qualitative,75–80or intervention.6 58 81–83
In the data collection questionnaires, interviews (or a
combination of these two techniques), focus groups, or
experience sampling method (EMS84) have been used.
The means of SOC-29 range from 100.50 (SD 28.50)85to
164.50 (SD 17.10)71points (124 studies, see appendix table 2)
and SOC-13 from 35.39 (0.10)86to 77.60 (SD 13.80)12points
(127 studies, see appendix table 3). The mean values of the
modified versions cannot be compared because of the
diversity of the material (see appendix table 4).
Icelandic,30 39 40
Consensual validity refers to the agreement of experts that a
measure is valid.9To date the consensual validity of the SOC
scale seems to be moderate. Most of the studies used one of
the original scales (SOC-29, SOC-13) in scientific disciplines
like medicine/psychiatry/psychology, public health/health
science, nursing, sociology, social work, and pedagogy.
Until 1993 there were only a few attempts to modify the
SOC questionnaire.4However, the situation has completely
changed today. Besides the original SOC questionnaire
consisting of 29 items and the shorter version of 13 items
there is an array of alternative instruments. At least 15
different versions exist with different scoring alternatives
(including the two versions of the family sense of coherence
scale,87–91a questionnaire especially adjusted for children92–94
and the sense of school coherence instrument.)95 96The
alternative instruments are: 3 items29–32 34 35 97–1036 items,57 737
items,1049 items,28 58 105–11810 items,11911 items,4112 items,120
13 items (modified scoring alternatives),121–12616 items,64 127 128
28 items,65 129and 29 items102(modified scoring alternatives).
In addition, 17 items and 19 items instrument were used
before 1992.4Furthermore, a 39 item SOC questionnaire is
mentioned, perhaps this is a printing error.130 131Probably the
same when talking about the original 28 item scale.118
The intercorrelation between the original SOC question-
naires and the alternatives are acceptable. The SOC-16
version, tested on 61 randomly selected Finns, showed a
corresponding correlation of 0.87 with SOC-29.128
reliability of the shortest form or SOC-3 measured by
weighted k was 0.61.101
Antonovsky expressed that he wanted the SOC scale to be
empirically examined before creating new modified scales.4
Unfortunately reality looks different. Besides the two original
scales there are many modified versions in existence. The
reasons are probably manifold. One explanation expressed is
that the 29 item questionnaire sometimes seems to be too
long, sometimes even the 13 items. An other argument for
modifying the SOC questionnaire is to reach a better
coherence with other measures used in the studies.132
The factorial structure of the scale in the three dimensions is
not completely clear. Studies on whether the SOC scales
actually correlate with the theoretical construction prin-
ciples present differing results. Factor analysis has in some
studies confirmed the one factor solution proposed by
Antonovsky,17 133–136while in others the analyses have failed
to confirm this solution.48 70 137 138A three factor and a second
order factor model seemed to best fit the data on Finnish
employees.139Among 300 Swedish students a five factor
solution was reported: meaning in life, control of feelings,
negative feelings, trust/distrust, and changing future explain-
ing 53% of the variance in SOC.140More in line with
Antonovsky are the findings from a Polish study on women
staying in hospital after delivery.48Here they found two main
dimensions corresponding with meaningfulness and com-
prehensibility and threesubdimensions.
accounted for 50% of the variance in SOC. The comprehen-
sibility dimension seemed to consist of feelings of uncer-
tainty, life events ordinary or surprisingly, and attitudes
towards people. A three factor solution, but not the same as
Antonovsky, is proposed by Sandell and colleagues on
Swedish patients and controls.16Here the meaningfulness
component was interpreted as a zest/depression dimension,
comprehensibility as intolerance compared with tolerance for
emotional conflict. The third factor was only distantly related
to manageability as interpersonal trust/mistrust. The three
factor solution had a lower explanation power of less than
40% of the variance.16SOC seems rather to be a multi-
dimensional than a unidimensional concept.
Antonovsky’s intention was to use the SOC questionnaire
as a measurement of the whole not examining the three
subscales separately. Despite this some studies report mean
values regarding manageability, meaningfulness, and com-
prehensibility (see appendix, table 5). No general pattern
emerges regarding the importance of the three dimensions.
Furthermore, he recommended the SOC concept to be
examined without dividing the sum of the item values into
low or high SOC.2Consequently, he never expressed the level
of a normal SOC. However, numbers of studies report
divisions into low, moderate, or high SOC (see appendix,
table 7). No general pattern of divisions emerges. Different
researchers have used separate divisions.
Sex differences can be found. Men usually have a slightly
higher SOC than women, although the differences are small
(see appendix, table 6).
Table 5 (see appendix) presents information about the
relation between the SOC scale and other standardised
instrument for measuring health, perceived self, stressors,
quality of life, wellbeing, attitudes, and behaviours used in
the studies. The extensive table follows the same structure
and uses the same division and classification as Antonovsky
in his only review, and gives detailed information on the
existing different SOC instruments today.4It would be
possible and important to provide an extensive examination
of the correlation and comparison of the different instru-
ments. However, this falls beyond the scope of this paper.
Correlation below 0.20 is assessed as poor, between 0.20–
0.35 slight, 0.35–0.65 moderate, 0.65–0.85 good, and above
0.85 very good.141The correlation with health range in general
from slight to good, using instruments such as the general
health questionnaire,142 143health index,144 145Hopkin’s symp-
tom checklist,146 147or mental health inventory18 148explaining
at highest 66% of the variance in SOC. Some correlations in
462Eriksson, Lindstro ¨m
table 5 are not significant. However, a p value in the non-
significant range only tells that either there is no difference
between groups or that there were too few subjects, but not
which one.149It is more important to examine the different
values of the coefficients and the explained variance.
The relatively high negative correlation with anxiety and
depression is striking, as is the strong positive correlation
with optimism and self esteem. The moderate correlation
with instruments measuring life events shows that SOC is
related to changes in the individual environment. There are
numbers of studies on the relation between SOC and quality
of life and wellbeing. In general they show that a high SOC is
related to a high quality of life. SOC seems also be connected
with attitudes and behaviours.
The capacity of the SOC scale to predict a future outcome—
that is, health—is expressed by the predictive validity.11
Examining the longitudinal studies the findings show a
comparatively high predictability, although there are diver-
gent results reported. In a short term perspective of three
months the SOC played an important part for discriminating
people at risk for developing post-traumatic stress symptoms
among survivors of the MS Estonia disaster.120In patients
with orthopaedic injuries150
obesity151the SOC predicted a better outcome after surgery
after one year. Support for the predictive validity of the SOC
(18 month) is reported among schizophrenic patients.152
Having a comparatively high SOC was a predictor of a
positive outcome among unemployed with a somatic disorder
after two years (OR: 3.5, CI: 1.5 to 8.4).153In a long term
perspective (five years) the SOC had a very good predictive
value for disability among Finnish patients.154Kalimo and
colleagues report findings from a 10 year follow up of Finnish
employees, where SOC and changes in support from superior
were the best predictors of burnout.74However, there are
other findings reported. In a group of Finnish municipal
employees and technical designers the findings failed to
support the SOC theory. Here predictive relations from health
to SOC were not found.73
and patients with morbid
The SOC seems to be comparatively stable over time, at least
for people with an initial high SOC, but not as stable as
Antonovsky assumed. The variation in means over time
shows small differences. No differences or very small ones are
reported in a three to five year perspective.61 63–65 73However,
the same situation emerges in a 10 year follow up study
among Finnish employees.74Furthermore, SOC tends to
increase with age over the whole life span. Using SOC-29
items (based on the mean age of the cross sectional studies)
the oldest people show the highest mean scores on SOC—
that is, 18 year old American college students 131.00,15537
year old French adults 133.60,134American older women (76
years) 157.21,156and 81 year old people 158.90.157
The internal consistency measured by Cronbach’s158a ranges
from 0.70159to 0.95160using SOC-29 (124 studies, see
appendix table 2), 0.70161to 0.92154(127 studies, see appendix
table 3) using SOC-13. Among the modified versions of the
SOC scale The EPIC-Norfolk United Kingdom prospective
cohort study reports the lowest a of 0.35 using the shortest
form of SOC-3.103The highest a of 0.91102is reported in a
study using a modified scoring alternative of the original 29
item questionnaire (5 point Likert scale) (60 studies, see
appendix table 4). Coefficients above 0.70 reflect good
internal consistency.162The SOC scale shows high internal
Antonovsky assumed the individual SOC was stabilised by
the end of early adulthood. Thereafter the SOC fluctuates
marginally.2Very few longitudinal studies were undertaken
before 1993.4This means the longitudinal studies reporting
test-retest reliability are few. Test-retest reliability of the
scales range from 0.92 (one week),1330.65 (three weeks),36
0.93 (one month),1330.77 (six months)72using SOC-29.
Fiorentino70reports a one year correlation range of 0.78
(SOC-29). Using SOC-13 the corresponding range is 0.6959to
0.7217. Among Swiss adolescents the correlation was 0.77
after 18 months.59However, the few longitudinal studies
with an greater time span report correlations of 0.64 (three
years),730.42 to .0.45 (four years),620.59 to 0.67 (five years),72
and a 10 year correlation of 0.54 (personal communication
with Pahkin December 2004). Such statistical data are in line
with data reported by Antonovsky.4
The purpose of this paper was to review the validity and
reliability of Antonovsky’s SOC scale 1992–2003 as a part of a
more extensive review on the salutogenic research. There is a
need for a comprehensive understanding of the SOC concept.
Therefore our attempt to make sense of the comprehensive
researchshould be beneficial
Furthermore, the extensive documentation of references
serves as bibliography on the salutogenesis.
As of semantics some authors used the word salutogenetic
to describe the concept. To our opinion salutogenic is a more
preferable word, because the knowledge about how SOC
might be related to genetic factors is not clear.
A full meta-analysis as method has not been used. Because
of the diversity of the material we have adopted another
approach and have tried to provide a research synthesis
according to Cooper.9This could be seen as a limitation.
Another limitation could be the choice of included languages,
but despite the location of the studies most are published in
English. We have checked the English abstracts of studies in
other languages. Because they generally lack statistical data
they are excluded from this paper.
The SOC scale has proved to be psychometrically compara-
tively sound. However, the structure of the SOC concept is
still not completely clear. SOC seems to have a multi-
dimensional character rather than a unidimensional. To our
opinion there is at present no need for further testing of the
SOC instrument because the findings prove the SOC
instrument being reliable, valid, feasible, and cross culturally
applicable. Furthermore, there is no need to develop new SOC
versions. There is rather a need of consolidation and a
standardisation of the instruments. It would be more
relevant to develop qualitative methods.
SOC does not seem to be as stable as Antonovsky assumed.
The evidence shows that SOC tends to increase with age
through the whole life span. The older the age of the
population sample the higher the SOC score. Whether the
increases in the individual SOC are an effect of natural
selection of people—healthy people survive—or a question of
people developing a strong SOC staying well is not clear. We
suggest the second explanation.
Some authors propose the SOC questionnaire could be
used as a screening instrument aiming at the identification of
people at risk of developing a low SOC. This is perhaps
justified, but there is still the problem of interpreting the
individual position on the health/ease and dis-ease con-
tinuum. It is not clear where SOC no longer protects the
movement towards the healthy end. Knowledge about this is
for further research.
Validity of Antonovsky’s sense of coherence scale463
still incomplete. There is also a risk of negative health effects
if one stigmatises people in groups regarding their SOC. What
does the individual level of SOC at a given time really mean
in practice? Therefore, we do not recommend the use of the
SOC questionnaire as a screening instrument. Instead we
suggest that the SOC concept could be implemented as a
systematic orientation and perspective in the daily activities
and actions of the professionals. There is a need to change
focus from problems and obstacles to resources. The most
important immediate research focus now would be to
implement the theory in practice.
The appendix, papers used in the review, and the
doctoral theses papers are available on the journal
web site (http://www.jech.com/supplemental).
M Eriksson, B Lindstro ¨m, Nordic School of Public Health, Gothenburg,
Funding: this study was supported by grants from the European
Commission (European Masters in Health Promotion, EUMAHP) and
the Nordic School of Public Health.
Conflicts of interest: none.
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