The Sense of Coherence and Its Measurement 12
Monica Eriksson and Maurice B. Mittelmark
Antonovsky (1987) developed a questionnaire to measure
the sense of coherence. The original form, the Orientation to
Life Questionnaire, consists of 29 items, 11 items measuring
comprehensibility, 10 items measuring manageability, and
8 items measuring meaningfulness. The response
alternatives are a semantic scale of 1 point to 7 points,
where 1 and 7 indicate extreme feelings about questions
(and statements) about how one’s life is experienced (e.g.,
‘when you talk to people, do you have the feeling that they
do not understand you?’is scored from 1 ¼never have this
feeling to 7 ¼always have this feeling). The questionnaire
is a summed index with a total score ranging from 29 to
203 points for the original scale of 29 questions (SOC-29). A
shorter version of 13 questions (SOC-13) of the original
form was developed by Antonovsky (1987), where the
score ranges between 13 and 91 points. Antonovsky
intended that the sense of coherence scales be scored with
a single total score and not component scores (Fig. 12.1),
since he theorized that it was the sense of coherence in its
totality that inﬂuenced movement along the ease/dis-ease
continuum. This issue is taken up again later in this chapter.
Examples of items measuring the comprehensibility
dimension are as follows (Antonovsky, 1987, p. 190ff.):
•When you talk to people, do you have a feeling that they
don’t understand you? (from ‘never have this feeling’to
‘always have this feeling’)
•Do you have a feeling that you are in an unfamiliar
situation and don’t know what to do? (from ‘very often’
to ‘very seldom or never’)
The following items are examples that measure
•When something unpleasant happened in the past your
tendency was: (from ‘to eat yourself up about it’to ‘to say
“ok that’s that, I have to live with it”and go on’)
•When you do something that gives you a good feeling:
(from ‘it’s certain that you’ll go on feeling good’to ‘it’s
certain that something will happen to spoil the feeling’)
Meaningfulness is measured with items like these:
•Doing the things you do every day is: (from ‘a source of
deep pleasure and satisfaction’to ‘a source of pain and
•When you think about your life, you very often: (from ‘feel
how good it is to be alive’to ‘ask yourself why you exist
Comprehensibility, the cognitive dimension, refers to the
extent to which one perceives internal and external stimuli as
rationally understandable, and as information that is orderly,
coherent, clear, structured rather than noise—that is, chaotic,
disordered, random, unexpected, and unexplained
(Antonovsky, 1991, p. 39). The ability to create structure
out of chaos makes it easier for us to understand one’s
context and one’s own part in it, for example, one’s role in
the family or in the workplace. A prerequisite to be able to
cope with a stressful situation is that one can to some extent
understand it. What one comprehends is easier to manage.
Manageability, the instrumental or behavioral dimension,
deﬁned as the degree to which one feels that there are
resources at one’s disposal that can be used to meet the
requirements of the stimuli one is bombarded by
M. Eriksson (*)
Department of Health Sciences, Section of Health Promotion and Care
Sciences, Center on Salutogenesis, University West, Gustava Mellins
gata 2, Trollha
¨ttan SE-46186, Sweden
Department of Health Promotion and Development,
University of Bergen, Christiesgt. 13, Bergen 5020, Norway
#The Author(s) 2017
M.B. Mittelmark et al. (eds.), The Handbook of Salutogenesis, DOI 10.1007/978-3-319-04600-6_12
(Antonovsky, 1991, p. 40). Formal resources include, for
example, social services and care staff in public and private
organizations. Informal resources include, for example, fam-
ily, circle of friends, colleagues, and signiﬁcant others; in
other words, people who are trusted and who can be relied on
difﬁcult situations. Coping also requires that one is
motivated to solve the problems that cause stress, is willing
to invest energy to solve the problem, and ﬁnds meaning in
being able to manage the situation. This leads to the third
dimension of the sense of coherence, meaningfulness.
Meaningfulness, the motivational dimension, refers to the
extent to which one feels that life has an emotional meaning,
that at least some of the problems faced in life a face are
worth commitment and dedication, and are seen as
challenges rather than only as burdens (Antonovsky, 1991,
p. 41). One needs to have a clear desire to resolve
difﬁculties, and willingness to invest energy to get through
experiences of stress that have the potential to cause distress.
The Validity and Reliability of the Sense
Face validity: The sense of coherence scales have been
empirically tested in different cultures, both Western and
cultures in Africa and Asia. Studies have been conducted
on different samples: general populations, different
professions, in persons with disabilities, different patient
groups as well as in children, adolescents, adults, and elderly,
in families, in organizations, and also on a societal level.
A systematic research review shows that as of 2003, the
SOC-29 and SOC-13 had been used in at least 33 different
languages in 32 different countries (Eriksson & Lindstro
2005). An update shows that another 16 languages can be
added: Albanian (Roth & Ekblad, 2006), Croatian (Singer &
¨hler, 2007), Brazilian (Bonanato et al., 2009), Hungarian
(Biro, Balajti, Adany, & Kosa, 2010), Korean (Han et al.,
2007), Lingala (Bantu language spoken in parts of Africa)
(Pham, Vink, Kinkodi, & Weinstein, 2010), Persian,
Swahili (Rohani, Khanjari, Abedi, Oskouie, & Langius-
¨f, 2010) as well as local languages in Africa Afar, Bilein,
Hidareb, Kunama people, Nara, Saho, Tigre, and Tigrinya
(Almedom, Tesfamichael, Mohammed, Mascie-Taylor, &
Since 2003, the SOC-29 and the SOC-13 has been used
in a further 13 countries (Eriksson, 2014): Eritrea
(Almedom et al., 2007), Croatia (Pavicic Bosnjak,
Rumboldt, Stanojevic, & Dennis, 2012), Hungary (Biro
et al., 2010), India (Suraj & Singh, 2011), Iran (Rohani
et al., 2010), Italy (Ciairano, Rabaglietti, Roggero, &
Callari, 2010), Korea (Han et al., 2007), Kosovo, the Dem-
ocratic Republic of Congo (Pham et al., 2010), Spain
´ga, Martinez-Martin, Del Barrio, Lozano, &
Grupo Espanol, 2007), Sudan (Abdelgadir, Shebeika,
Eltom, Berne, & Wikblad, 2009), Taiwan (Tang & Li,
2008), and Turkey (O
¨ztekin & Tezer, 2009). More recent
research shows three additional countries: Austria
(Mautner et al., 2014), Estonia (Ho
¨jdahl, Magnus, Mdala,
Hagen, & Langeland, 2015), and Malaysia (Rostami,
Lamit, Khoshnava, & Rostami, 2014).
In sum, the SOC-29 and the SOC-13 have been used in at
least 49 different languages in at least 48 different countries
around the world (Fig. 12.2).
Construct validity: The structure of the sense of coher-
ence is complex. Recent research shows that the sense of
coherence seems to be a multidimensional construct rather
than a unidimensional as proposed by Antonovsky (1987),
with all three dimensions constantly interacting with each
other and together to form a common, overarching factor,
sense of coherence. Following from that, Antonovsky
maintained that on theoretical grounds, one should avoid
lifting out individual dimensions in order to examine them
SENSE OF COHERENCE (SOC)
Fig. 12.1 The original view of the Sense of coherence and its three
dimensions (Antonovsky, 1987)
Demokratic Republic of Kongo
The SOC questionnaire has
been used in studies all over
the World, on different
samples of various ages,
cultures and disciplines
Fig. 12.2 The distribution of studies using the sense of coherence
scale 1992–2015 in a global context
98 M. Eriksson and M.B. Mittelmark
Nevertheless, recent research has focused on the study
of the structure and content of sense of coherence. There
are studies that support Antonovsky’s idea of the sense of
coherence as a general factor with three dimensions
Mastekaasa, Sørensen, Sandanger, & Kleiner, 2007; Rajesh
et al., 2015;So
¨derhamn & Holmgren, 2004;So
Sundsli, Cliffordson, & Dale, 2015;SpadotiDantasetal.,
¨derhamn et al. (2015) found evidence in a conﬁr-
matory factor analysis that conﬁrmed the SOC-29 as one
theoretical construct with three dimensions, comprehensi-
bility, manageability, and meaningfulness. In a cross-
sectional survey among Norwegian cognitively intact
nursing home residents, Drageset and Haugan (2015)
found that the three-factor model ﬁt their data. However,
the item ‘has it happened in the past that you were surprised
by the behavior of people whom you thought you knew
well?’was troublesome, and removing this item resulted in
a better ﬁt. Recent research suggests that the sense of
coherence seems to be a multidimensional concept
consisting of many different dimensions rather than a sin-
gle factor (Eriksson & Lindstro
Naaldenberg, Tobi, van den Esker, & Vaandrager, 2011).
Figure 12.3 shows the sense of coherence as a multidimen-
Sandell et al. (1998) examined the sense of coherence
instrument among a sample of Swedes and could not ﬁnd
support for a common factor, nor the three dimensions of
comprehensibility, manageability, and meaningfulness.
Three more or less stable dimensions emerged, where lust
and depression were two extremes which could best be
referred to the dimension of meaningfulness. Antonovsky’s
concepts comprehensibility could in this study be seen in the
form of tolerance versus intolerance. The third factor, man-
ageability, was reﬂected by trust and distrust (Sandell et al.,
1998, p. 701).
Consensual validity is a term that indicates the extent to
which various scientists agree on the properties of an
instrument (Cooper, 1998). The consensual of validity is
somewhat weak. While many researchers use either the
SOC-29 or the SOC-13, there are also many different
modiﬁed versions in use, with different numbers of
questions and different possibilities of response options.
Most of the modiﬁed versions have partially abandoned the
original scale of 1–7 points (but the wording of the questions
is usually the same as in the SOC-29 and SOC-13). Results
from a research review 1992–2003 showed that there were at
least 15 different modiﬁed forms from form consisting of
only three questions to 28 questions (Eriksson & Lindstro
2005). This includes the special version adapted for families
(FSOC) (Antonovsky & Sourani, 1988; Sagy & Antonovsky,
1992), for children (Margalit & Efrati, 1996), and a version
for a school context (Nash, 2002). The Children’s Orienta-
tion to Life Scale consists of 16 questions plus 3 distracters
(Idan & Margalit, 2014; Margalit & Efrati, 1996). The
response options follow a scale of 1–4, where 4 indicates
the highest degree of sense of coherence. There are also two
variants of the FSOC, the original with 26 questions and a
shorter version with 12 questions (Antonovsky & Sourani,
1988; Sagy, 2008; Sagy & Antonovsky, 1992). The
questions are the same as in the original form, but tailored
to the child or to a family context. Table 12.1 provides a
summary of some of the other sense of coherence scales in
the literature, demonstrating a range of items from 3 to
16, and intended for use by various sociodemographic
Antonovsky (1979) originally described the sense of
coherence as an individual property. He later widened the
perspective (Antonovsky, 1987) with sense of coherence also
conceived at the family level. Recent research shows that the
sense of coherence concept and measurement also can be
applied in organizations such as a workplace (Bauer & Jenny,
´n, 2010; Bringse
´n, Andersson & Ejlertsson,
2009; Forbech & Hanson, 2013; Graeser, 2011; Mayer &
Krause, 2011; Mayer & Boness, 2011; Nilsson, Andersson,
Ejlertsson, & Troein, 2012; Orvik & Axelsson, 2012; Vogt,
Jenny & Bauer, 2013).
Comprehensibility Manageability Meaningfulness
Zest vs. Depression
Trust vs. Distrust
Tolerance vs. Intolerance
Two factor solution with two dimensions3)
SENSE OF COHERENCE
One general factor solution with three dimensions1)
Three factor solution with three dimensions2)
Fig. 12.3 The sense of
coherence as a multidimensional
construct. 1) Antonovsky, 1987,
2) Sandell, Blomberg, & Lazar,
1998, 3) Sakano & Yajima, 2005
12 The Sense of Coherence and Its Measurement 99
Table 12.1 A selection of different versions of the sense of coherence instrument
Authors Country Sample N
Agardh, E. E., Ahlbom, A., Andersson, T. et al. (2003). Work stress
and low sense of coherence is associated with type 2 diabetes in
middle-aged Swedish women. Diabetes Care, 26 (3), 719–724
Sweden Healthy middle
4821 SOC-3 3
Schumann, A., Hapke, U., Meyer, C. et al. (2003) Measuring Sense
of Coherence with only three items: A useful tool for population
surveys. British Journal of Health Psychology, 8, 409–421
Bayard-Burﬁeld, L., Sundquist, J., Johansson, S-E. (2001)
Ethnicity, self-reported psychiatric illness, and intake of
psychotropic drugs in ﬁve ethnic groups in Sweden. Journal of
Epidemiology and Community Health, 55, 657–664
4981 SOC-3 7 - Likert
¨ki, M., Elovainio, M., Vahtera, J. et al. (2002) Sense of
coherence as a mediator between hostility and health. Seven-year
prospective study on female employees. Journal of Psychosomatic
Research, 52, 239–247
433 SOC-6 7 - Likert 0.76
Toft Würtz, E., Fonager, K., Tølbøll Mortensen, J. (2015).
Association between sense of coherence in adolescence and social
beneﬁts later in life: a 12-year follow-up study. BMJ Open, doi: 10.
Denmark Pupils 773 SOC-7 7 - Likert 0.77
¨rde, M., Westman, B., Nygren, L. (2000) Ethical discussion
groups as an intervention to improve the climate in inter-
professional work with the elderly and disabled. Journal of
Interprofessional Care, 14(4), 351–361
354 SOC-9 3 - Likert 0.60–0.69
Klepp, O.M., Mastekaasa, A., Sørensen, T. et al. 2007 Structure
analysis of Antonovsky’s sense of coherence from an
epidemiological mental health survey with a brief nine-item sense
of coherence scale. International Journal of Methods in Psychiatric
Research, 16(1), 11–22
Norway Adults 1062 SOC-9 7 - Likert 0.79
Li, W., Leonhart, R., Schaefert, R. et al. (2014) Sense of coherence
contributes to physical and mental health in general hospital
patients in China. Psychology, Health & Medicine, doi: 10.1080/
China Patients in
491 SOC-9 7 - Likert
Mayer, J., Thiel, A. (2014) Health in elite sports from a
salutogenetic perspective: Athletes’sense of coherence. PLOS
Germany Elite sports 698 SOC-L9
Naaldenberg, J., Tobi, H., van den Esker, F. et al. 2011
Psychometric properties of the OLQ-13 scale to measure Sense of
Coherence in a community-dwelling older population. Health and
Quality of Life Outcomes, 9, 37–45
1361 SOC-11 7 - Likert
Kanhai, J., Harrison, V.E., Suominen, A.L. (2014) Sense of
coherence and incidence of periodontal disease in adults. Journal
of Clinical Periodontology, 41, 760–765
Finland Adults 848 SOC-12 7 - Likert 0.85
Sagy, S. (1998) Effects of personal, family, and community
characteristics on emotional reactions in a stress situation. Youth &
Society, 29(3), 311–330
Israel School children
7 - Likert 0.81
Margalit, M., Efrati, M. (1996) Loneliness, coherence and
companionship among children with learning disorder.
Educational Psychology, 16(1), 69–80
Israel Children with
324 SOC-16 þ3
7 - Likert 0.72
Suominen, S., Blomberg, H., Helenius, H. et al. (1999) Sense of
coherence and health—does the association depend on resistance
resources? Psychology and Health, 14, 937–948
3115 SOC-16 4 - Likert 0.84
Sagy, S., Antonovsky, A. (1992) The family sense of coherence and
the retirement transition. Journal of Marriage & Family, 54(4),
Israel Retirees and
7 - Likert 0.88
100 M. Eriksson and M.B. Mittelmark
Research that examines and discusses salutogenesis and
the sense of coherence at a societal level is sparse.
Braun-Lewensohn and Sagy (2011) report ﬁndings from
studies using an instrument adapted for societal sense of
coherence (Sense of Community Coherence), which
contains seven questions describing how the individual
experiences the society in terms of comprehensibility,
manageability, and meaningfulness. Comprehensibility at
the societal level addresses the experience of society as
more or less organized in a way that makes life somewhat
predictable, that the structure of society can be more or less
understood, and that society is perceived as more or less safe
and secure. Manageability is a state in which the individual
experiences a society with resources that support
individuals, for example , in emergencies or in critical
situations. Societal support includes, for example, programs
to support young people’s mental health and initiatives to
create conditions so that people from different generations
can meet each other. Meaningfulness refers to the experi-
ence that society supports people to experience fulﬁllment,
to develop their abilities, and to feel satisfaction with life
(Braun-Lewensohn & Sagy, 2011, p. 535).
The relevance of salutogenesis and the sense of coher-
ence to the building of healthy public policy has also been a
focus of theorizing and research (Eriksson, Lindstro
Lilja, 2007; Lindstro
¨m & Eriksson, 2009). To develop a
social policy based on the salutogenic framework means to
identify resources for health and welfare of the society, in
the past as well as in the present, including risks of illnesses,
and how this knowledge and the most effective measures can
be used to resolve the current challenges. The core of such
policy is to create coherence and synergies, from individuals
to groups and organizations in the local community, and
ﬁnally to the whole of society (Eriksson & Lindstro
¨m & Eriksson, 2009).
Criterion validity: Eriksson and Lindstro
information about the relation between the SOC-29 to other
instruments measuring health, perceived self, stressors, qual-
ity of life, well-being, attitudes, and behaviors. The correla-
tion with health ranges in general from slight to good, using
instruments such as the General Health Questionnaire, the
Health Index, the Hopkin’s Symptom Checklist, and the
Mental Health Inventory, with such health measures
explaining up to 66 % of the variance in the SOC-29.
There are numbers of studies on the relation between SOC
and quality of life and well-being. In general, they show that
a high SOC is related to a high quality of life Eriksson and
Predictive validity: The ability of an instrument to predict
how, for example, health develops in the future is called
predictive validity (Abramson & Abramson, 1999). The
predictive validity of the sense of coherence questionnaire
seems to be relatively good, based on a review of longitu-
dinal studies (Eriksson & Lindstro
¨m, 2005). There are
studies that support predictive ability (Lundman et al.,
2010; Luutonen, Sohlman, Salokangas, Lehtinen, &
Dowrick, 2011; Poppius, Virkkunen, Hakama & Tenkanen,
2006; Surtees, Wainwright, Luben, Khaw, & Day, 2003),
whereas other studies have not done so (Norekva
2010). It seems the time for follow-up is an important
factor for the predictive ability of the instrument. The
results of a study among elderly persons, the Umea
study, show that the sense of coherence predicted mortality
at 1-year follow-up, but not at follow-up after 4 years
(Lundman et al., 2010).
Reliability: SOC-29 test–retest correlations range from
0.69 to 0.78 (1 year), 0.64 (3 years), 0:42 to 00:45
10-year follow-up (Eriksson & Lindstro
¨m, 2005). The
internal consistency measured by Cronbach’salpharanges
from 0.70 to 0.95 using SOC-29 (124 studies) and 0.70 to
0.92 (127 studies) using SOC-13 (Eriksson & Lindstro
2005, p. 463). The sense of coherence scale shows high
Critique of the SOC-29 and SOC-13
One indirect form of criticism has practical roots: as men-
tioned earlier, various sense of coherence measures have
been developed that are shorter than even the SOC-13, as
short as just three items. This reﬂects the reality that in many
health survey applications, questionnaires must be very short.
More directly, the SOC-29 and SOC-13 have been criticized
on the basis of supposed shortcomings in the instruments’
psychometric properties (Korotkov, 1993; Larsson &
Kallenberg, 1999; Schnyder, Büchi, Sensky, & Klaghofer,
2000). It is asserted also that the sense of coherence concept
does not deal adequately with emotional aspects of life expe-
rience (Flannery & Flannery, 1990; Flensborg-Madsen,
Ventegodt, & Merrick, 2006c; Korotkov, 1993; Korotkov
& Hannah, 1994). Inconsistent evidence about the lability/
stability of the sense of coherence over the life course has
also been noted by critics (Geyer, 1997). Criticism of
salutogenesis generally includes implicit doubt about efforts
to measure the sense of coherence via any means (Bengel,
Strittmatter, & Willman, 1999; Kumlin, 1998). The leveling
of such criticism is welcome as part of the healthy evolution
of a ‘living’theory or model, and responses to the critics are
published (Eriksson, 2007; Lindstro
¨m & Eriksson, 2010).
In the limits of this chapter, we focus on just the critical
ideas of Trine Flensborg-Madsen, Søren Ventegodt and Jaov
Merrick. The critique stems from their conclusion that the
SOC-29 and SOC-13 are only moderately-to-weakly related
to various measures of physical health (Flensborg-Madsen,
12 The Sense of Coherence and Its Measurement 101
Ventegodt, & Merrick, 2005a), leading them to construct
and test a new measure of the sense of coherence, intended to
overcome limitations in the SOC-29 and SOC-13
(Flensborg-Madsen, Ventegodt, & Merrick, 2006a,2006b).
Their critique can be summarized in this way:
• Antonovsky presumed that one’s internal and external
environment have to be predictable in order for a person
to have a high sense of coherence
• Predictability should not be included in conceptualizing
and measuring the sense of coherence, because lack of
predictability is not necessarily unhealthy
• Rather, unpredictability is what makes life matter in the
ﬁrst place; it can provide a state of initiative, energy, and
Since the SOC-29 includes several items that have to do
with predictability, Flensborg-Madsen, Ventegodt, and
Merrick (2005b) regard the instrument as ﬂawed and they
developed an alternative 9-item measure that excluded the
concept of predictability, but that otherwise was purportedly
built, as they write, on the exact same idea, theory, and
conceptualization used by Antonovsky (Flensborg-Madsen
et al., 2006a,2006b).
Their conclusion about a weak association between the
SOC-29 and SOC-13 and physical health is based on a
review of about 50 studies (2005a). They categorize the
health instruments in the reviewed studies as having foci
on: physical health, biological measures, psychological
measures, health measures incorporating psychological
aspects, stress, and behavioral aspects. They conclude that
the SOC scales are unable to explain health that is measured
only by means of physical terms (Flensborg-Madsen et al.,
2005a, p. 665). As a solution, Flensborg-Madsen
et al. (2006c) propose the concept of ‘emotional coherence’
in relation to physical health and ‘mental coherence’in
relation to psychological health supported by Endler, Haug,
and Spranger (2008).
Such fragmentation of the concept of the sense of coher-
ence into physical and mental components breaks signiﬁ-
cantly from Antonovsky’s fundamental notion of an
‘orientation to life’(1979, 1987). Such fragmentation also
reinforces the physical health/mental health divide in mod-
ern health care (and in the public’s imagination), which has
been challenged vigorously (WHO, 2001).
We move on to the issue of excluding predictability in
sense of coherence measurement; to do so is to depart
emphatically from ‘the exact same idea, theory and concep-
tualization’used by Antonovsky’, who wrote:
From the time of birth, or even earlier, we constantly go through
situations of challenge and response, stress, tension, and reso-
lution. The more these experiences are characterized by consis-
tency, participation in shaping outcome, and an underload-
overload balance of stimuli, the more we begin to see the
world as being coherent and predictable. When, however,
one’s experiences all tend to be predictable, one is inevitably
due for unpleasant surprises that cannot be handled, and one’s
sense of coherence is weakened accordingly. Paradoxically,
then, a measure of unpredictable experiences-which call forth
hitherto unknown resources—is essential for a strong sense of
coherence. One then learns to expect some measure of the
unexpected. When there is little or no predictability, there is
not much one can do except seek to hide until the storm (of life)
is over, hoping not to be noticed. Or else one strikes out blindly
and at random until exhaustion sets in. No defense mechanisms
can be adequate. We must note an implicit assumption here. If a
strong sense of coherence is to develop, one’s experiences must
be not only by and large predictable but also by and large
rewarding, yet with some measure of frustration and punish-
ment. (Antonovsky, 1979, p. 187)
As this extended passage makes clear, reasonable predict-
ability functions inextricably with many other aspects of
experience to shape the sense of coherence.
Sense of Coherence Develops Over Time
According to Antonovsky (1987) sense of coherence
develops until the age of about 30 years, thereafter sense of
coherence was estimated to remain relatively stable until
retirement, after which a decrease was expected. This
assumption ﬁnds no support in subsequent empirical
research. The sense of coherence seems to be relatively
stable over time, but not as stable as Antonovsky assumed.
Research shows that sense of coherence develops over the
entire life cycle, that is, it increases with age (Feldt et al.,
2007; Nilsson, Leppert, Simonsson & Starrin, 2010). Nilsson
and coauthors were able to demonstrate on a sample of
43,500 Swedish respondents, aged 18–85 years, that sense
of coherence increases with age in both men and women.
Support for a corresponding development of the sense of
coherence over time could also be seen in a longitudinal
study of more than 18,000 Finns, in the Health and Social
Support Study, where the sense of coherence continuously
increased with age. A strong sense of coherence initially
appears to determine its development over time (Feldt
et al., 2011). There is a lack of longitudinal studies with
long-term follow-up. The longest follow-up is that of
13 years (Hakanen, Feldt, & Leskinen, 2007). Table 12.2
shows ﬁndings from longitudinal studies with different time
spans for follow-ups.
102 M. Eriksson and M.B. Mittelmark
Salutogenesis Is More than the Measurement
of the Sense of Coherence
Salutogenesis, focusing on health and on people’s resources,
is something more than the measurement of the sense of
coherence. Today, we can talk about salutogenesis as an
umbrella concept with many different theories and concepts
with salutogenic elements and dimensions (Lindstro
Eriksson, 2010). There is extensive research that focuses
on the resources of individuals, groups, and communities.
All this and more can be accommodated under the common
umbrella. Figure 12.4 shows some related concepts to the
sense of coherence collected under an umbrella.
Open Access This chapter is distributed under the terms of the
Creative Commons Attribution-Noncommercial 2.5 License (http://
creativecommons.org/licenses/by-nc/2.5/) which permits any noncom-
mercial use, distribution, and reproduction in any medium, provided the
original author(s) and source are credited.
The images or other third party material in this chapter are included
in the work’s Creative Commons license, unless indicated otherwise in
the credit line; if such material is not included in the work’s Creative
Commons license and the respective action is not permitted by statutory
regulation, users will need to obtain permission from the license holder
to duplicate, adapt or reproduce the material.
Abdelgadir, M., Shebeika, W., Eltom, M., Berne, C., & Wikblad,
K. (2009). Health related quality of life and sense of coherence in
Sudanese diabetic subjects with lower limb amputation. Tohoku
Journal of Experimental Medicine, 217, 45–50.
Abramson, J. H., & Abramson, Z. H. (1999). Survey methods in com-
munity medicine. Epidemiological research programme evaluation
clinical trials (5th ed.). Edinburgh: Churchill Livingstone.
Almedom, A. M., Tesfamichael, B., Mohammed, Z. S., Mascie-Taylor,
C. G. N., & Alemu, Z. (2007). Use of “Sense of Coherence (SOC)”
scale to measure resilience in Eritrea: Interrogating both the data
and the scale. Journal of Biosocial Science, 39(1), 91–107.
Antonovsky, A. (1987). Unraveling the mystery of health. How people
manage stress and stay well. San Francisco: Jossey-Bass Publishers.
Antonovsky, A. (1993). The salutogenic approach to aging. Lecture
held in Berkeley, January 21, 1993.
Antonovsky, A., & Sourani, T. (1988). Family sense of coherence and
family adaptation. Journal of Marriage and Family, 50, 79–92.
Bauer, G., & Jenny, G. J. (2012). Moving towards positive
organisational health: Challenges and a proposal for a research
model of organisational health development. In J. Houdmondt,
S. Leka, & R. R. Sinclair (Eds.), Contemporary occupational health
psychology: Global perspectives on research and practice (Vol. 2).
Bengel, J., Strittmatter, R., & Willman, H. (1999). What keeps people
healthy? The current state of discussion and the relevance of
Antonovsky’s salutogenic model of health. Cologne: Federal Centre
for Health Education (FCHE).
Table 12.2 The development of sense of coherence over time based on a sample of longitudinal studies
1!2 year 0.2 points SOC-13 Virtanen and Koivisto (2001)
1!2 year 0.8 points SOC-13 Bergman, Årestedt, Fridlund, Karlsson, and Malm (2012)
1!3 year 14.2 points SOC-28 Kuuppeloma
¨ki and Utriainen (2003)
1!3 year 0.1 points SOC-13 Honkinen et al. (2008)
1!5 year 1.6 points SOC-13 Volanen, Suominen, Lahelma, Koskenvuo, and Silventoinen (2007)
1!5 year 1.8 points SOC-13 Bergman et al. (2012)
1!5 year 3.6 points SOC-13 Lo
¨vheim, Graneheim, Jonse
´n, Strandberg, and Lundman (2013)
1!9 year 0.1 points SOC-13 Luutonen et al. (2011)
1!10 year 2.7 points SOC-13 Kalimo, Pahkin, Mutanen, and Toppinen-Tanner (2003)
1!12 year 0.3 points SOC-29 Holmberg and Thelin (2010)
1!13 year 0.4 points SOC-13 Hakanen et al. (2007)
Sense of Coherence
Learned hopefulness Learned resourcefulness
Will to meaning Flourishing Thriving
Social and emotional intelligence
Posttraumatic Personal Growth
Locus of Control
Quality of Life
Ecological system theory
Assets for health and well-being
Fig. 12.4 The salutogenic
umbrella, salutogenesis as
an umbrella concept
12 The Sense of Coherence and Its Measurement 103
Bergman, E., Årestedt, K., Fridlund, B., Karlsson, J.-E., & Malm,
D. (2012). The impact of comprehensibility and sense of coherence
in the recovery of patients with myocardial infarction: A long-term
follow-up study. European Journal of Cardiovascular Nursing, 11
Biro, E., Balajti, I., Adany, R., & Kosa, K. (2010). Determinants of
mental well-being in medical students. Social Psychiatry and Psy-
chiatric Epidemiology, 45, 253–258.
Bonanato, K., Paiva, S. M., Pordeus, I. A., Ramos-Jorge, M. L.,
Barbabela, D., & Allison, P. J. (2009). Relationship between
mothers’sense of coherence and oral health status of preschool
children. Caries Research, 43, 103–109.
Braun-Lewensohn, O., & Sagy, S. (2011). Salutogenesis and culture:
Personal and community sense of coherence among adolescents
belonging to three different cultural groups. International Review
of Psychiatry, 23(6), 533–541.
´n, Å. (2010). Taking care of others—What’s in it for us?
Exploring workplace-related health from a salutogenic perspective
in a nursing context. Doctoral thesis. Lund: Lund University.
´n, Å., Andersson, I. H., & Ejlertsson, G. (2009). Development
and quality analysis of the Salutogenic Health Indicator Scale
(SHIS). Scandinavian Journal of Public Health, 37(1), 13–19.
Ciairano, S., Rabaglietti, E., Roggero, A., & Callari, T. C. (2010). Life
satisfaction, sense of coherence and job precariousness in Italian
young adults. Journal of Adult Development, 17, 177–189.
Cooper, H. (1998). Synthesizing research. A guide for literature review.
Thousand Oaks, CA: Sage.
Drageset, J. & Haugan, G. (2015). Psychometric properties of the
Orientation to Life Questionnaire in nursing home residents. Scan-
dinavian Journal of Caring Sciences, August 29, doi:10.1111/scs.
Endler, C. P., Haug, T. M., & Spranger, H. (2008). Sense of Coherence
and physical health. A “Copenhagen interpretation”of
Antonovsky’s SOC concept. The Scientiﬁc World Journal, 8,
Eriksson, M. (2007). Unravelling the Mystery of Salutogenesis. The
evidence base of the salutogenic research as measured by
Antonovsky’s Sense of Coherence Scale. [Doctoral thesis]. Åbo
Akademi University, Department of Social Policy. Folkha
Research Centre, Health Promotion Research Programme, Research
Report 2007:1. Turku: Folkha
Eriksson, M. (2014). The salutogenic framework for health promotion
and disease prevention. In D. I. Mostofsky (Ed.), The handbook of
behavioral medicine. Hoboken: Wiley-Blackwell.
Eriksson, M., & Lindstro
¨m, B. (2005). Validity of Antonovsky’s sense
of coherence scale—A systematic review. Journal of Epidemiology
& Community Health, 59(6), 460–466.
Eriksson, M., & Lindstro
¨m, B. (2014). The salutogenic framework for
well-being: Implications for public policy. In T. J. Ha
J. Michaelson (Eds.), Well-being and beyond. Broadening the pub-
lic and policy discourse (pp. 68–97). Cheltenham: Edward Elgar.
Eriksson, M., Lindstro
¨m, B., & Lilja, J. (2007). A sense of coherence
and health. Åland, a special case. Journal of Epidemiology and
Community Health, 61(8), 684–688.
Feldt, T., Metsa
¨pelto, R.-L., Kinnunen, U. & Pulkkinen, L. (2007).
Sense of coherence and ﬁve-factor approach to personality. Con-
ceptual relationships. European Phychologist, 12(3), 165–172.
Feldt, T., Leskinen, E., Koskenvuo, M., Suominen, S., Vahtera, J., &
¨ki, M. (2011). Development of sense of coherence in adult-
hood: A person-centered approach. The population-based HeSSup
cohort study. Quality of Life Research, 20(1), 69–79.
Feldt, T., Lintula, H., Suominen, S., Koskenvuo, M., Vahtera, J., &
¨ki, M. (2007). Structural validity and temporal stability of
the 13-item sense of coherence scale: Prospective evidence from the
population-based HeSSup study. Quality of Life Research, 16(3),
Flannery, R. B., & Flannery, G. J. (1990). Sense of coherence, life
stress, and psychological distress: A prospective methodological
inquiry. Journal of Clinical Psychology, 46(4), 415–420.
Flensborg-Madsen, T., Ventegodt, S., & Merrick, J. (2005a). Sense of
coherence and physical health. A review of previous ﬁndings. The
Scientiﬁc World Journal, 5, 665–673.
Flensborg-Madsen, T., Ventegodt, S., & Merrick, J. (2005b). Why is
Antonovsky’s sense of coherence not correlated to physical health?
Analysing Antonovsky’s 29-item Sense of Coherence Scale
(SOC-29). The Scientiﬁc World Journal, 5, 767–776.
Flensborg-Madsen, T., Ventegodt, S., & Merrick, J. (2006a). Sense of
coherence and physical health. Testing Antonovsky’s theory. The
Scientiﬁc World Journal, 6, 2212–2219.
Flensborg-Madsen, T., Ventegodt, S., & Merrick, J. (2006b). Sense of
coherence and physical health. A cross-sectional study using a new
scale (SOC II). The Scientiﬁc World Journal, 6, 2200–2211.
Flensborg-Madsen, T., Ventegodt, S., & Merrick, J. (2006c). Sense of
Coherence and physical health. The Emotional Sense of Coherence
(SOC-E) was found to be the best-known predictor of physical
health. The Scientiﬁc World Journal, 6, 2147–2157.
Forbech, V. H., & Hanson, A. L. (2013). Salutogenic presence supports
a health-promoting work life. Journal of Social Medicine, 6,
Geyer, S. (1997). Some conceptual considerations on the sense of
coherence. Social Science & Medicine, 44(12), 1771–1779.
Government Ofﬁces of Sweden. (2006). The Convention of the Rights
of the Child. [Elektronic]. Retrieved December 30, 2015, from
Government Ofﬁces of Sweden. (2008). UN:s convention on the Rights
of Persons with disabilities. [Elektronic]. Retrieved December
30, 2015, from http://www.regeringen.se/content/1/c6/10/19/18/
Government Ofﬁces of Sweden. (2011). United Nations. The Universal
Declaration of Human Rights. [Elektronic]. Retrieved December
30, 2015, from http://www.regeringen.se/content/1/c6/18/37/41/
Graeser, S. (2011). Salutogenic factors for mental health promotion in
work settings and organizations. International Review of Psychia-
try, 23(6), 508–515.
Hakanen, J. J., Feldt, T., & Leskinen, E. (2007). Change and stability of
sense of coherence in adulthood: Longitudinal evidence from the
Healthy Child Study. Journal of Research in Personality, 41,
Han, K., Lee, P., Park, E., Park, Y., Kim, J., & Kangh, H. (2007).
Family functioning and mental illness a Korean correlational study.
Asian Journal of Nursing, 10, 129–136.
E. (2015). Emotional distress and sense of coherence in women
completing a motivational program in ﬁve countries. A prospec-
tive study. International Journal of Prisoner Health, 11(3),
Holmberg, S., & Thelin, A. G. (2010). Predictors of sick leave owing to
neck or low back pain: A 12-year longitudinal cohort study in a rural
male population. Annals of Agricultural and Environmental Medi-
cine, 17(2), 251–257.
Honkinen, P. L., Suominen, S., Helenius, H., Aromaa, M., Rautava, P.,
Sourander, A., et al. (2008). Stability of the sense of coherence in
adolescence. International Journal of Adolescent Medicine and
Health, 14(4), 587–600.
Idan, O., & Margalit, M. (2014). Socioemotional self-perceptions,
family climate, and hopeful thinking among students with learning
disabilities and typically achieving students from the same classes.
Journal of Learning Disabilities, 47(2), 136–152.
104 M. Eriksson and M.B. Mittelmark
Kalimo, R., Pahkin, K., Mutanen, P., & Toppinen-Tanner, S. (2003).
Staying well or burning out at work: Work characteristics and
personal resources as long-term predictors. Work & Stress, 17(2),
Klepp, O. M., Mastekaasa, A., Sørensen, T., Sandanger, I., & Kleiner,
R. (2007). Structure analysis of Antonovsky’s sense of coherence
from an epidemiological mental health survey with a brief nine-item
sense of coherence scale. International Journal of Methods in
Psychiatric Research, 16(1), 11–22.
Korotkov, D. (1993). An assessment of the (short-form) sense of
coherence personality measure: Issues of validity and well-being.
Personal and Individual Differences, 14(4), 575–583.
Korotkov, D., & Hannah, E. (1994). Extraversion and emotionality as
proposed superordinate stress moderators: A prospective analysis.
Personal and Individual Differences, 16(5), 787–792.
Kumlin, T. (1998). Sense of coherence in theory, empiri and criticism.
[In Swedish]. (Vol. 9). Stockholm: The Swedish Research Council.
¨ki, M., & Utriainen, P. (2003). A 3 year follow-up study of
health care students’sense of coherence and related smoking,
drinking and physical exercise factors. International Journal of
Nursing Studies, 40(4), 383–388.
Larsson, G., & Kallenberg, K. (1999). Dimensional analysis of sense of
coherence using structural equation modelling. European Journal
of Personality, 13, 51–61.
¨m, B., & Eriksson, M. (2009). The salutogenic approach to the
making of HiAP/healthy public policy: Illustrated by a case study.
Global Health Promotion, 16(1), 17–28.
¨m, B., & Eriksson, M. (2010). The Hitchhiker’s Guide to
Salutogenesis. Salutogenic pathways to health promotion. Helsinki:
¨lsan and IUHPE Global Working Group on Salutogenesis.
¨vheim, H., Graneheim, U. H., Jonse
´n, E., Strandberg, G., &
Lundman, B. (2013). Changes in sense of coherence in old age—
A 5-year follow-up of the Umea
˚85þstudy. Scandinavian Journal
of Caring Sciences, 27, 13–19.
Lundman, B., Forsberg, K. A., Jonse
´n, E., Gustafson, Y., Olofsson, K.,
Strandberg, G., et al. (2010). Sense of coherence (SOC) related to
health and mortality among the very old: The Umea
Archives of Gerontology and Geriatrics, 51(3), 329–332.
Luutonen, S., Sohlman, B., Salokangas, R. K. R., Lehtinen, V., &
Dowrick, C. (2011). Weak sense of coherence predicts depression:
1-year and 9-year follow-ups of the Finnish Outcomes of Depres-
sion International Network (ODIN) sample. Journal of Mental
Health, 20(1), 43–51.
Margalit, M., & Efrati, M. (1996). Loneliness, coherence and compan-
ionship among children with learning disorder. Educational Psy-
chology, 16(1), 69–80.
Mautner, E., Ashida, C., Greimel, E., Lang, U., Kolman, C., Aalton, D.,
& Inoue, W. (2014). Are there differences in the health outcomes of
mothers in Europe and East-Asia? A cross-cultural health survey.
BioMed Research International, doi:10.1155/2014/856543
Mayer, C. H., & Boness, C. (2011). Concepts of health and well-being
in managers. An organizational study. International Journal of
Qualitative Studies on Health and Well-being, 6. doi:10.3402/
Mayer, C.-H., & Krause, C. (2011). Promoting mental health and
salutogenesis in transcultural organizational and work contexts.
International Review of Psychiatry, 23(6), 495–500.
Naaldenberg, J., Tobi, H., van den Esker, F., & Vaandrager,
L. (2011). Psychometric properties of the OLQ-13 scale to mea-
sure Sense of Coherence in a community-dwelling older popula-
tion. Health and Quality of Life Outcomes, 23(9), 37. doi:10.1186/
Nash, J. K. (2002). Neighborhood effects on sense of school coherence
and educational behavior in students at risk of school failure. Chil-
dren & Schools, 24(2), 73–89.
Nilsson, P., Andersson, I. H., Ejlertsson, G., & Troein, M. (2012).
Workplace health resources based on sense of coherence theory.
International Journal of Workplace Health Management, 5(3),
Nilsson, K. W., Leppert, J., Simonsson, B., & Starrin, B. (2010). Sense
of coherence and psychological well-being: Improvement with age.
Journal of Epidemiology and Community Health, 64(4), 347–352.
˚l, T. M., Fridlund, B., Rokne, B., Segadal, L., Wentzel-Larsen,
T., & Nordrehaug, J. E. (2010). Patient-reported outcomes as
predictors of 10-year survival in women after acute myocardial
infarction. Health and Quality of Life Outcomes, 8, 140.
Orvik, A., & Axelsson, R. (2012). Organizational health in health
organizations: Towards a conceptualization. Scandinavian Journal
of Caring Sciences, 26(4), 796–802.
¨ztekin, C., & Tezer, E. (2009). The role of sense of coherence and
physical activity in positive and negative affect of Turkish
adolescents. Adolescence, 44, 421–432.
Pavicic Bosnjak, A., Rumboldt, M., Stanojevic, M., & Dennis, C. L.
(2012). Psychometric assessment of the croatian version of the
breastfeeding self-efﬁcacy scale-short form. Journal of Human
Lactation, 28(4), 565–569.
Pham, P. N., Vink, P., Kinkodi, D. K., & Weinstein, H. M. (2010).
Sense of coherence and its association with exposure to traumatic
events, posttraumatic stress disorder, and depression in eastern
democratic Republic of Congo. Journal of Traumatic Stress, 23,
Poppius, E., Virkkunen, H., Hakama, M., & Tenkanen, L. (2006). The
sense of coherence and incidence of cancer - role of follow-up time
and age at baseline. Journal of Psychosomatic Research, 61,
Rajesh, G., Eriksson, M., Pai, K., Seemanthini, S., Naik, D. G., & Rao,
A. (2015). The validity and reliability of the Sense of Coherence
scale among Indian university students. Global Health Promotion,
April 20, doi:10.1177/1757975915572691
Rohani, C., Khanjari, S., Abedi, H. A., Oskouie, F., & Langius-Eklo
A. (2010). Health index, sense of coherence scale, brief religious
coping scale and spiritual perspective scale: Psychometric
properties. Journal of Advanced Nursing, 66, 2796–2806.
Rostami, R., Lamit, H., Khoshnava, S. M., & Rostami, R. (2014). The
role of historical Persian gardens on the health status of contempo-
rary urban residents: gardens and health status of contemporary
urban residents. Ecohealth, 11(3), 308–321. doi:10.1007/s10393-
Roth, G., & Ekblad, S. (2006). A longitudinal perspective on
depression and sense of coherence in a sample of mass-evacuated
adults from Kosovo. Journal of Nervous and Mental Disease, 194,
Sagy, S. (2008). Sense of Coherence in a family context. The Interna-
tional Seminar on Salutogenesis and The 1st Meeting of the IUHPE
Thematic Working Group on Salutogenesis, Helsinki Finland,
12–13 May, 2008.
Sagy, S., & Antonovsky, A. (1992). The family sense of coherence and
the retirement transition. Journal of Marriage and Family, 54(4),
Sakano, J., & Yajima, Y. (2005). Factors structure of the SOC scale
13-item version in Japanese university students. Japanese Journal
of Public Health, 52(1), 34–45.
Sandell, R., Blomberg, J., & Lazar, A. (1998). The factor structure of
Antonovsky’s sense of coherence scale in Swedish clinical and
nonclinical samples. Personality and Individual Differences, 24
Schnyder, U., Büchi, S., Sensky, T., & Klaghofer, R. (2000).
Antonovsky’s sense of coherence: Trait or state? Psychotherapy
and Psychosomatics, 69, 296–302.
12 The Sense of Coherence and Its Measurement 105
Singer, S., & Bra
¨hler, E. (2007). Die “Sense of Coherence Scale”.
Testhandbuch zur deutschen Version.Go
¨ttingen: Vandenhoeck &
Spadoti Dantas, R. A., Silva, F. S., & Ciol, M. A. (2014). Psychometric
properties of the Brazilian versions of the 29- and 13-item scales of
the Antonovsky’s Sense of Coherence (SOC-29 and SOC-13)
evaluated in Brazilian cardiac patients. Journal of Clinical Nursing,
¨derhamn, O., & Holmgren, L. (2004). Testing Antonovsky’s
sense of coherence (SOC) scale among Swedish physically
active older people. Scandinavian Journal of Psychology, 45,
¨derhamn, U., Sundsli, K., Cliffordson, C., & Dale, B. (2015). Psy-
chometric properties of Antonovsky’s 29-item Sense of Coherence
scale in research on older home-dwelling Norwegians. Scandina-
vian Journal of Public Health, 43(8), 867–874.
Suraj, S., & Singh, A. (2011). Study of sense of coherence health
promoting behaviour in north Indian students. Indian Journal of
Medical Research, 134, 645–652.
Surtees, P., Wainwright, N., Luben, R., Khaw, K.-T., & Day, N. (2003).
Sense of coherence and mortality in men and women in the EPIC-
Norfolk United Kingdom prospective cohort study. American Jour-
nal of Epidemiology, 158(12), 1202–1209.
Tang, S. T., & Li, C.-Y. (2008). The important role of sense of
coherence in relation to depressive symptoms for Taiwanese family
caregivers of cancer patients at the end of life. Journal of Psycho-
somatic Research, 64, 195–203.
Virtanen, P., & Koivisto, A. M. (2001). Wellbering of professionals at
entry into the labour market: A follow up survey of medicine and
architecture students. Journal of Epidemiology and Community
Health, 55(11), 831–835.
´ga, J., Martinez-Martin, P., Del Barrio, J. L., Lozano, L. M.,
& Grupo Espanol, E. (2007). Cross-cultural validation of
Antonovsky’s Sense of Coherence Scale (OLQ-13) in Spanish
elders aged 70 years or more. Medicina Clinica, 128, 486–492.
Vogt, K., Jenny, G. J., & Bauer, G. F. (2013). Comprehensibility,
manageability and meaningfulness at work: Construct validity of a
scale measuring work-related sense of coherence. South African
Journal of Industrial Psychology, 39(1), 8.
Volanen, S. M., Suominen, S., Lahelma, E., Koskenvuo, M., &
Silventoinen, K. (2007). Negative life events and stability of sense
of coherence: A ﬁve-year follow-up study of Finnish women and
men. Scandinavian Journal of Psychology, 48(5), 433–441.
WHO. (2001). The World health report 2001: Mental health: New
understanding, new hope. Geneva: World Health Organization.
106 M. Eriksson and M.B. Mittelmark