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The Sense of Coherence and Its Measurement

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Antonovsky developed the 29 item Orientation to Life Questionnaire to measure the sense of coherence, having 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. The questionnaire yields a summed score with a range from 29 to 203. A shorter version of 13 questions of the original form was developed by Antonovsky, where the score ranges between 13 and 91 points, and other scales have been developed, for example, to measure the sense of coherence at the family and community levels. Antonovsky’s scales have been used in at least 49 different languages in at least 48 different countries. Recent research shows that the SOC seems to be a multidimensional construct rather than unidimensional as Antonovsky believed. Antonovsky maintained that the SOC develops until the age of 30 years, thereafter remaining relatively stable until retirement, and decreasing in old age. This assumption finds no support in subsequent empirical research. As Antonovsky hypothesized, a wealth of research shows his scales to be reliable, valid, and cross-culturally applicable instruments. Criticism of the SOC concept is described and discussed.
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The Sense of Coherence and Its Measurement 12
Monica Eriksson and Maurice B. Mittelmark
Introduction
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 ones 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
dont understand you? (from never have this feelingto
always have this feeling)
Do you have a feeling that you are in an unfamiliar
situation and dont know what to do? (from very often
to very seldom or never)
The following items are examples that measure
manageability:
When something unpleasant happened in the past your
tendency was: (from to eat yourself up about itto to say
“ok thats that, I have to live with itand go on)
When you do something that gives you a good feeling:
(from its certain that youll go on feeling goodto its
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 satisfactionto a source of pain and
boredom)
When you think about your life, you very often: (from feel
how good it is to be aliveto ask yourself why you exist
at all)
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 ones
context and ones own part in it, for example, ones 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 ones 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
e-mail: monica.eriksson@hv.se
M.B. Mittelmark
Department of Health Promotion and Development,
University of Bergen, Christiesgt. 13, Bergen 5020, Norway
e-mail: Maurice.Mittelmark@gmail.com
#The Author(s) 2017
M.B. Mittelmark et al. (eds.), The Handbook of Salutogenesis, DOI 10.1007/978-3-319-04600-6_12
97
(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
of Coherence
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
¨m,
2005). An update shows that another 16 languages can be
added: Albanian (Roth & Ekblad, 2006), Croatian (Singer &
Bra
¨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-
Eklo
¨f, 2010) as well as local languages in Africa Afar, Bilein,
Hidareb, Kunama people, Nara, Saho, Tigre, and Tigrinya
(Almedom, Tesfamichael, Mohammed, Mascie-Taylor, &
Alemu, 2007).
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
(Virues-Orte
´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
separately.
SENSE OF COHERENCE (SOC)
Comprehensibility
Manageability
Meaningfulness
Fig. 12.1 The original view of the Sense of coherence and its three
dimensions (Antonovsky, 1987)
Austria
Australia
Belgium
Brazil
Bulgaria Canada
Czechia
China
Colombia
Croatia
Denmark
Finland
France
Eritrea
Estonia
Germany
Greece
Hungary
Iceland
India
Iran
Israel
Italy
Poland
Demokratic Republic of Kongo
Korea
Kosovo
Lithuania
New Zealand
Netherlands
Norway
Japan
Rumania
Russia
Serbia
Singapore
Slovakia
South Africa
Spain
Sudan
Sweden
Switzerland
Taiwan
Thailand
Turkey
United Kingdom
USA
The SOC questionnaire has
been used in studies all over
the World, on different
samples of various ages,
cultures and disciplines
Malaysia
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 Antonovskys idea of the sense of
coherence as a general factor with three dimensions
(Antonovsky, 1993;Drageset&Haugan,2015;Klepp,
Mastekaasa, Sørensen, Sandanger, & Kleiner, 2007; Rajesh
et al., 2015;So
¨derhamn & Holmgren, 2004;So
¨derhamn,
Sundsli, Cliffordson, & Dale, 2015;SpadotiDantasetal.,
2014). So
¨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
¨m, 2005;Feldt,2007;
Naaldenberg, Tobi, van den Esker, & Vaandrager, 2011).
Figure 12.3 shows the sense of coherence as a multidimen-
sional construct.
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. Antonovskys
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
¨m,
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 Childrens 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
groups.
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,
2012; Bringse
´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
Comprehensebility-managability Meaningfulness
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
Number of
items
Response
options
Cronbachs
alpha
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
aged women
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
Germany General
population
3515 SOC-3
BASOC
Brief
Assessment—
SOC
3 0.45
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
Sweden Immigrants/
refugees
4981 SOC-3 7 - Likert
Swedes
Kivima
¨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
Finland Women
employed in
municipalities
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.
1136/bmjopen-2014-006489
Denmark Pupils 773 SOC-7 7 - Likert 0.77
Forsga
¨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
Sweden Health
professionals
354 SOC-9 3 - Likert 0.60–0.69
Klepp, O.M., Mastekaasa, A., Sørensen, T. et al. 2007 Structure
analysis of Antonovskys 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/
13548506.2014.952644
China Patients in
hospitals
491 SOC-9 7 - Likert
Mayer, J., Thiel, A. (2014) Health in elite sports from a
salutogenetic perspective: Athletessense of coherence. PLOS
One, 9(7),1–11
Germany Elite sports 698 SOC-L9
Leipzig Short
Scale
2 0.82
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
Netherlands Elderly
people 65
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
and their
parents
399 SOC-12
Family-SOC
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
learning
disabilities
Barn med
inla
¨rnings-
sva
˚righeter
324 SOC-16 þ3
Childrens’-
SOC
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
Finland General
population
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),
983–994
Israel Retirees and
their relatives
214 SOC-26
Family-SOC
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 peoples 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
¨m, &
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,
2014; Lindstro
¨m & Eriksson, 2009).
Criterion validity: Eriksson and Lindstro
¨m(2005) present
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 Hopkins 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
Lindstro
¨m(2005).
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
˚letal.,
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
˚85þ
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
(4years),0:59to0.67(5years),andfinally0:54afterthe
10-year follow-up (Eriksson & Lindstro
¨m, 2005). The
internal consistency measured by Cronbachsalpharanges
from 0.70 to 0.95 using SOC-29 (124 studies) and 0.70 to
0.92 (127 studies) using SOC-13 (Eriksson & Lindstro
¨m,
2005, p. 463). The sense of coherence scale shows high
internal consistency.
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 livingtheory 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 ones 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
positive attitudes
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 coherencein
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 Antonovskys 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 publics 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-
tualizationused 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,
ones experiences all tend to be predictable, one is inevitably
due for unpleasant surprises that cannot be handled, and ones
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, ones 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 peoples 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
¨m&
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
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creativecommons.org/licenses/by-nc/2.5/) which permits any noncom-
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original author(s) and source are credited.
The images or other third party material in this chapter are included
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the credit line; if such material is not included in the work’s Creative
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to duplicate, adapt or reproduce the material.
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Sense of Coherence
Learned hopefulness Learned resourcefulness
Cultural capital
Social capital
Resilience
Will to meaning Flourishing Thriving
Self-efficacy
Empathy
Coping
Reasonableness
Humour
Inner strength
Social and emotional intelligence
Learned optimism
Posttraumatic Personal Growth
Attachment
Locus of Control
Hardiness
Gratitude
Quality of Life
Connectedness
Belonging
Action competence
Empowerment
Flow Wellbeing
Self-transcendence
Interdisciplinarity
Ecological system theory
SALUTOGENESIS
Assets for health and well-being
Fig. 12.4 The salutogenic
umbrella, salutogenesis as
an umbrella concept
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... A sample item on the scale, which is scored on a 7point scale, is, "How often do you have feelings that you're not sure you can keep under control?" A 2017 review reported that the scale had been used in at least 48 countries and translated into 49 languages, with reliability coefficients in these studies ranging from 0.70 to 0.95 [58]. ...
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Fear has been the most common emotional response to the COVID-19 pandemic, and excessive fear is associated with various indices of psychological distress, particularly loneliness. Although most people have experienced pandemic-related fear and distress, certain groups who are on the front of service provision have experienced the pandemic in distinct ways, owing to its impact on the nature of their work. Schoolteachers represent one such group; therefore, it is imperative to identify resources that can safeguard against negative mental-health outcomes in schoolteachers. The current study investigated the potential protective role of sense of coherence (SOC) and resilience in the relationship between COVID-19 fear and loneliness. The participants were South African schoolteachers (N = 355); the participants completed the Fear of COVID-19 Scale, the University of California Loneliness Scale, the Connor-Davidson Resilience Scale-10, and the Sense of Coherence Scale-13. The results indicated that SOC and resilience had significant direct effects on loneliness, thereby suggesting their health-sustaining role. SOC and resilience also fully mediated the relationship between COVID-19 fear and loneliness. Therefore, although the provision of material resources is important, it is equally necessary to enhance people’s ability to comprehend, give meaning to, and manage the challenges associated with the pandemic. A salutogenic approach to mental health promotion in the workplace may be beneficial for enhancing SOC and resilience among schoolteachers. Keywords Loneliness; fear of COVID-19; resilience; sense of coherence; mediator
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Background International humanitarian aid workers (iHAWs) are motivated strongly to travel abroad to help communities affected by war, famine, disaster and disease. They expose themselves to dangers and hardships during their field assignments. Despite working under such challenging circumstances, most workers remain healthy. The objective of the present study was to unravel the mechanism that enables workers to remain healthy under the same circumstances that affect these communities. We hypothesised that the different components of the Sense of Coherence (SOC) health mechanism mediate the relationship between field stressors and post-assignment health. Methods and findings The stress-health model was tested among 465 international aid workers using a longitudinal pre-post assignment study design and structural equation modelling for path analyses. The (health) outcome variables were PTSD, anxiety, depression, emotional exhaustion, and work engagement. Our findings highlight the importance of being healthy before aid assignment and the negative health impact of field stressors that were not potentially traumatic. The SOC components mediated the relationship between field stress and post-assignment health, with males and females using different SOC components to alleviate stress. Males are more likely trying to understand the nature of the stressor, whereas females mobilise their resources to manage stressors. In both groups, a high level of meaningfulness of the work was an important component in maintaining health. Regarding using the SOC concept for understanding the process of maintaining health, our findings indicated that SOC is best considered context-specific and multidimensional. Conclusion In addition to good pre-mission health, the SOC components help prevent field assignment-related negative health effects in iHAWs. Our findings support the idea to compose gender-balanced teams of iHAWs to maintain and promote health. The findings can be used to develop or refine health conversation tools and SOC based health interventions to promote health and wellbeing and prevent ill-health among aid workers and other stress-exposed populations.
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Purpose The objective was to examine whether the 13-item Sense of coherence scale (SOC-13) can be reported as a unidimensional interval-scale metric, when new approaches based on the Rasch model to address local item dependency are applied, and to determine whether an interval-scale scoring can be made available. Methods Data were derived from two samples of patients with hand-related disorders (merged n = 915). Rasch analyses of the SOC data were conducted using item-level analysis and a testlet approach. Results Initial item-level analysis of the SOC-13 confirmed previous findings of misfit to the Rasch model. In resolving local dependency by constructing three testlets, which corresponded to the three components of the SOC construct, fit to the Rasch model (χ²(df) = 43.11 (27), p = 0.163) and unidimensionality of the SOC-13 could be established. A transformation table was successfully created to convert the SOC-13 raw ordinal score to corresponding Rasch interval-scaled values. Conclusions The results of this study indicate that data obtained by the SOC-13 can be regarded as essentially unidimensional, and an interval-scale transformation table of the SOC-13 total scores was developed, for use in clinical practice and research on coping resources in patients with hand-related disorders. • IMPLICATIONS FOR REHABILITATION • The 13-item Sense of coherence scale (SOC-13) comprises three complexly interrelated components • To assess coping resources in patients with hand-related disorders, an interval-scale transformation table of the SOC-13 total scores can be used
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Introduction: The aim of this study was to investigate the association between physical fitness, physical activity, and sense of coherence (SOC) in Swedish adolescents (n = 2028 males, n = 1287 females) aged 14 to 18 using a cross-sectional design. Methods: Using the Swedish Physical power Mental harmony and Social capacity (FMS) student profile, participants performed physical tests measuring their cardiovascular ability (CV) and muscular strength. Questionnaires were used to measure physical activity levels (PA), the participation in organized physical training, sedentary behavior (SB), screen time, and SOC value. Multiple linear regression analyses were used to analyze the association between SOC and independent variables. Results: The regression analyses explained a small, shared variance between SOC and the independent variables in boys (4.3%) and girls (3.3%). SB showed a positive association with SOC both in girls (β = 0.114, p = 0.002) and boys (β = 0.109, p = 0.013). Abdominal strength was positively associated, while VO2max was inversely associated, with SOC (β = 0.113, p = 0.022; β = -0.109, p = 0.026, respectively) in boys. Girls had poorer fitness than boys did across all age groups except at age 18. PA levels decreased from age 14 to 18 in girls and boys, but without differences between sexes. Abdominal strength decreased from age 14 to 18 in girls and boys. In general, girls had lower SOC than boys across all age groups. Conclusions: Poor sedentary behavior was significantly associated with weaker SOC for both genders, indicating overall physical activity as the most important factor for stronger SOC. However, emotional support in vulnerable environments may have a bigger impact than physical activity or sedentary behavior on the SOC value for adolescents.
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Objectives: The aim of this study was to investigate whether attitudes to ageing were associated with attitudes to positive psychology constructs. Methods: A cross-sectional online survey of 572 UK adults aged 50+ (mean age 64.6 years, SD = 8.4, 73.8% female) assessed attitudes to ageing using the Attitudes to Ageing Questionnaire (AAQ) in relation to measures of positive psychology including (1) belief in a just world—Just World Scale (JWS-Self and JWS-Other), (2) sense of coherence—Sense of Coherence Scale (SOC) and (3) positive well-being—Control, Autonomy, Self-Realization, and Pleasure Scale (CASP-19). Other factors included difficulties with hearing and eyesight, relative and carer status and demographics. Results: People with hearing and eyesight difficulties had lower CASP-19 and SOC scores, and more negative attitudes to ageing compared to people without sensory problems. Hierarchical regression analyses showed all three positive psychology scales predicted more positive attitudes to ageing. Being a carer for a person with dementia was associated with more negative attitudes to ageing. Conclusion: Whereas health and sensory problems relate to more negative attitudes to ageing, this study highlights the importance of positive psychological factors which could inform approaches seeking to promote well-being and health in older people.
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This study investigated the reliability and predictive validity of the Sense of Coherence (SOC) scale for 299 American survivors of gender-based violence (GBV). First, confirmatory factor analysis examined the construct validity of the SOC-13. Then, relationships between SOC and clinical scales were examined. Confirmatory factor analysis supported the 3-factor solution, and Cronbach's alpha reliability values for comprehensibility, manageability, and meaningfulness subscales and total score of SOC-13 were: .62, .53, .65, and .81, respectively. Multiple regression revealed that age, posttraumatic growth, depression, and posttraumatic stress scores explained 53% of the variance of SOC scores. We interpret this to suggest that SOC is a protective factor in GBV, especially in younger women. Clinical implications are suggested.
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Purpose Parents of children with autism spectrum disorder often report poorer sleep compared to parents of typically developing children. When parents do not obtain enough quality sleep, functioning may be compromised placing the onus of care on already stressed parents. However, improving sleep duration may not improve sleep quality and is not always feasible. This study aimed to measure sleep quality in parents of children with autism spectrum disorder, determine if stress and children’s sleep are associated with sleep quality and whether resources, appraisals, and coping moderate these relationships. Materials and Methods Multivariable regression was used to determine the effects of stress and children’s sleep problems on sleep quality and test modifying effects. Results Mean (SD) Pittsburgh Sleep Quality Index scores was 8.81 (3.76), with 77.6% of parents scoring above the clinical cut-off. Mean (SD) Children’s Sleep Habits Questionnaire scores was 54.03 (8.32), with 96.3% of parents rating their child’s sleep above the clinical cut-off. Children’s sleep was the only significant predictor and none of the expected effect modifiers were significant. Conclusion Children’s sleep may be an important target to improve parent sleep quality but requires systematic assessment with interventional research. • Implications for rehabilitation • Both parents and their 4–10-year-old children with ASD experience high levels of sleep disturbances. • Clinicians can start the conversation early with parents about their children’s sleep by providing them with information to increase awareness and recognize healthy sleep habits in their children. • Clinicians are important in the assessment, management, and evaluation of pediatric sleep problems, which may have significant spillover effects on parents of children with ASD. • There is a need for more resources and training to be available to clinicians to assess children and their parents for sleep problems, which could extend beyond the assessment of sleep and consider parent’s daytime functioning and mental health.
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Purpose – The purpose of this paper is to investigate changes in, and associations between, sense of coherence (SOC) and emotional distress in women who participated in an accredited motivational program (VINN) in correctional institutions in five countries. Design/methodology/approach – A prospective study with a pre- and post-test design included 316 participants from Sweden, Estonia, Denmark, Russia and Norway. Global emotional distress was measured by the Hospital Anxiety and Depression Scale. SOC was measured using the 13-item Orientation to Life Questionnaire. One-way analysis of variance and multilevel regression models were used in the statistical analyses. Findings – An increase in SOC was associated with a decrease in emotional distress. Emotional distress decreased significantly −3.80 points (95 percent CI (−4.61, −2.97)), and SOC significantly improved from pre- to post-measurement by 1.82 points (95 percent CI (0.72, 2.92)), regardless of country and correctional institution. Practical implications – The results add new knowledge regarding a coherent theoretical foundation of a motivational program for women. The ability of a program promoting health is important for researchers, health-care workers and facilitators delivering programs for women in correctional facilities. An increase in SOC can act as a protective factor in order to manage stressors and risk factors among women serving in correctional facilities. Originality/value – The present study indicates that enhancing women’s coping resources and providing income alternatives to crime is fundamental to their capacity to desist from criminal behavior.
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The aim of this study was to test the homogeneity and construct validity of the Sense of Coherence 29-item scale (SOC-29) among older home-dwelling Norwegians. A postal questionnaire, consisting of background variables, five health-related questions, the SOC-29, and three other instruments measuring mental health, self-care ability, and risk for undernutrition, was sent to 6033 home-dwelling older people (65+ years) in southern Norway. A total of 2069 participants were included. Homogeneity was assessed with Cronbach's alpha coefficient and item-to-total correlations. The construct validity was assessed with "the known-groups technique," a linear stepwise regression analysis with SOC score serving as the dependent variable and with confirmatory factor analysis. With a Cronbach's alpha coefficient of 0.91 and statistically significant item-to-total correlations, the SOC-29 was found to be homogeneous. Construct validity was supported because the SOC-29 could separate known groups with expected high and low scores. The factors that could predict SOC were mental health, self-care ability, feeling lonely, being active, and chronic disease or handicap. Evidence of construct validity was displayed in a confirmatory factor analysis that confirmed SOC-29 as one theoretical construct with the three dimensions, comprehensibility, manageability, and meaningfulness. The Norwegian version of the SOC-29 is a reliable and valid instrument for use in research among older people. The results confirm that SOC has a particularly strong relationship with mental health and self-care ability. © 2015 the Nordic Societies of Public Health.
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Maintaining good health is a broader and more positive goal than preventing disease. The chapter discusses the role of diet in heart disease and cancer. Obesity, hypertension, and diabetes are also important, on their own and as contributors to heart disease and stroke. Although much public attention has been directed to the role of an adequate supply of calcium in bone health and in reducing the incidence of osteoporosis, attention needs to be directed toward obtaining an adequate supply of this essential nutrient. The chapter provides an overview on the role of nutrition in reducing the incidence of obesity, heart disease, diabetes, hypertension, cancer, and osteoporosis. It is important to remember that nutrition has a broader role to play in health promotion. An optimal intake of protein, vitamins, and minerals is needed to provide for growth of children, successful pregnancies and breast feeding experiences, and good health and well-being for all adults.
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Appraising ValidityEvaluation of Screening and Diagnostic TestsEvaluation of Risk MarkersNotes and References
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Aim: To identify the factors influencing family functioning in families providing care for a member with chronic mental illness. Methods: This descriptive study collected data by questionnaires from 365 families having a family member with chronic mental illness who was receiving treatment at the psychiatric outpatient centres at the University Hospital and National Mental Hospital in Seoul, Korea. Study variables and instruments were family functioning, continuous family stress, knowledge of disease, family hardiness, family support, family sense of coherence, and family coping. Results: The data indicated a statistically significant positive correlation for family functioning, knowledge of disease, family hardiness, family support, family sense of coherence, and family coping. A statistically significant negative correlation was found between family functioning and family stress. Stepwise multiple regression analysis showed that the most powerful predictor of family functioning was family support (55.1%). The combination of family support, family hardiness, family coping, knowledge of disease, and family stress accounted for 61.4% of the variance in family functioning. Conclusions: The results indicate that family support, family hardiness, family coping, knowledge of disease, and family stress are important factors in family functioning. These results may be used for mental health nurses in caring for families and developing nursing interventions.
Article
Aim: Older residents of nursing homes have several illnesses and face various Challenges regarding losses of physical and mental functioning. Thus, coping and the quality of life are vital aspects in long-term care. Sense of coherence is considered an important resource for coping and the quality of life, and sense of coherence therefore needs to be validly and reliably measured in this population. We investigated the dimensionality, reliability and construct validity of the Orientation to Life Questionnaire in assessing sense of coherence among cognitively intact nursing home residents. Methods: We collected cross-sectional data from 227 cognitively intact nursing home residents representing 30 Norwegian nursing homes. We performed confirmative factor analysis and correlations with the selected construct. Results and conclusion: In accordance with the salutogenic theory of sense of coherence, the three-factor model revealed the best fit to our data. In particular, item OLQ2 seemed troublesome. Removing this item resulted in good fit to the present data. Rewording or deleting item OLQ2 seems needed to get a reliable instrument measuring sense of coherence among nursing home residents.
Article
The importance of salutogenesis, with the focus of what creates health rather than what causes diseases, has been highlighted for a long time. This has been operationalized by Aaron Antonovsky as the Sense of Coherence (SOC-13) scale. The aim of this study was to further examine the psychometric properties of the SOC-13 in India. The present study was carried out among second-year degree students at three randomly chosen institutions at Mangalore University. Investigators assessed the appropriateness, relevance, comprehensiveness and understandability of the scale. Further, the scale was assessed by five subject experts. The SOC-13 was then pretested by administering it to peers, individuals and a few of the study subjects. Internal consistency was assessed by Cronbach's alpha and split-half reliability. Test-retest reliability was assessed by administering the instrument to the same study participants after two weeks. Confirmatory factor analysis employing varimax rotation was employed. The SOC-13 revealed a Cronbach's alpha value of 0.76. Split-half reliability and Guttman split-half reliability were found to be 0.71 and 0.70, respectively. Test-retest reliability was found to be 0.71 (p < 0.01). Factor analysis revealed a three-factor solution explaining 40.53% of the variation in SOC. SOC-13 was found to be a reliable and valid instrument for measuring SOC in an Indian context. The present study contributes to health promotion in an Indian context, and could be useful even in other developing countries and for further research in India. © The Author(s) 2015.