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Sense of Coherence

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This chapter introduces the concept of sense of coherence which is a core concept in the salutogenic model defined by Aron Antonovsky. The salutogenic model posits that sense of coherence is a global orientation, where life is understood as more or less comprehensible, meaningful, and manageable. A strong sense of coherence helps the individual to mobilize resources to cope with stressors and manage tension successfully with the help of identification and use of generalized and specific resistance resources. Through this mechanism, the sense of coherence helps determine one’s movement on the health ease/dis-ease continuum. Antonovsky developed an instrument named Orientation to Life Questionnaire to measure the sense of coherence which exists in two original versions: a 29-item and a 13-item version. This chapter presents the measurement of the sense of coherence and the validity and reliability of the 13-item scale. It gives a brief overview of empirical research of the role of sense of coherence in association with mental health and quality of life and also on sense of coherence in different patient groups including nursing home residents, patients with coronary heart disease, diabetes, cancer, and mental health problems. It also briefly discusses the implications of using salutogenesis in health care services and the importance of implementing this perspective in meeting with different patient groups. The salutogenic approach may promote a healthy orientation toward helping the patient to cope with everyday stressors and integrate the effort regarding how to help the patient manage to live with disease and illness and promote quality of life.
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35
© The Author(s) 2021
G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_4
Sense ofCoherence
UnniKarinMoksnes
Abstract
This chapter introduces the concept of sense
of coherence which is a core concept in the
salutogenic model dened by Aron
Antonovsky. The salutogenic model posits
that sense of coherence is a global orientation,
where life is understood as more or less com-
prehensible, meaningful, and manageable. A
strong sense of coherence helps the individual
to mobilize resources to cope with stressors
and manage tension successfully with the help
of identication and use of generalized and
specic resistance resources. Through this
mechanism, the sense of coherence helps
determine one’s movement on the health ease/
dis-ease continuum. Antonovsky developed an
instrument named Orientation to Life
Questionnaire to measure the sense of coher-
ence which exists in two original versions: a
29-item and a 13-item version. This chapter
presents the measurement of the sense of
coherence and the validity and reliability of
the 13-item scale. It gives a brief overview of
empirical research of the role of sense of
coherence in association with mental health
and quality of life and also on sense of coher-
ence in different patient groups including
nursing home residents, patients with coro-
nary heart disease, diabetes, cancer, and men-
tal health problems. It also briey discusses
the implications of using salutogenesis in
health care services and the importance of
implementing this perspective in meeting with
different patient groups. The salutogenic
approach may promote a healthy orientation
toward helping the patient to cope with every-
day stressors and integrate the effort regarding
how to help the patient manage to live with
disease and illness and promote quality of life.
Keywords
SOC · Resistance resources · Salutogenesis
Health promotion · Nursing
4.1 Introduction
Aron Antonovsky introduced the key concept of
sense of coherence as part of the salutogenic
model in the book Health, Stress and Coping in
1979. Salutogenesis focuses on what are the
sources for people’s resources and capacity to
U. K. Moksnes (*)
Department of Public Health and Nursing,
NTNU Norwegian University of Science
andTechnology, Trondheim, Norway
NTNU-Center for Health Promotion Research,
Trondheim, Norway
Faculty of Nursing and Health Science,
Nord University, Levanger, Norway
e-mail: unni.moksnes@ntnu.no
4
36
create health as distinct from, and yet a comple-
mentary perspective to pathogenesis, focusing
on risk for disease, which traditionally had been
the leading focus in research [1, 2]. One of
Antonovsky’s deviations from pathogenesis was
to reject the dichotomization into categories of
sick or well and instead understand health as an
ease/dis-ease continuum; a horizontal line
between total absence of health (H) and total
health (H+) [3] (Fig.4.1). We are all more or less
ill or well at any given point in time and conse-
quently positioned on different places on this
health continuum during the life course. The
important point is to focus on what moves an
individual toward the ease-pole of the contin-
uum, regardless of where he/she was initially
located with a focus on what promotes health,
well- being, and quality of life. The interesting
question stated by Antonovsky was therefore
what explains movement toward the health end
of the ease/dis-ease-continuum? His answer to
this salutogenic question was formulated in
terms of sense of coherence (SOC) and general-
ized resistance resources (GRR) and specic
resistance resources (SRR) [4, 5]. The saluto-
genic theory posits that life experiences shape
the SOC.This capacity is a prerequisite for peo-
ples’ ability to move in the positive direction on
the health continuum and is a combination of
peoples’ ability to assess and understand the sit-
uation they are in, to nd a meaning to move in a
health-promoting direction, and also having the
capacity to do so [4, 5].
When Antonovsky introduced salutogenesis,
it was originally aimed to be a stress theory.
Antonovsky saw stress as a natural and inevita-
ble part of life, assuming that life was challeng-
ing and health being continuously threatened by
ubiquitous stressors [1, 2, 6]. Stressors place a
load on us, which causes tension. However, ten-
sion and strain are considered as potentially
health promoting, rather than as inevitably
health damaging, depending on the individual
ability to identify and use GRRs to cope ade-
quately with stressors. Antonovsky was inter-
ested in the explanation for why some people,
regardless of major stressful situations, manage
to stay healthy, and live good lives, while others
do not [7]. This may involve major life events
such as experience of acute and serious illness,
changes in the family, or changes in the work-
place. The frequency, intensity, and duration of
the stressor(s) are all factors that affect the indi-
vidual’s ability to cope adequately. Three poten-
tial reactions and outcomes of stress are (1)
being neutral against the stressors, (2) being
able to manage stress for the movement toward
the health end, and (3) being unable to manage
stress which leads to a breakdown expressed in
terms of diseases and death [2] (see Fig. 4.1).
Under the inuence of stressors, the individual
experiences tension and is constantly challenged
to adapt to the stressor and to identify and use
personal and environmental GRRs to cope ade-
quately with the stressor(s). The individual’s
ability to identify and use GRRs affects the indi-
vidual’s ability to cope adequately with the
stressor, which further affects health, that is,
where the individual is positioned on the ease/
dis-ease continuum [4, 5].
Antonovsky referred to the ability to compre-
hend the whole situation, and the capacity to
identify and use the resources available, as the
SOC [1, 3]. As a medical sociologist, Antonovsky
saw the individual in continuous interaction with
the context and daily life as something in con-
stant change. For the individual, the challenge is
to manage the stimuli and nd strategies and
resources available for coping with the changes
in everyday life and manage complexity.
Complexity may lead to conicts but also offers
opportunities for different and exible choices,
possibilities for adapting to change. It becomes
STRESSOR
TENSION
PATHOGENESIS
SALUT
OGENESIS
BREAKDOWN
H
H+
Fig. 4.1 The ease/dis-ease continuum. (Published with
permission from Folkhälsan Research Center, Helsinki,
Lindström & Eriksson [3])
U. K. Moksnes
37
vital how the individual can manage this chaos.
SOC is the term Antonovsky introduced as an
opportunity to manage and adapt to life’s chaos.
The primary focus is on the dynamic interaction
between health promoting factors and stressors in
human life and how people can move to the
healthier end of the ease/dis-ease continuum.
SOC is proposed to be a signicant variable in
affecting this movement [2, 5].
4.2 The Concept ofSense
ofCoherence
The concept sense of coherence (SOC) is dened
as “a global orientation that expresses the extent
to which one has a pervasive, enduring though
dynamic feeling of condence that 1) the stimuli
deriving from one’s internal and external envi-
ronments in the course of living are structured,
predictable, and explicable, 2) the resources are
available to one to meet the demands posed by
these stimuli; and 3) these demands are chal-
lenges, worthy of investment and engagement”
([2], p. 19). These three components, termed
comprehensibility, manageability, and meaning-
fulness are thought to be highly interrelated but
separable, forming the SOC (Fig. 4.2).
Comprehensibility is the cognitive component
and refers to the degree to which the individual
sense that information that concerns themselves,
the social environment, and the context is not
only understandable but also ordered, structured,
and consistent. However, perceiving events as
comprehensible does not mean that they are com-
pletely predictable or without difculty; the point
is that stimuli experienced are explicable and
logic. Manageability is the “instrumental” com-
ponent and refers to the extent to which individu-
als perceive that available resources are at their
disposal and sufcient to adequately cope with
the demands. Meaningfulness is the motivational
component and refers to the extent to which indi-
viduals feel that certain areas of life are worthy of
time, effort, personal involvement, and commit-
ment [2, 3, 6]. All the three dimensions interact
with each other. According to Antonovsky, the
most important component is meaningfulness,
which he thought was the driving force in life.
When the individual perceives at least some of
life’s problems and demands as worthy of com-
mitment and engagement, that also gives a greater
sense of the two components of comprehensibil-
ity and manageability as well. However, this
statement has been discussed. In a study of myo-
cardial infarction patients, this hypothesis was
rejected, showing that the dimension of compre-
hensibility was more important than meaningful-
ness for changes in SOC [8].
The three components in the SOC concept are
strongly connected and reect an individual
resource and life orientation that enables the indi-
vidual to reect on its external and internal
resources in order to cope with stressors and the
ability to resolve tension in a health-promoting
way [6]. Further, the life orientation of SOC is a
way of thinking, being, and acting as a human
being, which gives direction in life. The SOC
concept also reects a person’s view of life and
capacity to respond to stressful situations, which
leads people to identify and mobilize the GRR at
disposal [1, 2, 6]. Antonovsky saw the individual
in interaction with the context. However,
Antonovsky stressed that the salutogenic theory
Sense of Coherence
Comprehensibility Managebility Meaningfulness
Fig. 4.2 Dimensionality
of the construct of sense
of coherence
4 Sense ofCoherence
38
and its key concept, SOC, also can be applied at
a collective level, and not only with a focus on the
individual level [6].
4.3 Generalized Resistance
Resources (GRRs)
Along with the concept of SOC, a key concept in
the salutogenic theory/model is the role of gener-
alized and specic resistance resources [1, 2],
which are seen as important prerequisites for the
development of SOC.Antonovsky promoted that
generalized resistance resources (GRR) and spe-
cic resistance resources (SRR) are not exchange-
able concepts. Others seem to agree that the
distinction is not particularly important [9]. As
though most focus has been given to the role of
GRR in the literature, that will also be the focus
in this chapter.
Overall, the term generalized resistance
resources (GRR) was established by Antonovsky
[1, 2] and constitutes the assets and characteris-
tics of a person, a group, or a community that
facilitate the individual’s abilities to cope effec-
tively with stressors and that contribute to the
development of the individual’s level of SOC [2].
Consequently, higher levels of GRRs are associ-
ated with stronger SOC.Resources fall into three
basic (but interrelated) domains: those that
enhance comprehensibility, those that enhance
manageability, and those that enhance meaning-
fulness. Because the person and the environment
will always interact, it is not possible to identify
all possible GRRs. Therefore, Antonovsky for-
mulated the following denition that provides a
criterion to identify GRRs: “every characteriza-
tion of a person, group or environment that pro-
motes effective management of tension” ([1],
p.99). Resistance resources may exist at the indi-
vidual, the group, in the subculture, and at the
whole society levels ([1], p.103). Antonovsky’s
[1, 2] illustration of GRR is given in Fig.4.3, and
such resources may include the following factors:
(1) physical and genetic (strong physic, strong
immune system, genetic strength); (2) material
resources (e.g., money, accommodation, food);
(3) cognitive and emotional (knowledge, intelli-
gence, adaptive strategies for coping, emotional
intelligence); (4) ego identity (positive percep-
tion of self); (5) valuative and attitudinal (coping
strategies characterized by rationality, exibility
foresight); (6) interpersonal-relational (attach-
ment, social support from friends and family); (7)
macro sociocultural aspects (culture, shared val-
ues in society).
The initial GRR resources [1] may be per-
ceived as manifested within the life experiences.
Four types of life experiences are assumed to
contribute to the SOC developmental process
during the course of growing up: consistency,
load balance, participation in shaping outcomes,
and emotional closeness [10]. Experiences of
consistency in an individual’s life provide the
Generalised
Resistance
Resources (GRR)
physical
biochemical
material
cognitive
emotional
values
interpersonal
relational
macrosociocultural
individual
primary
group
subculture
society
that is
effective in
a wide range of
stressors
characteristic of an
and thus preventing tension from being transformed into stress
1. avoiding
or
2. combating
Fig. 4.3 Illustration of
generalized resistance
resources (Source:
Antonovsky, 1979 [1],
p.103)
U. K. Moksnes
39
basis for the comprehensibility component of the
SOC [4, 10, 11]. Consistency refers to the extent
to which messages were clear and that there were
order and structure from experienced stimuli
rather than chaos. The second life experience,
load balance, refers to the extent to which one
experienced overload or underload in the balance
between the demands experienced and one’s
resources to cope. Load balance is important for
the manageability component of SOC.The third
life experience including participation in shaping
outcomes refers to the extent to which the indi-
vidual perceives autonomy, has impact in decid-
ing her/his fate, and is not under pressure of
others. Participation in shaping outcomes pro-
vides the basis for the meaningfulness compo-
nent. The fourth life experience, emotional
closeness, refers to the extent to which one feel
consistent emotional bonds and a sense of belong-
ing in social groups of which one was a member
[10, 11]. A person with a strong SOC is able to
mobilize GRRs to promote effective coping. This
resolves tension in a health-promoting manner
and leads toward the salutary health end of the
health ease/dis-ease continuum [6]. SOC and dif-
ferent GRRs work together in a mutual interplay.
The more GRRs people are conscious of, able to
mobilize and make use of, the stronger SOC.A
stronger SOC will in turn help people mobilize
more of their resources, leading to better health
and well-being.
Antonovsky divided resistance resources into
GRR, which are resources that have wide-rang-
ing utility to facilitate effective salutary tension
management, while SRRs have situation-specic
utility in particular situations of tension [1]. As
described by Mittelmark etal. [9], the relation-
ship between GRR and SRR is that via the SOC,
the GRRs enable one to recognize, pick up, and
use SRR in ways that keep tension from turning
into debilitating stress. For example, Sullivan
[12] makes a differentiation, stating that nursing
is a GRR, while the nurse providing help with a
particular problem is an SRR.Hence, supportive
environments may include both GRR and SRR,
but they have distinctions in reference to specic-
ity. When being confronted with a special
stressor, a strong SOC enhances one’s ability to
recognize and activate the most appropriate SRR
from those that may be available. A study investi-
gating the role of different SRRs and GRRs in
informal caregivers originating from themselves
and their care recipients as dyads showed the
necessity of living in a well-functioning relation-
ship which enabled dyads to solve challenges
through cooperation and use of SRRs/GRRs
(e.g., mutual understanding of the situation, good
communicative skills, and enjoying togetherness)
[13]. These resistance resources were important
to be able to resolve the challenges they encoun-
tered, that is, through cooperation and use of their
specic dyadic tension management. The study
suggests that good past and present relationships
wherein the dyad can use SRRs/GRRs might
facilitate the dyad’s adaptation to the caregiving
situation [13].
4.4 Assessment ofSense
ofCoherence
Antonovsky developed the Orientation to Life
Questionnaire (OLQ) to operationalize SOC.The
questionnaire exists in two forms: a long version
consisting of 29 items and a short 13-item ver-
sion [2]. The OLQ has been translated in several
languages and seems to be a cross-culturally
valid, reliable, and feasible instrument, especially
in adult samples [3, 7].
According to Antonovsky [2, 7], the OLQ
comprises one general factor of SOC with three
correlated components of comprehensibility (ve
items), manageability (four items), and meaning-
fulness (four items). However, previous valida-
tion studies have shown that the factor structure
of the scale is complex and seems to measure a
multidimensional rather than a one-dimensional
construct [3, 7]. Following from that, Antonovsky
maintained that on theoretical grounds, one
should avoid lifting out individual dimensions in
order to examine them separately. Studies inves-
tigating the factor structure of the 13-item OLQ
based on exploratory and conrmatory
approaches in adult and older populations have
shown support for a three-factor structure [14
17], a second-order three-factor structure [14,
4 Sense ofCoherence
40
1820], and a one-factor structure [21].
Accordingly, the construct validity of the OLQ-
13 does not seem to be clear in reference to that
different factor structures are evident in different
populations. It may also be a question whether
the items included in the instrument adequately
represent the construct of SOC and that there
may be variations in how the items are under-
stood across different cultures and age groups.
Validations of the factor structure in adolescent
populations are less investigated, but previous
studies have found support for a one-factor struc-
ture in a sample of Swedish adolescents [22] and
three-factor structure in Norwegian adolescents
[23]. While many translations of the OLQ and the
research that has used it have given condence
that the SOC construct is measurable, the sub-
stance of the SOC construct needs to be further
explored. This may include using the salutogenic
model and qualitative methods investigating the
core of the SOC components of comprehensibil-
ity, manageability, and meaningfulness [3].
4.5 Sense ofCoherence
inAssociation withHealth
andQuality ofLife
A strong SOC is associated with good health,
especially mental health and quality of life in dif-
ferent groups and populations [2427]. Further, a
strong SOC is associated with positive perceived
health [24, 28] and is found to be inversely and
strongly related to psychological problems like
symptoms of anxiety and depression [24]. SOC is
positively related to other health resources, such
as optimism, hardiness, resilience, and coping.
Individuals with a strong SOC also show more
positive health behavior, with less use of alcohol,
being a non-smoker, better oral health care [29
31] and more healthy food choice [32]. The SOC
construct has been questioned regarding the weak
relationship with physical health contrary to
mental health [3, 33, 34]. The weak correlation to
physical health may not be surprising since SOC
mainly focuses on the mental, social, and spiri-
tual ability to manage life [35]. The SOC con-
struct has also been criticized for being too close
to the construct of mental health, suggesting they
overlap [35]. The lack of evidence of the stability
of SOC over time has also been criticized.
Antonovsky [2] claimed that SOC like personal-
ity traits develops during childhood and early
adulthood and becomes stabilized in the period
of early adulthood. The SOC seems to be rela-
tively stable over time, at least for people with an
initial strong SOC [27, 36]. However, the SOC
seems to be stronger with age and continues to
develop over the whole life span [3, 27].
4.6 Sense ofCoherence
andHealth inDierent
Patient Groups
4.6.1 Nursing Home Residents
Long term care facilities, including nursing
homes, provide most institutional care for older
people in many western countries. Moving to a
nursing home results from numerous losses, ill-
nesses, disabilities, loss of functions and social
relations, and approaching mortality; all of which
increase an individual’s vulnerability and dis-
tress. In particular, loneliness and depression are
identied as risks to the emotional and social
well-being of older people [37, 38]. Thus, an
important core function of health care profes-
sionals is to support everyday living, health, well-
being, and quality of life [39]. Studies that have
investigated the role of SOC in nursing home
residents have found support for that SOC is an
important component of functioning in old age.
SOC has been shown to be associated to better
health-related quality of life among nursing home
residents [40, 41]. Stronger SOC also relates to
lower emotional and social loneliness among
nursing home residents [37, 42]. The challenge
for health professionals is to help residents to
reduce mental health problems and emotional
and social loneliness and to strengthen their
SOC. Promoting respectful and present nurse–
patient interaction, acknowledging the individual
as a person, might be a crucial resource in rela-
tion to nursing home patients’ health and
well-being.
U. K. Moksnes
41
4.6.2 Coronary Heart Disease (CHD)
Studies on SOC in coronary heart disease (CHD)
patients is important in reference to their ability
to cope with their life situation. A study of
Bergman etal. [43] showed that the level of SOC
seems to be relatively stable among patients who
had suffered from myocardial infarction;
although there were signicant individual varia-
tions over the years. A longitudinal study of
Silarova et al. [44] have shown that SOC is a
predictor of mental and physical health-related
quality of life of patients with CHD at 12- to
28-month follow-up and in female myocardial
infarction survivors [45]. Stronger SOC has been
shown to be associated with better health behav-
ior related to physical activity [8, 46] and quality
of life in patients after myocardial infarction [8,
47]. A study of Bergman etal. [43] which inves-
tigated the components of SOC in myocardial
patients showed that comprehensibility was the
most important component of SOC changes for
2years after a myocardial infarction. Coping has
been emphasized as an important factor in
explaining differences between patients’ percep-
tions of their life situations when affected by a
life-threatening disease. Although SOC does not
refer to a specic type of coping strategy, it com-
prises factors that may be regarded as a basis for
successful coping with stressors. Hence, a posi-
tive outcome from a stressor is primarily depen-
dent on successful management of the stressor
and the presence of strong SOC. Within the
dimensions of a strong SOC, critically ill patients
may be able to show better ability to cope and to
manage their lives after discharge from hospital
by supporting their SOC.
4.6.3 Diabetes
The prevalence of diabetes is rapidly increasing;
this is the case especially for type 2 diabetes.
Given that type 2 diabetes is partly preventable, it
is important to identify not only physical and
health behavioral risk factors but also psycho-
logical risk factors that can promote coping and
good health. Previous studies have shown that a
strong SOC has been associated with more posi-
tive health behavior change [48] related to physi-
cal activity and food choices, which are factors
relevant in the development of type 2 diabetes.
Antonovsky did not use the concept “health
behavior” but used a related concept “a health
orientation,” that served as a GRR. Combined
with other GRRs, a healthy orientation serves as
a prerequisite for the development of a strong
SOC [2]. Study ndings have shown that patients
with type 2 diabetes report lower SOC than a
control group of patients without diabetes, and
especially men [49]. The relationship between
SOC and the incidence of diabetes was prospec-
tively studied among Finnish male employees
(5827 at baseline) [50], showing that a weak SOC
was associated with a 46% higher risk of diabetes
(50 years of entry). This association was sig-
nicant, independent of age, education, marital
status, psychological distress, self-rated health,
smoking status, binge drinking, and physical
activity. Studies have also shown that patients
with type 1 diabetes that report stronger SOC
also show better metabolic control than those
with weaker SOC, through adherence to self-care
behaviors related to food choices and physical
activity [51, 52].
4.6.4 Cancer
For most people, receiving a cancer diagnosis
often causes severe distress. Therefore, working
on supporting the patient’s coping resources in
order to promote positive psychological adjust-
ment is important. The concept of SOC has been
studied in individuals with various forms of can-
cer and moreover, in survivors of various forms
of cancer, SOC is a strong predictor of quality of
life [53, 54] and fewer symptoms of anxiety and
depression [55]. In breast cancer patients, reports
of stronger SOC relate to higher quality of life
[53, 54, 56] through better emotional functioning
and less fatigue and pain [53]. Further, stronger
SOC is associated with less report of stress, dis-
tress [57, 58], and more positive coping strategies
4 Sense ofCoherence
42
such as direct action and relaxation [54].
However, cancer patients are reported to score
lower on SOC than the general population [56].
4.6.5 Mental Health
According to WHO, depression is one of the
leading causes of disease burden in terms of dis-
ability. Although some people only suffer a sin-
gle episode of depression, the high prevalence
together with the associated impairment of func-
tioning and socioeconomic consequences under-
scores the need to understand this illness fully.
The experience of having a serious illness such as
depression affects the individual’s quality of life
and requires signicant adaptation by the patient
and his/her family in order to cope. Research
shows the signicance of the salutogenic
approach in mental health promotion, including
various mental health problems [59]. One buffer-
ing component may be the individual’s percep-
tion of SOC.In a 4-year and a 1-year follow-up
study of people with major depression, SOC was
shown to increase signicantly as patients recov-
ered after therapy [60, 61]. SOC is also found to
predict life satisfaction in people with chronic
mental health problems [62], and stronger SOC is
found to be associated with reduced risk of psy-
chiatric disorders during a long time period [63].
4.7 Implications forPractice
The WHO Ottawa Charter for health promo-
tion [64] states that health is created and lived
by people within the settings of their everyday
life where they learn, work, play, and love.
Salutogenesis has been applied to guide health
promotion research and practice in various set-
tings, however, mainly in everyday life set-
tings. A central question is therefore what
implications salutogenesis and related con-
cepts have for practice in the health care
setting?
With advances in medical technology and
improvement in the living standard globally, the
life expectancy of people is increasing worldwide
[65]. Meanwhile, we also see an increasing prev-
alence of non-communicable diseases and
chronic illnesses in the population [66]. With
more advanced medical technology and medical
treatment, more people survive from serious dis-
eases but that also leads to that more people will
have to learn to live with different chronic impair-
ments in their everyday life. A new life situation
is demanding and requires adaptation in many
life areas for the individual. The preferences, or
what is evaluated as valuable in life changes in
meeting with illness, therefore, the experience of
quality of life is a highly individual matter. At the
same time, most people have a unique ability to
adapt to and cope with inevitable life situations,
and our expectations change according to life’s
realities. Here, health care personnel have a great
responsibility in identifying possibilities for
change and help the patient to cope with a new
life situation. These aspects also challenge the
health care sector’s provision of efcient primary
health care and long-term care, where more
responsibility is given to the health care sector in
the community/municipality.
The salutogenic perspective can be used to
guide health promotion interventions in health
care practice and to (re)orient health care practice
[67]. The health care sector is generally a chal-
lenging area for applying salutogenesis and to
reorient in a health-promoting direction, as the
focus is and should be disease treatment. The
reorientation of the health care services in a
health-promoting direction therefore seems to be
the least systematically developed, implemented,
and evaluated key action of the ve action areas
outlined in the Ottawa Charter. The goal of
implementing the salutogenic perspective is
therefore that salutogenesis can be a complemen-
tary perspective to the pathogenic perspective
where these perspectives interact in the planning
and implementation of actions. In meeting with
all patient groups, and especially with patients
living with chronic diseases, health professionals
need to focus on the patient’s salutary resources
as well as focusing on how to diminish and reduc-
ing risk factors. Further, it is important that the
individual is seen in holistic terms, interacting
with his/her daily life context. One of the central
aspects implies promoting a more active patient
role, where the health care professionals empower
U. K. Moksnes
43
the patient to activate the use of knowledge and
clarication of resources and needs in the plan-
ning of health care needed. An important role of
health professionals is to identify the patient’s
experiences and prerequisites and help the patient
to identify and activate resistance resources, in
order to promote coping with everyday life chal-
lenges. This challenges the health care person-
nel’s ability to work holistically with the patient’s
resources and needs and to see the patient as an
equal partner in the planning of health care. This
approach is important in order to integrate the
resources and efforts needed regarding how to
help the patient mange lives’ challenges and pro-
mote quality of life.
In reference to intervention work, using salu-
togenesis as a basis for providing health-
promoting interventions is found to be effective,
e.g., toward strengthening SOC in patients liv-
ing with long-term illness [6870]. For instance,
in patients with severe mental disorders, a com-
bination of perspectives in order to provide
holistic nursing is found to be important; this
includes applying salutogenic knowledge about
living a good and meaningful life in addition to
knowledge anchored in the biomedically domi-
nated understanding of mental illness [70].
Consequently, mental health care services
should offer education programs with a comple-
mentary perspective on mental health, denoted
“salus education” [70]. This implies a shift in
practice to identify and build upon each indi-
vidual’s assets, strengths, and competence and
support the person in managing his or her condi-
tion in order to gain a meaningful, constructive
sense of being a part of a community [70]. The
focus is not only how to combat and survive dis-
ease, but to help and “educate” people to “swim
in the river of life.
4.8 Conclusion
This chapter has given an introduction to saluto-
genesis and the concept of sense of coherence
(SOC) and generalized and specic resistance
resources (GRR/SRR). It has also presented empir-
ical research on assessment of SOC with use of the
Orientation to Life Questionnaire developed by
Antonovsky. The chapter has presented empirical
research on the central role of SOC as a personal
coping resource and life orientation in relation to
health and quality of life in different populations
and patient groups. Today, we can talk about salu-
togenesis more as a salutogenic umbrella and assets
apprach with many different concepts with saluto-
genic elements and dimensions besides SOC [35].
The application of salutogenesis as a perspective
guiding work in the health care settings seems to be
vital and important as a complementary approach
to the biomedical paradigm, since it is about imple-
menting salutogenesis into a territory which is still
predominantly dominated by the biomedical para-
digm. Salutogenic thinking also seems to have
good potential to be applied in health promoting
interventions, and in supporting health promoting
work in health care institutions for better everyday
practice and quality of life for patiens [67].
Take Home Messages
Sense of coherence is an important concept
within salutogenesis and is considered as a
personal coping resources and life orientation,
where life is understood as more or less com-
prehensible, meaningful, and manageable.
A strong sense of coherence helps the indi-
vidual to mobilize resources to cope with life
stressors and manage tension successfully
with help of identication and use of general-
ized and specic resistance resources.
Antonovsky developed the 29-item and a
shorter 13-item version of the Orientation to
Life Questionnaire (OLQ) to measure the
sense of coherence.
The OLQ scale has been translated in sev-
eral languages and seems to be a cross-cul-
turally valid and reliable instrument.
Criticism of the SOC concept covers the
multidimensionality of the concept. The
substance of the SOC construct needs to be
further explored.
In health care, salutogenesis can be used to
guide health promotion interventions in health
care practice and/or to (re)orient health care
services into a more health-promoting
direction.
4 Sense ofCoherence
44
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Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOCthat helps to mobilize resources to cope with stressors and manage tension successfully (determining one’s movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky’s original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal’s work to strengthen salutogenesis as a theory base for health promotion
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Objective: To present Specific and Generalized Resistance Resources (SRRs/GRRs) and Deficits (SRDs/GRDs) described by 32 informal caregivers as originating from themselves and their older adult carerecipients as dyads. Method: Salutogenic interviewing was used to assemble data from caregivers. A theory-driven, memo-guided and comparative analysis using within- and across- case analysis was applied to unravel resources and deficits influencing the outcomes when they managed tension associated with caregiving. Findings: Living in fellowship in a well-functioning dyad unites the essence of having access to dyadic SRRs/GRRs. Such access enables dyads to use their specific dyadic tension management to resolve challenges through cooperation, derives ‘positive’ life-experiences and preserves dyad functioning. Struggling alone in a malfunctioning dyad indicates the presence of dyadic SRDs/GRDs counteracting such a development. If these SRDs/GRDs accumulate, the dyad become less able to resolve challenges, ‘negative’ life-experiences accumulates, the carerecipient's capability to cooperate decreases, caregiver's workload increases, the dyad becomes increasingly malfunctioning and moves towards the point where caregiving ends due to lack of usable SRRs/GRRs. Conclusions: Findings reveals the complex duality of caregiving and the necessity to assess all available SRRs/GRRs and SRDs/GRDs for caregiving dyads, including out of the carerecipient's perspective. Appropriate ‘salutogenic’ support reduces SRDs/GRDs, makes available SRRs/GRRs usable or provides alternative SRRs/GRRs, thereby dyadic tension management and dyadic functionality is preserved during this phase of life labelled Caregivinghood. The study adds new knowledge to the salutogenic framework regarding central, theoretical concepts and suggests how data for health promoting initiatives conducted the ‘salutogenic way’ may be acquired.
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Background: Chronic illness health interventions aim to strengthen individuals' wellness resources, in addition to their ability to handle their condition. This presupposes a partnership between patients and professionals and flexibility in care organization. Aim: This study aims to investigate possible changes in individuals' sense of coherence while living with long-term illness as they engage in a broadly applicable health promotion intervention developed in specialist care settings that was later implemented in the community care context. Method: This study had a pre-postdesign. Sense of coherence was measured using the SOC-29 questionnaire at baseline and within 14 days of programme completion. The total baseline sample included 108 Norwegian adults (aged 21-89) with chronic illness. Data were analysed using paired samples t-tests. Results: In both clinical sites, the total sample's mean SOC score changed positively from the baseline to the follow-up 4 months later. This change was larger for the participants in the community care context. Manageability increased significantly for women. Significant positive changes in SOC score and the manageability dimension were also identified among participants who had children. Similar findings were found for those who were living with a partner, as well as for public transfer payment recipients. Conclusion: The intervention contributed to a positive change in participants' SOC while living with illness. The findings revealed that the intervention is a flexible health promotion tool across age, diagnostic categories and clinical sites. The community participants' SOC changed the most, which indicates that the intervention is especially relevant in the follow-up of persons living with long-term illness within the community. The intervention contributes to a shift of perspectives in health care towards strenght-based care and health within illness.
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The application of salutogenesis in curative settings is specific, since it is about implementing salutogenesis into a territory which is still predominantly dominated by the paradigm of pathogenesis. But a case can be made that health care and its different curative settings would profit by integrating the principles of salutogenesis into their quality philosophy and management. Health gain for patients, their families, for health care professionals, and citizen could be improved by using a salutogenic orientation, parts of the salutogenic model and the concept and instrument of the sense of coherence in health care practice, research, and policy. This chapter summarizes how and why this could be done in different kinds of curative and other health care settings and what the actual status of practice and research using concepts and instruments from salutogenesis in these settings already is and how it could be further developed. The specific health care settings included are: salutogenic architecture in health care settings, the application of salutogenesis in hospitals, in mental health care settings, in the training of health professionals, in vocational rehabilitation settings, to aged and highly aged persons: residential care and community—dwelling settings, and in health development in youth with chronic conditions. Even, if for most health care settings health promotion practice still is limited, and outside hospitals salutogenic research is scarce, there exists enough promising evidence to recommend more extended integration of salutogenesis into health care practice and more and more systematic and complex salutogenic research in health care settings.
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This section aims to describe the salutogenic construct of the sense of coherence. It begins with a reflection of the ontological and epistemological background of salutogenesis, which is not particularly described and explained to any significant extent in the publications by Antonovsky. The core concepts, the sense of coherence and the generalized resistance resources within the salutogenic model of health are explained. The measurement of the sense of coherence and the validity and reliability of the sense of coherence scales are extensively described. The sense of coherence is a concept that can be applied at different system levels, at an individual level, a group (family), on organizations and societal level. Therefore, a life cycle perspective is adopted for this section, describing sense of coherence in children and families, in adolescents and in older adults. Finally, salutogenesis, a resource-oriented approach on peoples’ abilities, is much more than the measurement of the sense of coherence. The salutogenic umbrella is here used as a metaphor for showing some related concepts.
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This chapter discusses conceptual and concrete differences between generalised and specific resistance resources in the salutogenic model of health. This is important to health promotion research and practice, because the means by which these different types of resources are strengthened are dissimilar. It is important to distinguish between the two types of resistance resources, to ensure that health promotion pays balanced attention to both types. Generalised resistance resources arise from the cultural, social and environmental conditions of living and early childhood rearing and socialisation experiences, in addition to idiosyncratic factors and chance. Specific resistance resources, on the other hand, are optimised by societal action in which health promotion has a contributing role, for example the provision of supportive social and physical environments. Specific resistance resources actually have as much or more relevance to health promotion practice as do generalized resistance resources. By drawing attention to the special nature of specific resistance resources, one also draws attention to what should be a core aim of health promotion: to ensure that availability of the right specific resistance resource at the right time is not all too often a matter of ‘chance or luck’, as Antonovsky worried.
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Problem Emergency care in child and adolescent psychiatry often lacks a coherent treatment model. This study reports on the development and implementation of a salutogenic treatment model at the Child & Adolescent Psychiatric Emergency Unit in Malmö, Sweden. Methods The development and implementation involved all staff categories and was guided by a recognized authority on salutogenesis. Generalized resistance resources (GRR) were identified that could be implemented at the unit to improve patients’ sense of coherence. Findings Eight GRR were developed and implemented at the unit. During the 6‐month period following the implementation, patients (n = 41) and parents reported satisfaction with the treatment, while mental health improved between admission and discharge, and both treatment length and readmission rates were reduced. Conclusion A salutogenic treatment model involving GRR seems to be a promising approach in child and adolescent psychiatric emergency treatment.
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Antonovsky’s concept “sense of coherence” (SOC) and the related measurement instrument “The Orientation to Life Questionnaire” (OLQ) has been widely applied in studies on health and well-being. The purpose of the present study is to investigate the cultural differences in factor structures and psychometric properties as well as mean scores of the 13-item form of Antonovsky’s OLQ among Australian (n = 201), Finnish (n = 203), and Turkish (n = 152) students. Three models of factor structure were studied by using confirmatory factor analysis: single-factor model, first-order correlated-three-factor model, and the second-order three-factor model. Results obtained in all three countries suggest that the first- and second-order three-factor models fitted the data better that the single-factor model. Hence, the OLQ scoring based on comprehensibility, manageability, and meaningfulness scales was supported. Scale reliabilities and inter-correlations were in line with those reported in earlier studies. Two-way analyses of variance (gender × nationality) with age as a covariate showed no cultural differences in SOC scale scores. Women got higher scores on the meaningfulness scale than men, and age was positively related to all SOC scale scores indicating that SOC increases in early adulthood. The results support the three-factor model of OLQ which thus should be used in Australia, Finland, and Turkey instead of a single-factor model. Need for cross-cultural studies taking into account cultural correlates of SOC and its relation to health and well-being indicators as well as studies on gender differences in the OLQ are emphasized.
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Reorientation of healthcare services towards more efficient health promotion interventions is an urgent matter. Despite policies and guidelines being in place, it is the least developed key action area of the Ottawa charter. User involvement, or the voice of the patient, is missing from the knowledge base of health promotion in the mental healthcare services. The aim of this study was to add experiential knowledge from former patients. We explored the lived experience of 12 former inpatients at a mental healthcare hospital. We describe what they perceive as mental health promoting efforts. A salutogenic theoretical framework and the methodology of interpretative phenomenological analysis were used. The analysis revealed an appetite for learning in order to develop an in depth understanding of their former experiences. This was motivated by a desire to master daily life despite living with an illness and to increase health and well-being. The participants perceived the learning processes within the healthcare setting as mental health promoting. This craving for a better life is compatible with health promotion. It may turn out to be an opportunity to complement the curative activity of healthcare services with health promotion educational activities.
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The aim of this systematic review was to describe the association between adolescent sense of coherence (SOC) and health and identify the future direction for research in this area. Systematic searches were conducted (2007–2014) in the PubMed, CINAHL, PsycINFO and Cochrane electronic databases and carried out manual searches in three scientific journals. A total of 827 original papers were found and 23 were selected. Based on the results, adolescents’ sense of coherence (SOC) was related to health in terms of the adolescents’ quality of life, health behaviour, mental health and family relationships by using 31 different health-related instruments. In conclusion, the use of the SOC approach for adolescents can provide a useful view of their health during this transition phase to adulthood. Due to the large variation in the additional instruments used, combining and comparing the results proved challenging. More comparative and longitudinal research is needed to increase understanding of adolescents’ health in relation to SOC and develop services that support both elements.