Keywords

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 create health as distinct from, and yet a complementary 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 consequently 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 continuum, 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 generalized resistance resources (GRR) and specific resistance resources (SRR) [4, 5]. The salutogenic theory posits that life experiences shape the SOC. This capacity is a prerequisite for peoples’ ability to move in the positive direction on the health continuum and is a combination of peoples’ ability to assess and understand the situation they are in, to find a meaning to move in a health-promoting direction, and also having the capacity to do so [4, 5].

Fig. 4.1
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The ease/dis-ease continuum. (Published with permission from Folkhälsan Research Center, Helsinki, Lindström & Eriksson [3])

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When Antonovsky introduced salutogenesis, it was originally aimed to be a stress theory. Antonovsky saw stress as a natural and inevitable part of life, assuming that life was challenging and health being continuously threatened by ubiquitous stressors [1, 2, 6]. Stressors place a load on us, which causes tension. However, tension 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 adequately with stressors. Antonovsky was interested 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 workplace. The frequency, intensity, and duration of the stressor(s) are all factors that affect the individual’s ability to cope adequately. Three potential 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 influence 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 adequately with the stressor(s). The individual’s ability to identify and use GRRs affects the individual’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 comprehend 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 constant change. For the individual, the challenge is to manage the stimuli and find strategies and resources available for coping with the changes in everyday life and manage complexity. Complexity may lead to conflicts but also offers opportunities for different and flexible choices, possibilities for adapting to change. It becomes 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 significant variable in affecting this movement [2, 5].

2 The Concept of Sense of Coherence

The concept sense of coherence (SOC) is defined as “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that 1) the stimuli deriving from one’s internal and external environments 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 challenges, worthy of investment and engagement” ([2], p. 19). These three components, termed comprehensibility, manageability, and meaningfulness 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 completely predictable or without difficulty; the point is that stimuli experienced are explicable and logic. Manageability is the “instrumental” component and refers to the extent to which individuals perceive that available resources are at their disposal and sufficient to adequately cope with the demands. Meaningfulness is the motivational component and refers to the extent to which individuals feel that certain areas of life are worthy of time, effort, personal involvement, and commitment [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 commitment and engagement, that also gives a greater sense of the two components of comprehensibility and manageability as well. However, this statement has been discussed. In a study of myocardial infarction patients, this hypothesis was rejected, showing that the dimension of comprehensibility was more important than meaningfulness for changes in SOC [8].

Fig. 4.2
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Dimensionality of the construct of sense of coherence

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The three components in the SOC concept are strongly connected and reflect an individual resource and life orientation that enables the individual to reflect 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 reflects 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 and its key concept, SOC, also can be applied at a collective level, and not only with a focus on the individual level [6].

3 Generalized Resistance Resources (GRRs)

Along with the concept of SOC, a key concept in the salutogenic theory/model is the role of generalized and specific resistance resources [1, 2], which are seen as important prerequisites for the development of SOC. Antonovsky promoted that generalized resistance resources (GRR) and specific resistance resources (SRR) are not exchangeable 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 characteristics of a person, a group, or a community that facilitate the individual’s abilities to cope effectively with stressors and that contribute to the development of the individual’s level of SOC [2]. Consequently, higher levels of GRRs are associated with stronger SOC. Resources fall into three basic (but interrelated) domains: those that enhance comprehensibility, those that enhance manageability, and those that enhance meaningfulness. Because the person and the environment will always interact, it is not possible to identify all possible GRRs. Therefore, Antonovsky formulated the following definition that provides a criterion to identify GRRs: “every characterization of a person, group or environment that promotes effective management of tension” ([1], p. 99). Resistance resources may exist at the individual, 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, intelligence, adaptive strategies for coping, emotional intelligence); (4) ego identity (positive perception of self); (5) valuative and attitudinal (coping strategies characterized by rationality, flexibility foresight); (6) interpersonal-relational (attachment, social support from friends and family); (7) macro sociocultural aspects (culture, shared values in society).

Fig. 4.3
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Illustration of generalized resistance resources (Source: Antonovsky, 1979 [1], p. 103)

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The initial GRR resources [1] may be perceived 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 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 individual perceives autonomy, has impact in deciding her/his fate, and is not under pressure of others. Participation in shaping outcomes provides the basis for the meaningfulness component. The fourth life experience, emotional closeness, refers to the extent to which one feel consistent emotional bonds and a sense of belonging 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 different 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-ranging utility to facilitate effective salutary tension management, while SRRs have situation-specific utility in particular situations of tension [1]. As described by Mittelmark et al. [9], the relationship 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 specificity. 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 investigating 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 relationship 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 encountered, that is, through cooperation and use of their specific 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 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 version [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 (five items), manageability (four items), and meaningfulness (four items). However, previous validation 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 investigating the factor structure of the 13-item OLQ based on exploratory and confirmatory approaches in adult and older populations have shown support for a three-factor structure [14,15,16,17], a second-order three-factor structure [14, 18,19,20], 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 understood 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 structure 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 confidence that the SOC construct is measurable, the substance 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 comprehensibility, manageability, and meaningfulness [3].

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 different groups and populations [24,25,26,27]. 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 [29,30,31] 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 spiritual ability to manage life [35]. The SOC construct 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 personality traits develops during childhood and early adulthood and becomes stabilized in the period of early adulthood. The SOC seems to be relatively 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].

6 Sense of Coherence and Health in Different Patient Groups

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, illnesses, disabilities, loss of functions and social relations, and approaching mortality; all of which increase an individual’s vulnerability and distress. In particular, loneliness and depression are identified as risks to the emotional and social well-being of older people [37, 38]. Thus, an important core function of health care professionals 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 relation to nursing home patients’ health and well-being.

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 significant individual variations 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 behavior 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 investigated 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’ perceptions of their life situations when affected by a life-threatening disease. Although SOC does not refer to a specific type of coping strategy, it comprises factors that may be regarded as a basis for successful coping with stressors. Hence, a positive outcome from a stressor is primarily dependent 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.

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 psychological risk factors that can promote coping and good health. Previous studies have shown that a strong SOC has been associated with more positive health behavior change [48] related to physical 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 findings 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 prospectively 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 significant, 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].

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 adjustment is important. The concept of SOC has been studied in individuals with various forms of cancer 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, distress [57, 58], and more positive coping strategies such as direct action and relaxation [54]. However, cancer patients are reported to score lower on SOC than the general population [56].

6.5 Mental Health

According to WHO, depression is one of the leading causes of disease burden in terms of disability. Although some people only suffer a single episode of depression, the high prevalence together with the associated impairment of functioning and socioeconomic consequences underscores 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 significant adaptation by the patient and his/her family in order to cope. Research shows the significance of the salutogenic approach in mental health promotion, including various mental health problems [59]. One buffering component may be the individual’s perception of SOC. In a 4-year and a 1-year follow-up study of people with major depression, SOC was shown to increase significantly as patients recovered 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 psychiatric disorders during a long time period [63].

7 Implications for Practice

The WHO Ottawa Charter for health promotion [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 settings, however, mainly in everyday life settings. A central question is therefore what implications salutogenesis and related concepts 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 prevalence of non-communicable diseases and chronic illnesses in the population [66]. With more advanced medical technology and medical treatment, more people survive from serious diseases but that also leads to that more people will have to learn to live with different chronic impairments 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 efficient 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 challenging 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 five action areas outlined in the Ottawa Charter. The goal of implementing the salutogenic perspective is therefore that salutogenesis can be a complementary 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 reducing 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 the patient to activate the use of knowledge and clarification of resources and needs in the planning 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 challenges. This challenges the health care personnel’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 promote quality of life.

In reference to intervention work, using salutogenesis as a basis for providing health-promoting interventions is found to be effective, e.g., toward strengthening SOC in patients living with long-term illness [68,69,70]. For instance, in patients with severe mental disorders, a combination 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 dominated understanding of mental illness [70]. Consequently, mental health care services should offer education programs with a complementary perspective on mental health, denoted “salus education” [70]. This implies a shift in practice to identify and build upon each individual’s assets, strengths, and competence and support the person in managing his or her condition 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 disease, but to help and “educate” people to “swim in the river of life.”

8 Conclusion

This chapter has given an introduction to salutogenesis and the concept of sense of coherence (SOC) and generalized and specific resistance resources (GRR/SRR). It has also presented empirical 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 salutogenesis more as a salutogenic umbrella and assets apprach with many different concepts with salutogenic 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 implementing salutogenesis into a territory which is still predominantly dominated by the biomedical paradigm. 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 comprehensible, meaningful, and manageable.

  • A strong sense of coherence helps the individual to mobilize resources to cope with life stressors and manage tension successfully with help of identification and use of generalized and specific 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 several languages and seems to be a cross-culturally 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.