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Abstract

Antonovsky introduced the salutogenic model whose aim is to explain the origins of health and to describe how health can be promoted. Sense of coherence (SOC) is the core concept in the model and is defined as the degree of meaningfulness, comprehensibility, and manageability that people feel in their life. The aim of this article is to bring attention to some topics on SOC that need to be explored in future research. First, SOC and how it is measured are briefly described. Thereafter, there is a brief discussion of the following seven topics: (a) the dimensionality of the SOC scale, (b) SOC as the causal variable, (c) SOC as the outcome variable, (d) general SOC versus domain-specific SOC, (e) the concept of boundary in the measurement of SOC, (f) SOC as a continuous versus a dichotomized or trichotomized variable, and (g) the importance of relating SOC to salutogenic outcome measures. In conclusion, the salutogenic model, with its core concept of SOC, is an excellent guide for research on health and well-being, but there are still some parts of this model that deserve further theoretical and empirical attention.

Keywords

Antonovsky salutogenic model sense of coherence problems future research

Sense of Coherence: Definition and Measurement

Mother Teresa once said, “If you hold an anti-war rally, I will not attend. But if you hold a pro-peace rally, invite me” (Azquotes.com, n.d.). Thus, she thought that working against war is not the same thing as working for peace. In a somewhat similar way, the World Health Organization (WHO) defines health not only as the absence of disease but also as a state of complete physical, mental, social, and spiritual well-being (WHO, 1986). Thus, the knowledge of what causes diseases and how diseases can be cured should be complemented with the knowledge of which factors contribute to well-being and how these factors can be strengthened.

The salutogenic model was introduced by Antonovsky (1979, 1987). Salutogenic can be derived from the Latin word salus (health) and the Greek word genesis (origins). The model aims to explain the origins of health and focus primarily on the promotion of health and is to be seen as a complement to the traditional and well-established pathogenic model that mainly deals with the causes of disease and primarily focuses on the prevention of ill-health. For a comprehensive review of the salutogenic model, see, for example, Mittelmark et al. (2017), and for an excellent comparison of the salutogenic and the pathogenic model, see, for example, Becker, Glascoff, and Felts (2010) and Vinje, Langeland, and Bull (2017).

The salutogenic model rests on two fundamental assumptions (Antonovsky, 1979, 1987). The first assumption is that humans are constantly under the attack of various stimuli, which leads to a state of imbalance (heterostasis). The second assumption is that unless we are able to cope with these stimuli, they will result in a movement toward disorder and disease (entropy).

Antonovsky (1979, 1987) defined a stimulus as a stressor if it elevates the entropy. A given stimulus can be evaluated as neutral (irrelevant), positive (beneficial), or negative (harmful). Furthermore, he classified stressors into three broad and fuzzy categories: chronic stressors (e.g., a disability), main life events (e.g., death of a family member), and daily hassles (e.g., an argument at work).

Within the frame of the salutogenic model, Antonovsky (1979, 1987) introduced generalized resistance resources (GRR). GRR can be described as various types of factors—material (e.g., money), genetic (e.g., intelligence), knowledge (e.g., coping strategies), and social (e.g., social network)—that help a person, a group, or a society to cope effectively with the stimuli by evaluating them as nonstressors, by avoiding the stressors, and by overcoming them. GRR can be characterized by their contribution to a sense that there is some consistency in our life, that we can affect the underload–overload balance in our life, and that we wish to participate in shaping outcomes in our life.

In the course of life, the repeated use of GRR leads to a sense of coherence (SOC), but SOC also affects the GRR (Antonovsky, 1979, 1987; Idan, Eriksson, & Al-Yagon, 2017). To exemplify this reciprocal interplay between the GRR and SOC, in the long run, a strong preventive health orientation (a GRR) should contribute to a strong SOC, but at the same time, a strong SOC should contribute to a strong preventive health orientation (Antonovsky, 1979, 1987). SOC is the core concept in the model and 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. (Antonovsky, 1987, p. 19)

Consequently, SOC comprises (a) a cognitive component, labeled comprehensibility, representing the extent of the belief that the problem faced is clear; (b) an instrumental or behavioral component, labeled manageability, representing the extent of the belief that necessary resources to successfully cope with the problem are available; and (c) a motivational component, labeled meaningfulness, representing the extent of the belief that one wishes to cope. According to the model, SOC is hypothesized to have positive effects on various types of indicators of health and well-being.

Antonovsky (1987, 1993) developed a self-rating scale—The Orientation to Life Questionnaire—to measure SOC (hereafter referred to as the SOC scale). The scale was constructed using the facet design (Guttman, 1974; Shye, 1978), where five aspects or facets were varied between the questions. More specifically, the respondent is asked to rate the degree of experienced (a) comprehensibility, manageability, or meaningfulness (SOC facet) (b) when confronted with an instrumental, a cognitive, or an affective stimuli (modality facet), (c) which derives from the persons internal world, external world, or both worlds (source facet) (d) and which constitutes a real, an ambiguous, or an abstract demand (demand facet) and (e) takes place in the past, the present, or the future (time facet). The full version of the scale consists of 29 questions and the short version consists of 13 questions. Comprehension is measured by 11 and 5 items, manageability by 10 and 4 items, and meaningfulness by 8 and 4 items. Responses to each question are given using a 7-point (1-7) scale, and a subtotal index is computed based on the answers to all the questions, where higher numeric values represent a higher degree of SOC. In the full version of the scale, responses to 13 of the 29 questions should be reversed, and in the short version, responses to 5 of the 13 questions should be reversed before the subtotal index is computed.

The psychometric properties of the SOC scale have been systematically reviewed in two studies (see Antonovsky, 1993; Eriksson & Lindström, 2005). From these systematic reviews, it can be concluded that the SOC scale is (a) reliable and (b) valid, but that (c) the factorial structure of the scale is not clear, and (d) the scores on the scale over time are moderately stable. Furthermore, systematic reviews have also shown that SOC is positively related to mental health (Eriksson & Lindström, 2006) and quality of life (Eriksson & Lindström, 2007), weakly related to physical health (Eriksson & Lindström, 2007; Flensborg-Madsen, Ventegodt, & Merrick, 2005), and negatively related to mortality (Surtees, Wainwright, & Khaw, 2006; Surtees, Wainwright, Luben, Khaw, & Day, 2003, 2006).

SOC: Some Challenges for Future Research

Throughout the years, various criticisms have been leveled against SOC (see, for example, Eriksson, 2015a; Geyer, 1997; Griffiths, 2010; Kumlin, 1998). The aim of the present article is not to review all the criticisms and how it have been met but briefly to point out some of the topics that have not received enough attention and that need to be more systematically explored in future research on SOC.

The Dimensionality of the SOC Scale

Antonovsky (1987, 1993) clearly stated that only one single total score should be calculated based on answers to all the questions of the scale and not three separate scores for each of the three components (comprehensibility, manageability, and meaningfulness). The somewhat unclear, theoretical argument for this is that Antonovsky (1987) assumed that every single GRR contributes to all three components, which, according to him, implies that the three components are insolubly interlaced with each other. The totally clear, methodological argument is that using the facet theory in the development of the scale makes it impossible to separate the three components because besides the SOC-facet, there are four additional facets (mentioned above) that affect the factorial structure of the scale (see Antonovsky, 1987). As mentioned above, psychometric assessments of the SOC scale have not given univocal results concerning the scale’s dimensionality (see Antonovsky, 1993; Eriksson & Lindström, 2005).

The problem at hand—which Antonovsky was very much aware of—is that although the SOC concept is defined as consisting of three distinct components, the three components cannot be measured separately by the SOC scale. In the article where he first extensively described the scale and its psychometric properties, he concluded that “It would indeed be a contribution were separate measures of the components to be developed, with relatively low interrelations” (Antonovsky, 1993, p. 732). Also, in his last article, where he presents SOC from a historical and a future perspective, he suggests that one of the tasks for future research is to construct a scale where the three components can be measured separately (Antonovsky, 1996a). However, such a scale has not yet been developed.

Let us look at just one example of the many questions that could be answered if the three dimensions could be measured relatively independently. Antonovsky (1987) hypothesized that meaningfulness was the most important dimension followed by comprehension that in turn was followed by manageability. Furthermore, he reasoned that if the three dimensions could be measured separately and the scores on each dimension dichotomized, then respondents could be divided into eight types, as shown in Table 1 (Antonovsky, 1987, p. 43). Finally, he hypothesized that Types 1 and 8 have a stable SOC; Types 2 and 7 are unusual because high manageability presupposes high comprehension; and Types 3 and 6 are pressed for change, but if the change will result in lower or higher SOC, then it is dependent of the level of meaningfulness, where the high meaningfulness of Type 3 should in the long run lead to a high manageability and consequently a higher SOC. The low meaningfulness of Type 6 should in the long run lead to a low comprehension and consequently a lower SOC. Types 4 and 5 also illustrate the importance of meaningfulness, where the low meaningfulness of Type 4 will in the long run lead to a low comprehension and low manageability and consequently a lower SOC. The high meaningfulness of Type 5 implies a good chance of an increase in comprehension and manageability and consequently a higher SOC. This is just one example of an interesting and important part of Antonovsky’s salutogenic model that cannot be tested, unless a scale is constructed that independently measures the three SOC dimensions.

Table 1.

The Dynamic Connection Between the Three SOC Components.

Type	Component			Predicted change
Type	Comprehension	Manageability	Meaningfulness	Predicted change
1	High	High	High	Stable
2	Low	High	High	Unusual
3	High	Low	High	Press upward
4	Low	Low	High	Press upward
5	High	High	Low	Press downward
6	High	Low	Low	Press downward
7	Low	High	Low	Unusual
8	Low	Low	Low	Stable

Note. SOC = sense of coherence.

An SOC scale where the three dimensions could be independently measured would make it possible to answer many research questions and would also have many practical implications. Purely theoretically, it would be interesting to know how the three dimensions affect each other or at least how they are related to each other. The practical implications, if we knew that meaningfulness affect comprehension and that comprehension in turn affects manageability, would be that we had better knowledge how to affect persons’ SOC and consequently make them more resilient to various stressors and ill-health. Thus, one task for future research is to develop a scale to measure SOC, where the three dimensions are measured relatively independent of each other. In brief, to construct an SOC scale with three uncorrelated or only modestly correlated dimensions, the first step would be to generate items, where each given item refers only to one of the three SOC dimensions (and where the four remaining facets are not taken into consideration when generating these items), and then in the next step, using factor analysis, sort out and retain those items that clearly and consistently produce the three SOC dimensions (cf. DeVellis, 1991).

SOC as the Causal Variable

The core postulate in Antonovsky’s model is that SOC protects against ill-health and promotes health (Antonovsky, 1979, 1987). To prove that SOC has a causal effect on health, at least the following conditions must be met: (a) the measurement of SOC should precede the measurement of health in time, (b) there should be a statistically significant association between SOC and health, (c) the association between SOC and health should not be due to a third variable, and (d) there should be a reasonable theoretical explanation of the relation between SOC and health (e.g., Taris & Kompier, 2003). It must also be noted that due to the reciprocity between SOC and health (Antonovsky, 1979, 1987) and due to the fact that SOC also can be perceived as one of the indicators of (mental) health (e.g., Geyer, 1997), the causal effect of SOC on health is extra difficult to study. If one is willing to accept Antonovsky’s assumption that SOC is a rather stable disposition after 30 years of age (Antonovsky, 1979, 1987), then cross-sectional data analyzed with simplistic statistical methods gives at best very preliminary results on the causal relation between the trait-like SOC and state-like measures of health. A less strict view would be to describe and treat SOC as a determinant-, moderator-, and mediator-variable of health (e.g., Albertsen, Nielsen, & Borg, 2001; Hochwälder, 2013). Also, the different possible types of relationships (e.g., simple causal, reciprocal) between SOC and various health indicators should be more precisely specified and studied empirically. To rigorously investigate the causal effect of SOC on health, longitudinal data must be collected and properly analyzed (e.g., de Lange, Taris, Houtman, & Bongers, 2003; Taris & Kompier, 2003). Furthermore, to study the causal effect of SOC on other variables like, for example, stress and performance, more experimental studies, which are rather scarce (e.g., Kimhi, 2015; McSherry & Holm, 1994), are badly needed.

SOC as the Outcome Variable

Antonovsky (1979, 1987) assumed that SOC becomes a rather stable disposition around 30 years of age, especially for those with a high initial SOC, and that it is difficult to actively affect or change SOC permanently in adults. However, empirical research has shown that SOC is not as stable as Antonovsky assumed and that SOC increases slightly with age (see Eriksson & Lindström, 2005) and also that SOC can actually be improved through various interventions (e.g., Griffiths, 2009a, 2009b; Hojdahl, Magnus, Hagen, & Langeland, 2013; Kähönen et al., 2012; Langeland, 2007; Langeland et al., 2013; Langeland, Wahl, Kristoffersen, Nortvedt, & Hanestad, 2007a). Based on the salutogenic model, a straightforward way to affect SOC in children, adolescence, or adults is by directly strengthening GRR and by more indirectly making the interaction with the surrounding environment more harmonious with regard to predictability or consistency (enhancing comprehensiveness), underload–overload balance (enhancing manageability), and participation in shaping outcomes (enhancing meaningfulness; see Antonovsky, 1979, 1987, 1996b). Langeland and her colleagues (e.g., Langeland, 2007; Langeland et al., 2006; Langeland & Vinje, 2013, 2017; Langeland & Wahl, 2009; Langeland, Wahl, Kristoferreson, Nortvedt, & Hanestad, 2007b) have performed some promising interventions, most notably in the form of salutogenic talk therapy, on how to strengthen SOC by targeting crucial GRR, such as social support and self-identity, and by in various ways enhancing comprehensibility, manageability, and meaningfulness. Also, some other empirical studies have shown that various factors, such as, for example, personality (e.g., neuroticism, conscientiousness: see, for example, Feldt, Metsäpelto, Kinnunen, & Pulkkinen, 2007; Hochwälder, 2012; Pallant & Lae, 2002), environment (e.g., negative life events, work conditions: see, for example, Feldt, Leskinen, & Kinnunen, 2005; Kivimäki, Vahtera, Elovainio, Lillrank, & Kevin, 2002; Volanen, Suominen, Lahelma, Koskenvuo, & Silventoinen, 2007), various types of social relationships and support (e.g., parent–child relationship, peer-group relationship: see, for example, Garcia-Moya, Moreno, & Rivera, 2014; Volanen, 2011; Volanen, Lahelma, Silventoinen, & Suominen, 2004; Volanen, Suominen, Lahelma, Koskenvuo, & Silventoinen, 2006), and various types of behavioral and perceptual mechanisms (e.g., empowerment and reflection processes: see Super, Wagemakers, Picavet, Verkooijen, & Koelen, 2016) are related to and can affect SOC. Thus, even though it goes against Antonovsky’s original assumptions that SOC is a generalized disposition which is not susceptible to change in adult age, there are, as mentioned above, studies that have shown that various interventions can have positive effects on SOC, even though it is not totally established how permanent these effect are (see also, for example, Eriksson, 2015b; Eriksson & Lindström, 2007; Lindström & Eriksson, 2005). Because of the positive effects of SOC on (mental) health (for a review, see Eriksson & Lindström, 2006) and quality of life (for a review, see Eriksson & Lindström, 2007), more research is needed regarding to in what way, to what degree, and how permanently SOC can be strengthened in various groups and settings (e.g., Eriksson, 2015b; Suominen & Lindström, 2008).

General SOC versus Domain-Specific SOC

The SOC scale is a general and trait-like measure because it was constructed to measure the generalized and dispositional way the individual perceives his or her world and life (Antonovsky, 1987). SOC—as measured by this scale—is quite often used to predict or explain various variables in a certain domain (e.g., work; see, for example, Albertsen et al., 2001) or to investigate how SOC is affected by an intervention on some variables in a certain domain (e.g., work; see, for example, Kähönen et al., 2012). In these cases, both the predictive power and the sensitivity to change would improve if a domain-specific state-measure of SOC was to be used (cf. Bandura, 1997; Quittner et al., 2012). Thus, when the aim is to study predictive power or sensitivity to change in specific domains, it might be worthwhile in future research to consider using some of the various existing domain-specific measures of SOC (e.g., work: see, for example, Vogt, Jenny, & Bauer, 2013; family: see, for example, Antonovsky & Sourani, 1988; Rivera, Garcia-Moya, Moreno, & Ramos, 2012) and also, if needed, to develop new measures for some other domains (e.g., school, leisure time, spouse relation, parent–child relation).

The Concept of Boundary in the Measurement of SOC

It is clearly stated in Antonovsky’s (1979) salutogenic model that SOC can mobilize GRRs (e.g., coping strategies) to deal with various challenging life events. However, Antonovsky (1987) also assumed that the boundaries we set with regard to which parts of the world and life we consider of importance to us have an effect on our SOC. By restricting the boundaries, so that a particular sector (e.g., working life) is considered as unimportant, that sector will no longer affect our SOC. By widening the boundaries, so that a certain sector is considered as important, that sector will affect our SOC. Furthermore, he suggested that the boundaries can never be restricted so much that the following four sectors are excluded: the person’s own inner feelings, the closest interpersonal relations, the main occupation, and the main existential themes. Antonovsky constructed the SOC scale so that it would include elements from these four sectors. However, Antonovsky (1987) pointed out that in future, it would be wise to include a measure of the boundaries, or in other words, a measure of which sectors of the world and life the person takes into consideration, when assessing his or her SOC. Such a measure of boundaries of SOC has still not been developed and remains a task for future research.

SOC as a Continuous versus a Dichotomized or Trichotomized Variable

Antonovsky (1987) sometimes treats—both theoretically and empirically—SOC as a continuous quantitative variable and sometimes as a dichotomous or trichotomized variable. To dichotomize or trichotomize continuous quantitative variables has its well-known disadvantages (see, for example, Cohen, 1983). However, if there is a not a perfect linear correlation between SOC and some other variable, such as mental ill-health, the question arises as to whether it is a high SOC that protects against mental ill-health or a low SOC that is a risk-factor for mental ill-health. Antonovsky (1996b, p. 16) formulated this problem in the following way: “Is there a linear relationship between SOC and health, or is having a particularly weak (or a particularly strong) SOC what matters?” Eriksson and Lindström (2005, pp. 463-464) have also noted this problem: “It is not clear where SOC no longer protects the movement towards the health end. Knowledge about this is still incomplete.” Lundberg (1996) was even more precise and wondered if it could be the case that a high SOC is not necessarily better for health than a moderate SOC and that it is a low SOC that is especially detrimental for health.

In a longitudinal study by Hochwälder (2015), the results indicated that persons that at Time 1 had a low SOC experienced at Time 2 (approximately 1 year later) more negative life events—which fell into the following three categories: conflict-separation (separation or distance from someone close through a conflict, for example, serious and long-lasting conflict with a close relative); integrity-offensive (an offensive act toward one’s own integrity, for example, bullying); and financial (negative event concerning one’s financial situation, for example, unsuccessful financial transactions)—than persons that at Time 1 had a moderate SOC or a high SOC. No differences between persons with a moderate and a high SOC were found. Thus, these results indicate that what is crucial for frequently experiencing negative life events that fall in those three categories is a low SOC and that there is no difference between those with a high and a moderate SOC. However, it should be noted that for variables other than negative life events (or even for other categories of negative life events), it might be that having a high SOC is what is significant. Super, Verschuren, Zantinge, Wagemakers, and Picavet (2014) found that persons with low SOC had a higher all-cause mortality risk, as compared to persons with moderate SOC, but that there was no difference between persons with moderate SOC and high SOC. Thus, both the study by Hochwälder (2015) and the study by Super et al. (2014) give some preliminary support for Lundberg’s (1996) hypothesis.

In sum, even though there are disadvantages in dichotomizing or trichotomizing SOC, this is justified to be able to investigate whether it is a low SOC or a high SOC that is crucial and also whether this cutoff depends on the variable being studied (e.g., physical health, mental health). This is a problem that deserves to be studied more thoroughly in future research.

The Importance of Relating SOC to Salutogenic Outcomes Measures

Antonovsky’s (1979, 1987) salutogenic perspective focuses primarily on what makes people move toward health and not about how to avoid ill-health. While the salutogenic approach focuses on promoting better health, gains, growth, and maximizing potentials, the pathogenic approach focuses on treating or preventing diseases, pain or loss, becoming worse, and minimizing problems (Becker et al., 2010). It is then logical that the pathogenic approach uses (pathogenic) outcomes measures such as burnout, anxiety, depression, prevalence of various diseases (e.g., cancer, coronary heart diseases), and mortality. Analogically, it would be logical that the salutogenic approach would use more frequently as outcome variables (salutogenic) measures of positive health and well-being. However, in the majority of studies, pathogenic variables are measured as outcome variables, which has as a consequence that the core idea of the salutogenic perspective is not being properly investigated (see Becker et al., 2010). To adequately study the fundamental thought that SOC promotes the movement toward the positive side of the “disease-ease” continuum, the existing salutogenic variables—such as, for example, perceived wellness (Adams, Bezner, & Steinhardt, 1997), wellness promotion (Becker et al., 2009; Becker, Whetstone, Glascoff, & Moore, 2008), mental health (Keyes, 2005), and health-promoting lifestyle (Berger & Walker, 1997; Walker, Sechrist, & Pender, 1987)—should be used more often than the pathogenic variables as outcome measures. If necessary, new scales should be developed to measure various types of salutogenic outcome variables.

Conclusion

Antonovsky’s salutogenic model with its core concept of SOC has become an important complement to the pathogenic model. The salutogenic model provides unique and detailed guidance to research on health and well-being. However, if the model is to continue to make a fruitful contribution to research, then more attention should be given to some theoretical and methodological problems. The present article has highlighted the following seven topics that need to be further explored in the future research on SOC: (a) the dimensionality of the SOC scale, (b) SOC as the causal variable, (c) SOC as the outcome variable, (d) general SOC versus domain-specific SOC, (e) the concept of boundary in the measurement of SOC, (f) SOC as a continuous versus a dichotomized or trichotomized variable, and (g) the importance of relating SOC to salutogenic outcome measures.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jacek Hochwälder

Author Biography

Jacek Hochwälder has an MSc in statistics and a PhD in psychology from Stockholm University (Stockholm, Sweden). At present he works as an associate professor of psychology at Mälardalen University (Eskilstuna, Sweden). He has published over 30 articles and a number of reports, mainly on person-related resistance factors (e.g. sense of coherence) against various forms of mental ill-health (e.g. burnout) and on psychometrics.

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Sense of Coherence: Notes on Some Challenges for Future Research

Abstract

Keywords

Sense of Coherence: Definition and Measurement

SOC: Some Challenges for Future Research

The Dimensionality of the SOC Scale

SOC as the Causal Variable

SOC as the Outcome Variable

General SOC versus Domain-Specific SOC

The Concept of Boundary in the Measurement of SOC

SOC as a Continuous versus a Dichotomized or Trichotomized Variable

The Importance of Relating SOC to Salutogenic Outcomes Measures

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Author Biography

References