Antonovsky: What Keeps People Healthy

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WHAT KEEPS PEOPLE HEALTHY? ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

RESEARCH AND PRACTICE OF HEALTH PROMOTION

BZgA ISBN 3-933191-20-3

THE CURRENT STATE OF DISCUSSION AND THE RELEVANCE OF ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

VOLUME 4 Volume 4

Bundeszentrale für gesundheitliche Aufklärung

WHAT KEEPS PEOPLE HEALTHY?

Publisher: Federal Centre for Health Education

The Federal Centre for Health Education (FCHE) is a government agency, based in Cologne, responsible to the Federal Ministry of Health. Its remit is to design and implement measures aimed at maintaining and promoting health. It develops campaign concepts and strategies, produces summaries of media and methods, cooperates with a variety of workers and agencies in the health education field, and carries out education measures both for the population as a whole and covering selected topics for specific target groups. The FCHE uses research results to plan and implement its work, as well as to evaluate its effectiveness and efficiency. This research includes projects on selected individual topics, evaluation studies, and the commissioning of representative repeat surveys. In order to promote an exchange of information and experience between theory and practice the FCHE holds national and international conferences. These studies and assessments, along with the results of specialist meetings, are published by the FCHE in its specialist booklet series on “Research and Practice of Health Promotion”. This is to be seen as a forum for scientific discussion. The aim of the series – like the existing series on sex education and family planning – is to further extend the dialogue between theory and practice.

Research and Practice of Health Promotion Volume 4

What Keeps People Healthy? The Current State of Discussion and the Relevance of Antonovsky’s Salutogenic Model of Health Jürgen Bengel, Regine Strittmatter and Hildegard Willmann

Expert report commissioned by the Federal Centre for Health Education

Federal Centre for Health Education (FCHE) Cologne, 1999

Die Deutsche Bibliothek – CIP-Einheitsaufnahme Bengel, Jürgen / Strittmatter, Regine / Willmann, Hildegard What Keeps People Healthy? The Current State of Discussion and the Relevance of Antonovsky’s Salutogenic Model of Health / [Publ. by the Bundeszentrale für gesundheitliche Aufklärung (BZgA) Köln.]. - Köln : BZgA, 1999 (Dt. Ausgabe u.d.T.: Was erhält Menschen gesund?) (Research and Practice of Health Promotion ; Vol. 4) ISBN 3-933191-20-3

This volume forms part of the specialist booklet series “Research and Practice of Health Promotion”, which is intended to be a forum for discussion. The opinions expressed in this series are those of the respective authors, which are not necessarily shared by the publisher.

This volume is a translation of the German edition: Bengel, Jürgen / Strittmatter, Regine / Willmann, Hildegard Was erhält Menschen gesund? – Antonovskys Modell der Salutogenese – Diskussionsstand und Stellenwert / Bundeszentrale für gesundheitliche Aufklärung (BZgA) Köln – Köln : BZgA, 1998 (Forschung und Praxis der Gesundheitsförderung ; Bd. 6) ISBN 3-933191-10-6 Order No. 60 606 000

Published by the Bundeszentrale für gesundheitliche Aufklärung (Federal Centre for Health Education - FCHE) Ostmerheimer Str. 220, D-51109 Köln, Germany Tel.: +49(0)221/89 92–0 Fax: +49(0)221/89 92–3 00 E-Mail: [email protected] All rights reserved. Editors: Stephan Blümel, Katharina Salice-Stephan Translated by Debbie Johnson Composition: Salice-Stephan, Cologne Printed by: Schiffmann, Bergisch Gladbach Impression: 1.2.06.99 Printed on 100% recycled paper. This publication can be obtained free of charge from: BZgA, D-51101 Köln, Germany or on the Internet at http://www.bzga.de Order No. 60 804 070

Preface An important task of the Federal Centre for Health Education (FCHE) is to investigate the extent to which new health concepts and models can contribute to the further development of strategies and methods of health promotion. The salutogenesis model conceived by the American-Israeli medical sociologist, Aaron Antonovsky, belongs to the most influential health concepts of the last few years and thus has met with growing interest in persons active in health promotion. For this reason, the FCHE commissioned an expert’s report with the goal of examining the utilisation of this concept for health promotion. In this expert’s report, Jürgen Bengel, Regine Strittmatter and Hildegard Willmann from the University of Freiburg, Germany, present the concept of salutogenesis and compare it to related concepts. They elucidate the current state of empirical foundation, give an overview of the importance and utilisation in diverse areas of application, and conclude with their recommendations. The FCHE presents this booklet, the fourth in the series “Research and Practice of Health Promotion”, as an additional contribution to the discussion on suitable concepts and strategies for the promotion of health and their continuous increase in quality.

Cologne, November 1998

What Keeps People Healthy?

Dr. Elisabeth Pott Director of the Federal Centre for Health Education

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Outline of the Study

Project title:

Antonovsky’s Salutogenic Model of Health. Current State of Discussion and Relevance

Goals:

• Examination of the literature • Evaluation of the concept of salutogenesis with respect to its application to health promotion

Material:

Research monographs Journals Textbooks

Sources:

Literature search in the databases Psyndex, Psyclit, Medline (1990–1998), Current Contents (1993–1997), Dissertations Abstracts (1989–1997), WISO III, PAIS, Social Sciences Index, ERIC; Internet searches.

Implementation period:

September 1997 – February 1998

Project implementation: Psychological Institute of the University of Freiburg, Dept. of Rehabilitation Psychology Belfortstrasse 16 D-79085 Freiburg Tel.: +49(0)7 61/2 03 30 46 Fax: +49(0)7 61/2 03 30 40 Project management:

Prof. Dr. Dr. Jürgen Bengel

Authors:

Prof. Dr. Dr. Jürgen Bengel, Dipl.-Psych. Dr. Regine Strittmatter, Dipl.-Psych. Hildegard Willmann, Dipl.-Psych.

Sponsor:

Bundeszentrale für gesundheitliche Aufklärung (Federal Centre for Health Education – FCHE) Ostmerheimer Str. 220 D-51109 Köln Tel.: +49(0)221/89 92-3 28 Fax: +49(0)221/89 92-3 00

Project management:

Stephan Blümel

What Keeps People Healthy?

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Contents Introduction

9

1.

Historical Background

13

2.

The Concept of Salutogenesis

21

2.1.

The Salutogenic Problem

22

2.2.

Criticism of Health Research and Health Care

24

2.3.

The Salutogenic Model of Health

25

2.3.1. The Sense of Coherence

26

2.3.2. The Health Ease/Dis-ease Continuum

29

2.3.3. Stressors and Tension

29

2.3.4. Generalised Resistance Resources

31

2.3.5. An Overview of the Salutogenic Model

32

Current State of Research

37

The Sense of Coherence: State of Empirical Foundation

38

Sense of Coherence as Compared to Related Concepts

49

Stress and Resilience Research

56

3. 3.1.

3.2.

3.3.

What Keeps People Healthy?

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Importance and Utilisation of the Concept in Different Areas of Application

61

4.1.

Health Promotion and Prevention

63

4.2.

Psychosomatics and Psychotherapy

66

4.3.

Rehabilitation

70

5.

Summary

75

5.1.

Summary and Evaluation of the Scientific Discussion

76

5.2.

Summary and Evaluation of the Importance and the Utilisation of the Concept

84

Outlook and Recommendations

87

Appendix

93

6.1.

Documentation of the Literature Search

94

6.2.

Original Works by Antonovsky

95

6.3.

References

97

6.4.

Overview of the Studies on the Sense of Coherence

105

6.5.

Orientation to Life Questionnaire (SOC-Scale)

124

4.

5.3.

6.

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Introduction The subject of salutogenesis has attracted a lot of attention in the social sciences and in medicine recently, especially in the fields of prevention and health promotion. The American-Israeli medical sociologist, Aaron Antonovsky (1923–1994), introduced this concept to the health sciences and public health care. He criticised an exclusively pathogenic-curative approach and juxtaposed it against a salutogenic orientation arguing that the question, why people stay healthy, should have priority over the question of the causes of disease and their risk factors. The salutogenic orientation primarily explores the conditions of health and the factors that protect health and contribute to invulnerability. It focuses on the factors which maintain health. In part, one is beginning to speak of a paradigm shift from a disease-centred model of pathogenesis to a health-centred, resource-oriented model of salutogenesis aimed at prevention. The concept of salutogenesis was put forth by A. Antonovsky in his two main books, “Health, stress and coping: New perspectives on mental and physical well-being” (1979, San Francisco, Jossey-Bass) and “Unraveling the mystery of health. How people manage stress and stay well” (1987, San Francisco, Jossey-Bass). In German-speaking countries, three volumes were published on the subject in 1997: A. Antonovsky, “Salutogenese: Zur Entmystifizierung der Gesundheit” (Salutogenesis: Unravelling the Mystery of Health), expanded edition by A. Franke (Tübingen, dgvt-Verlag), H. H. Bartsch & J. Bengel (Eds.), “Salutogenese in der Onkologie” (Salutogenesis in Oncology) (Basel, Karger), and F. Lamprecht & R. Johnen (Eds.), “Salutogenese – Ein neues Konzept in der Psychosomatik?” (Salutogenesis – a New Concept in Psychosomatics?) (Frankfurt, VAS). In 1998, two additional books followed: W. Schüffel et al. (Eds.), “Handbuch der Salutogenese. Konzept und Praxis” (Handbook of Salutogenesis. Concepts and Application) (Berlin/Wiesbaden, Ullstein & Mosby), and J. Margraf, J. Siegrist & S. Neumer (Eds.), “Gesundheits- oder Krankheitstheorie?” (Health or Disease Theory?) (Berlin, Springer). It is remarkable that Antonovsky’s views on salutogenesis were not taken up in the health care discussion until some time after the publication of his two main books on the subject in 1979 and 1987. Put simply, two general tendencies can be observed in the reception of his ideas and theses: Some authors as well as critics of the health care system address this concept, using it as a means of embellishing their own position. In such cases, long-established practices in health promotion are termed “salutogenic”, as are innovative preventive measures. Other authors conduct empirical studies specifically on the sense of coherence. They examine the extent to which the concept can be investigated methodically, the particular interactions that coincide with characteristics of mental and physical health and disease, or whether it can be used as an indication of success in the fields of psychotherapy and psychosomatic medicine. What Keeps People Healthy?

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The Federal Centre for Health Education planned to examine the extent to which a salutogenic orientation can open new opportunities for intervention and action in the promotion of health. For this purpose, it advertised an expert report on the subject of salutogenesis to discuss the status of the salutogenic model and its possible consequences for the practice of health care: “The expert report should provide an overview and an evaluation of the writings with respect to the concept’s application to the promotion of health.” This report by our working group describes Antonovsky’s concept of salutogenesis and documents its scientific treatment. We have attempted to make the basic ideas of the concept understandable and present them within the context of the historical development of the health sciences. The report was written to provide a clear, concise answer to the following questions: – – – –

What are the central statements and assumptions of the model? What importance do the health sciences attach to this concept? Which empirical evidence is available to support the concept? Which conclusions can be drawn for research and for medical, psychosocial and preventive care?

The material for the expert report was obtained by means of a thorough literature check in germane data banks as well as in the Internet: The following sources were examined under the search words “salutogenesis, salutogenic, sense of coherence, Antonovsky”: Psyndex (1990–1998), Psyclit (1990–1998), Medline (1990–1998), Current Contents (1993–1997), Dissertations Abstracts (1989–1997), WISO III, PAIS, Social Sciences Index and ERIC. In addition, we looked through health science journals and textbooks under the entry “salutogenesis”. The report is divided into a main text and a documentation of the sources. The first three chapters of the text are dedicated to the formulation of the theoretical background and the current research. Chapter 1 depicts the historical background of the salutogenic model. Chapter 2 introduces the concept of salutogenesis and Chapter 3 describes the current state of research. With respect to the status and the application of the concept (Chapter 4), three different applications are introduced: health promotion and prevention (Section 4.1.), psychosomatic medicine and psychotherapy (Section 4.2.) and rehabilitation (Section 4.3.). The last chapter, Chapter 5, contains a summary of the expert report and an evaluation of the concept. It summarises the discussion introduced in the first three chapters as well as the status and the merits of the concept and concludes with an outlook and recommendations. A bibliography of the literature used for the expert report can be found in Chapter 6 along with a bibliography of the works by Antonovsky. In addition, the empirical studies cited in Chapter 3 on the sense of coherence are presented in a table. The questionnaire on life-orientation (SOC-scale) appears in the final section.

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The authors have attempted to make the material easily understandable to the target audience. Technical terms have been explained where necessary. Chapter 3 on “Current Research” could not quite meet this demand, since in this case research methodological terms and jargon had to be used which were indispensable in describing and discussing the topics adequately. We would like to thank Dr. Michael Broda (Bad Bergzabern), Prof. Dr. Rainer Hornung (Zurich, Switzerland), Prof. Dr. Friedrich Lösel (Erlangen) and Prof. Dr. R. Horst Noack (Graz, Austria) for valuable advice as well as Dr. Martina Belz-Merk, Dipl. Psych. Ulrike Frank, cand. phil. Marcus Majumdar and cand. phil. Christian Schleier (all in Freiburg) for important additions and comments.

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1

Historical Background

1.

Historical Background

Before we illustrate the concept of salutogenesis in Chapter 2, we will first describe the historical background and the context in which Aaron Antonovsky formulated his deliberations and conducted his research. The model of salutogenesis and Antonovsky’s theses can only be understood when viewed against the background of the developments and trends in health care and in the health sciences of the past 50 years. To this end, the following developments, which took place concurrently, will be described: – – – –

the criticism of the health care system, the examination of the concepts of health and disease, the development of a biopsychosocial model of disease, the changes in the prevention and the promotion of health.

In addition, events in Antonovsky’s life certainly had an influence on the conception of the model of salutogenesis and will be briefly outlined at the end of this chapter.

Criticism of the Health Care System Our health care system or our treatment of disease is formed by thinking and actions which are often characterised as a pathogenic orientation: this view focuses on the patient’s complaints, symptoms or pain. All efforts made by the medical system, the physicians and the therapists are aimed at eliminating the symptoms and the complaints as quickly as possible. Patients expect a great deal from the possibilities of the medical care system. In the past decades, impressive achievements in the diagnosis and therapy of many illnesses have been made. Nevertheless, the criticism of the technological institutionalisation of medicine and the primary focus on the symptoms of disease have increased in the past few years. As the field of medicine becomes increasingly technical, it has been deplored as being impersonal, that is, accused of neglecting the whole person. Furthermore, critics consider our health care system to be too expensive, feel that it cannot handle the increase in chronic illnesses, and is not sufficiently concerned with ethical questions. “Communicative medicine” is in demand, which is not only oriented toward disease and handicaps diagnosed at high technical expense. The field of medicine should attach more importance to the dialogue between the physician and the patient, while devoting attention and support to the patient’s healthy components. In addition to the results of medical tests on organs, those psychosocial aspects of importance to the adjustment to the illness and its cure should get special attention. For example, how does the patient feel, what kind of surroundings does he or she live in, how does he or she cope with the illness? The criticism of our medical care system goes hand in hand with a discussion on the con-

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cepts of health and illness and an understanding of the causes of disease, its cure or alleviation. This has grown complex.

The Examination of the Concepts of Health and Disease At first glance, the concepts of “disease” and “health” seem to be clearly defined. “Health” can be described by well-being and the absence of complaints and symptoms. In contrast, “disease” is associated with complaints, pain and limitations. A closer look, however, reveals that the concepts of health and disease can be defined quite differently both personally as well as socially. For some, “health” is a synonym for well-being and happiness. Others consider it merely the absence of symptoms. Yet others consider health to be the capability of the organism to cope with stress and strain. These subjective notions develop in the course of the socialisation of every individual within a specific social context and climate. The perception of physical complaints is influenced by social and individual judgements. This assessment is not independent of the severity of the symptoms; however, the perception of personal and social resources has a decisive influence on the subjective condition and the health-related behaviour of the individual. Definitions of Health There are a number of approaches to defining health and disease. They are oriented on different health norms. The particular definitions of health and disease have a significant influence on which means are considered appropriate and necessary for the restoration, the maintenance and the promotion of health. This is essential, since these specifications determine the amount and type of influence and responsibility for the emergence of the disease and its cure that can or should be attributed to the patient (extent of selfresponsibility). An ideal norm of health depicts a state of perfection, whose attainment is desirable or valuable. By defining health as a state of complete psychological and physical well-being, the World Health Organisation established an ideal norm (WHO, 1948). However, such a definition must accept the reproach of being unrealistic, since such absolute states are not attainable. The statistical norm of health is determined by the frequency of a characteristic of the organism: whatever holds for the majority of humanity is defined as healthy. Deviations from these average values are considered to indicate disease. The classification of a person as either ill or healthy thus requires a reference group, for factors as age and gender as well as the predetermined value ranges. “Health” as a functional norm is based on the person’s ability to fulfil his or her role in society. In turn, the determination of functional norms requires the validity of superior hierarchical values (see Erben, Franzkowiak & Wenzel, 1986; Wetzel, 1980). In general, the definitions of health within the medical system are negative, i.e., “health” is described as the absence of disease. Consequently, the patient is classified as ill when What Keeps People Healthy?

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complaints and symptoms are present. This concept shared by experts, physicians and therapists collides with the ideas of health and disease of so-called laypersons, namely the patient. A pure biomedical perspective neglects important dimensions of the patient’s condition, such as life satisfaction and well-being. Persons with physical injuries can also be considered healthy under psychological aspects, if they can retain their ability to enjoy and perform. Thus “health” is not an unequivocally defined construct, but rather one that is difficult to grasp and to describe. In the social sciences and the medicine of today, it is unanimous that health must be seen multidimensionally: it includes not only physical well-being (e.g. a positive body feeling, absence of complaints or signs of disease) and psychological well-being (e.g. joy, happiness and life satisfaction), but also performance, self-realisation and a sense of meaningfulness. Health depends on the existence, on the perception and on the means of dealing with stress and strain, on risks and on hazards in the social and ecological environment, on the existence, on the perception, on the tapping and on the use of resources. The proposals now being made by the social sciences to define the phenomenon of health are distinguished by a complexity that can be considered new.

The Development of the Biopsychosocial Model of Disease The Biomedical Model of Disease At the outset of the 19th century, under the influence of the thoughts of the natural sciences, a concept of disease emerged that is called the biomedical model of disease (see Faltermaier, 1994). This model assumes that the human body is comparable to a machine. Its functions and functional disorders can best be understood when the organ systems and structures as well as the physiological processes are analysed as precisely as possible. Symptoms of disease (physical complaints, physical changes but also psychological irregularities) can be explained by organic defects. These anatomical or physiological defects make up the actual illness. The source of the defect was thought to originate from a limited number of causes as it is the case of viruses or bacteria. Decisive is the recognition of the defect and the search for a means to reverse or “repair” it. These assumptions determine the treatment of physical symptoms. The definition according to which a person could be classified as ill or not depends on whether anatomical or physiological changes can be determined. The ill person in the form of a subject and an agent is virtually excluded. He or she is a passive object of physiological processes, over which his or her psychological and social reality has no influence. Medical research which adheres to this model concentrates on the discovery of yet unknown defects and the proof that they are the cause of the disease. The medical treatment aims at repairing the defect. This concept of disease led to great medical progress in many areas, such as the treatment of metabolic disorders or the battle against infectious illnesses.

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Broadening the Biomedical Model Criticism of the biomedical model of disease was raised quite early and triggered heated debates in the 1970’s. The social medical scientist, Engel (1979), contrasted this model with an expanded biopsychosocial model, in which both somatic as well as psychosocial factors were used to explain the origin and the progression of disease. Research in the social sciences, psychology and psychosomatics demonstrates that psychological and social factors are relevant to the emergence and the progression of disease. They also influence the diagnosis and the treatment of disease. Even the perception of symptoms, the experiencing of pain, the decision to undergo medical treatment, and to follow doctor’s orders, to name only a few examples, are significantly influenced by psychological and social factors. Research on psychobiological coping and stress began to look at the protective resources, for example within the immune system, which the organism can activate during stressful conditions. It does not follow a pure vulnerability concept which examines how psychological stressors become detrimental under psychophysiological processes. Nowadays, in the interdisciplinary field of the health sciences, many disciplines such as medical psychology, the psychology of health, behavioural medicine and psychoneuroimmunology are involved. Psychoneuroimmunology is a relatively new field of research that integrates the knowledge and the methodology of psychology and different medical subdisciplines to examine which interactions between different systems of the body exist, such as the central and the autonomic nervous system, the hormone system and the immune system (Schulz, 1994). Broadening the biomedical model to include psychological causal factors is not, however, necessarily associated with a completely new orientation in the discussion on health. Indeed, the phrasing of biopsychosocial models is often oriented on a deficit model of humans as well. This tendency becomes apparent in the face of the political demands made regarding prevention concepts and the measures taken by health policies. At first glance, this seems to be a new orientation which is moving away from a curative system. However, a closer look reveals that the pragmatic concepts of prevention which can be subsumed under the concepts of early detection and health education have been shaped by medical thinking, even though health education in particular requires knowledge of psychology (Borgers, 1981; Oyen & Feser, 1982). Despite the diverse criticism and the fact that the importance of psychosocial and cultural factors has been established, the biomedical model of disease still dominates institutional medicine and prevention today.

The Development of Prevention and Health Promotion Throughout the history of medicine, efforts have been made to prevent disease. Measures taken to improve hygienic conditions and large-scale immunisation programmes, such as those introduced following World War II, are of great importance for the development What Keeps People Healthy?

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of society. In the meantime, preventive measures focus on the prevention of chronic degenerative disease and so-called civilisational disease. The Risk Factor Model The basis for preventive measures is still the risk factor model. This model was developed in the 1950’s in conjunction with the results of epidemiological studies and statistics from life insurance agencies in connection with coronary heart disease. Correlations between risk factors such as high lipid levels, tobacco consumption, obesity, psychological stressors and the incidence of coronary heart disease were demonstrated. The chance of having a heart attack increases with the number of risk factors present, especially for men. As is the case for any statistical model, such predictions actually apply to only a certain percentage of the persons examined. In other words, the coincidence (the correlation between risk factors and disease) does not allow a causal interpretation or prediction to be made for a given individual as to the morbidity (the frequency or chance of getting a certain disease) or the mortality (the frequency or the chance of dying from a certain disease). The effects of risk factors are not compulsory for each individual; they merely indicate an increased chance of developing the disease. Some research results on the significance of different risk factors and their interactions as well as the determination of critical values (At which point does a risk factor become dangerous?) and length of exposure (How long must a risk factor be present?) are contradictory. Since risk factors can be considered beginning diseases, measures of prevention concentrate on the avoidance of risk factors and on individual changes in behaviour. Thus far, the risk model contains predominantly behaviour-related risk factors (i.e., smoking, overweight or high blood pressure), whereas context and circumstantially related factors, such as chronic work pressure or environmental influences, are still largely neglected (see Franzkowiak, 1996, for a summary). As a consequence, the realisation of this model focuses mainly on individual changes in behaviour. Health Promotion Programme Since 1978, when the WHO Conference in Alma Alta ambitiously proclaimed “Health for all by the year 2000”, the aim to supplement the biomedical risk factor model and all it implies has been part of the agenda. The WHO introduced the Health Promotion Programme in the Ottawa Charter, whose key features can be characterised by the concept of lifestyles (Franzkowiak & Wenzel, 1982; Federal Centre for Health Promotion, 1983). The promotion of health as a social-ecological health and prevention model does not view health as a goal, but rather as a means of enabling positive shaping of individual and social life. Preventive measures are thus not prescribed by the professional system. They are targeted at active and responsible participation of the layperson in the establishment of health-promoting conditions and at collaboration between laypersons and professionals.

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With this goal, health promotion is similar to the empowerment approach which grew out of American communal psychology (Rappaport, 1985; Stark, 1996). “Empowerment” refers to the strengthening of competence, responsibility and resourcefulness of persons or groups. In this way, the promotion of health is a task which changes politics and society, which however does not make implementing the goals any easier. The health promotional approach continues the above-mentioned developments in the understanding of health and disease. It is based on a complex, multidimensional concept of health and is founded on a biopsychosocial model of disease. In addition to individualrelated approaches, this concept of health promotion primarily stresses the necessity of structural changes. Broadening the classic risk factor model to include psychosocial determinants as well as surroundings and circumstances, and developing a theory of the combined effects of risk and protective factors, fit the demands of health promotion and the principles of the stress-coping models.

A. Antonovsky’s Biography Aaron Antonovsky was born in the USA in Brooklyn, New York in 1923. After his military service in World War II, he completed his doctoral thesis in sociology. At this time, he was interested in culture and personality, social class-specific problems and ethnic relations (Antonovsky, 1979). In 1960, Antonovsky emigrated to Israel with his wife, Helen, and accepted a post at the Israel Institute for Applied Social Research in Jerusalem. Rather accidentally, he became interested in medical sociology by taking part in several different research projects in this field, including an epidemiological study on multiple sclerosis. In the course of the years following, he taught in the department of social medicine and worked on different research projects on the connection between stress factors and health or disease. In keeping with Lazarus (1966), Antonovsky began to support a stress concept in which stressors are not automatically considered to lead to disease. In his concept, stressors are viewed as stimuli that can trigger a state of tension which must not necessarily lead to stress. Thus Antonovsky's social epidemiological research was a preliminary for his psychological examination of individual processing patterns in the face of tension. In this context, Antonovsky rejected the idea of a specific effect of stressors and supported the opinion that the type of disease is determined by individual dispositional vulnerability and not by the profile of the stressful influences. Decisive for his further research were ideas that Antonovsky developed on the basis of a study of adaptation to climacterium in women of different ethnic groups. One of these groups consisted of women who had been born between 1914 and 1923 in central Europe and some of them were interned in concentration camps. As expected, the group of conWhat Keeps People Healthy?

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centration camp survivors exhibited significantly more signs of ill health than the women in the control group. However, as many as 29%(!) of the former prisoners claimed to be in relatively good mental health despite these traumatic experiences. Antonovsky wondered how these women managed to stay healthy despite this extreme toll on their health. This change in perspective influenced all his subsequent research. In the period following, he published many theoretical and empirical articles on the concept of salutogenesis. Particularly noteworthy are two books which he wrote in 1979 and 1987. In addition to his research, Antonovsky helped to found a community-oriented school of medicine in Beer Sheba, Israel. He returned to the USA twice as a visiting professor, from 1977 to 1978 and from 1983 to 1984. Antonovsky died at the age of 71 in 1994.

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2

The Concept of Salutogenesis

2.

The Concept of Salutogenesis

The goal of this chapter is to illustrate the basic ideas of salutogenesis and the salutogenic model of health. For this purpose, we will focus on Antonovsky’s original literature. Unless otherwise specified, the portrayal is based on Antonovsky’s book, “Unraveling the mystery of health”, published in 1987, which has been available in German since 1997, edited by A. Franke. First, the main questions of Antonovsky’s works will be presented. Then, the salutogenic model of health will be introduced, which centres around the construct of “the sense of coherence”.

2.1.

The Salutogenic Problem

Why do people stay healthy despite so many detrimental influences? How do they manage to recover from illnesses? What is special about people who do not get ill despite the most extreme strain? These are the central questions that served as the point of departure for Antonovsky's theoretical and empirical work. Antonovsky coined the term, “salutogenesis” (salus, Latin for “invincibility”, “well-being”, “happiness“; genese, Greek for “genesis”, “origin”) to emphasise its distinction from “pathogenesis” which has dominated the biomedical approach, the current model of disease, and also the risk factor model. Salutogenesis means not only the other side of the coin as compared to a pathogenicallyoriented perspective (Antonovsky, 1989). Thinking pathogenically means examining the origin and the treatment of disease. Salutogenesis does not refer to the opposite in the sense that it is devoted to the origin and maintenance of health as an absolute state. Rather, it refers to the fact that all people are to be considered more or less healthy while at the same time being more or less ill. Thus the question here is: How does a person become healthier and less ill? Antonovsky used a metaphor to compare the predominant thinking and action premises of medicine with the salutogenic perspective. The pathogenic approach is aimed at rescuing people at great expense from a raging river, without taking into consideration how they got in there and why they are not better swimmers. In contrast, seen from the perspective of health education, people jump into the river of their own volition, while at the

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same time refusing to learn to swim. Antonovsky applied another version of this metaphor to describe salutogenesis: “... my fundamental philosophical assumption is that the river is the stream of life. None walks the shore safely. Moreover, it is clear to me that much of the river is polluted, literally and figuratively. There are forks in the river that lead to gentle streams or to dangerous rapids and whirlpools. My work has been devoted to confronting the question: ‘Wherever one is in the stream – whose nature is determined by historical, social-cultural, and physical environmental conditions – what shapes one’s ability to swim well?’” (Antonovsky, 1987a, p. 90).

2

These images illustrate the different levels that characterise Antonovsky’s work and also the discourse on his ideas. The metaphor of the river as a symbol for life, and the idea that a person is always swimming in a more or less dangerous river, reflects his philosophical views. Research questions can be posed and phrased very differently depending on whether one intends to examine who will drown first, what is necessary to rescue someone from drowning or whether one asks which factors facilitate swimming. Whether people are rescued shortly before drowning or the course of the river is tamed or the people are taught to swim all depends on the public health care policies. The individual ability to swim is analogous to a personality disposition which Antonovsky called a “sense of coherence” (see Section 2.3.1.). His psychological model of health is a product of linking the various characteristics of the river and the people swimming in it. Antonovsky’s views on the origin of health were influenced by systems theoretical considerations. Health is not a normal, passive state of balance, but rather an unstable, active and dynamic self-regulating process. The basic principle of human existence is not balance and health but imbalance, disease and suffering. Disorganisation and the tendency toward entropy is omnipresent. “The human organism is a system and, like all systems, it is at the mercy of the power of entropy” (Antonovsky 1993a, p. 7). The concept of entropy is borrowed from thermodynamics and refers to the tendency of elementary particles to move to a state of increasing disorder. The lesser this tendency, the more order and organisation the system possesses. This capacity of a system toward organisation is termed negative entropy. In a figurative sense, Antonovsky employed the concept of entropy as an expression for the ubiquitous tendency of human organisms to lose their organised structure, but also the ability to reorder it again. Applied to one’s state of health, this means that health must constantly be re-established and that at the same time the loss of health is a natural and ubiquitous process. “The salutogenic approach regards the battle towards health as permanent and never quite successful” (Antonovsky, 1993a, p. 10). Antonovsky admitted that his weltanschauung tends to be pessimistic in this context (Antonovsky, 1987b).

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2.2.

Criticism of Health Research and Health Care

Antonovsky criticised the basic assumptions of western medical research and practice and contrasted them with the fundamentals of his salutogenic views. Nevertheless, he did not intend to dispense with pathogenically-oriented questions of medical research, but rather he regarded the salutogenic outlook as an important and indispensable counterpart. Salutogenesis and pathogenesis are complementary in their approaches. In the biomedical model, disease is seen as a deviation from the norm of health. This assumption is not tenable, or at least is not valid as the sole standard for the definition of health. Epidemiological data demonstrate that at least a third, perhaps even the majority of the population of a modern industrial society suffers from some illness (Antonovsky, 1979). When discussing health and disease, it is usually assumed that these two states are mutually exclusive, that is, that only one of the two states is present at any one time. According to this dichotomy, one is either healthy or ill. The classification is made according to a physician’s diagnosis, who finds a specific illness, or by the patient himself or herself and his or her environment. People who are classified as healthy are left unnoticed by the public health care system, after medical check-ups and early detection examinations. Antonovsky juxtaposed this dichotomy with a continuum he calls the “health ease/dis-ease continuum” on which people can be rated as more or less ill or healthy (see Section 2.3.2.). Modern medicine’s view of disease is based on a mechanistic model (see Chapter 1.). Defects that arise from noxious influences must be identified and eliminated by welldirected treatment. In this approach, disease is generally seen on the level of specific pathological processes. In the pathogenic paradigm, there are specific pathogenic conditions and agents for each illness, such as bacteria, viruses, etc., but also stressors and risk factors. The treatment consists largely of combating them. Antonovsky, however, directed his interest not toward specific symptoms, but rather toward the fact that an organism can no longer retain its order. He was not concerned with the exact type of disorder in this case and, with this in mind, coined the term organism “breakdown” (Antonovsky, 1972). Instead of exclusively combating pathogenic agents, the salutogenic approach aims at strengthening resources to make the organism more resistant to weakening influences. This resource-oriented thinking calls for taking into consideration the entire person with all of his or her life experience as well as the entire system in which the person lives (Antonovsky, 1993b). A person’s individual story is important because only in the awareness of a person’s life situation can the resources that contribute to recovery be found and fostered.

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“In science, the question is more important than the answer” (Antonovsky, 1993a, p. 18) and “...how one poses the question is crucial to the direction one takes in looking for the answers” (Antonovsky, 1979, p. 12). These two statements point out that his scientific work distinguishes itself from others mainly by the formulation of the thesis and the perspective taken. The concept of salutogenesis represents a criticism of a one-sided orientation of the research on detrimental living conditions and pathogenic factors. He repeatedly demonstrates that questions posed within the framework of pathogenicallyoriented research have “blind spots”. Salutogenically-oriented research examines questions such as, “Who are the Type A’s who do not get coronary disease? Who are the smokers who do not get lung cancer?” (Antonovsky, 1987a, p. 10). Pathogenically-oriented research compares patients with control groups that can be considered healthy, since they do not have a certain illness (see Section 3.3.). However, they might suffer from other illnesses that go undetected. In contrast, a salutogenic approach considers illnesses to be non-specific and asks why people stay healthy and which characteristics and skills distinguish them from others. For this purpose, a great deal more than merely the disease-related information must be registered.

2.3.

The Salutogenic Model of Health

In his salutogenic model of health, Antonovsky linked a number of constructs with the origin or maintenance of health. The striking thing about his model of health is that he did not formulate a definition of health. He claimed that he is not interested in explaining health either as an absolute or an ideal concept, since this does not correspond to the true conditions (Antonovsky, 1979). Furthermore, as he saw it, a definition of health always requires the establishment of norms and thus risks judging others according to values that do not apply to them (Antonovsky, 1995). The heart of the model, the sense of coherence, will be presented first in Section 2.3.1. Further elements are the health ease/dis-ease continuum, Section 2.3.2., stressors and states of tension, Section 2.3.3., and the generalised resistance resources, Section 2.3.4. Section 2.3.5. provides an overview of the model and the links between the components.

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2.3.1.

The Sense of Coherence

According to Antonovsky, a person’s state of health or disease is determined to a significant extent by an individual, psychological factor: an individual’s general attitude toward the world and his or her own life – a weltanschauung, as he once put it using the German word (Antonovsky, 1993d, p. 972). Antonovsky realised that external factors, such as war, starvation or poor hygienic conditions, can be detrimental to health. Yet even when exposed to the same external conditions, different people are in different states of health. Thus, to his mind, if the external conditions are comparable, then the individual state of health depends on how pronounced one’s cognitive and affective-motivational outlook on life is, which in turn influences the extent to which one is in a position to utilise the resources available to maintain one’s health and well-being. Antonovsky termed this basic outlook on life sense of coherence (SOC). “Coherence” means consistency, congruence and harmony. The more pronounced a person’s sense of coherence, the healthier he or she should be and the more quickly will that person regain health and remain healthy. In his first formulation, Antonovsky defined the sense of coherence as: “...a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected” (Antonovsky, 1979, p. 10). The adjective “dynamic” refers to the fact that this outlook on life is constantly encountering new life experiences and is influenced by them. In turn, the degree of SOC influences the kind of life experiences. As a result, life experiences tend to confirm the basic orientation to life, which thus becomes stable and enduring. The strength of the SOC is independent of the circumstances, the social roles that one currently fulfils or is expected to fulfil. For this reason, Antonovsky referred to this outlook on life as a dispositional orientation (a relatively enduring characteristic). It does not, however, stand for any particular personality trait. According to Antonovsky, this basic attitude of experiencing the world as coherent and meaningful is made up of three components: 1. The sense of comprehensibility This component describes the expectation or the ability of the person to process both familiar and unfamiliar stimuli as ordered, consistent, structured information and not to be confronted with stimuli that are chaotic, random, accidental and inexplicable. The term “comprehensibility” is used in the sense of a cognitive processing pattern.

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2. The sense of manageability This component describes a person’s conviction that difficulties are soluble. Antonovsky also called this “instrumental confidence” and defined it as “...the extent to which one perceives that resources are at one’s disposal which are adequate to meet the demands posed by the stimuli that bombard one” (Antonovsky, 1987a, p. 17). The extent of one’s sense of manageability does not necessarily depend on one’s own resources and competencies. It also subsumes the belief that other people or a higher power will help one to overcome difficulties. Someone who lacks this conviction is like a “sad sack” or “shlimazl” who invariably experiences unfortunate events without being able to do anything about them. Antonovsky considered the sense of manageability as a cognitive-emotional processing pattern. 3. The sense of meaningfulness This dimension describes “...the extent to which one feels that life makes sense emotionally, that at least some of the problems and demands posed by living are worth investing energy in, are worthy of commitment and engagement, are challenges that are ‘welcome’ rather than burdens that one would much rather do without” (Antonovsky, 1987a, p. 18). Antonovsky considered this motivational component to be the most important. Without the experience of meaningfulness and without positive expectations towards life, there will not be a high SOC value despite the pronouncement of the other two components. A person who does not experience meaningfulness will perceive life as a burden and consider each new task as additional agony. The distinction between the three components becomes clearer in the second definition of the SOC: “The sense of coherence is 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, 1987a, p.19). A pronounced sense of coherence enables a person to react flexibly to demands. He or she can activate the appropriate resources for specific situations. In contrast, a person with a weakly developed SOC would react to demands in a strong and rigid manner, since he or she perceives himself or herself as having less coping resources. The SOC works as a flexible directing principle, as a conductor who orchestrates the implementation of different coping styles according to the demands to be met. “What the person with a strong SOC does is to select the particular coping strategy that seems most appropriate to deal with the stressors being confronted” (Antonovsky 1987a, p. 138). What Keeps People Healthy?

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The SOC is thus not a particular coping style, but rather is situated higher up in the hierarchy and has a guiding or regulating function (Antonovsky, 1993d).

Development and Change According to Antonovsky, the SOC develops in the course of childhood and youth and is influenced by the experiences gathered. In adolescence, greater changes are still possible, since the adolescent has many open choices and many areas of life have not yet been established. In his opinion, the SOC is fully developed by the age of 30 and remains rather stable. Without explicitly mentioning them, Antonovsky explained the formation of the SOC with Piaget’s (1969) principles of assimilation and accommodation: external changes influence and modify internal perceptions. On the other hand, because of the pre-existing life views, familiar realms of experiences are preferably sought, so that these tend to confirm the pre-existing. The comprehensibility component is formed by experiences of consistency. Since stimuli and experiences do not occur in an arbitrary, contradictory and unpredictable manner, they can be classified, categorised and structured. Manageability develops through experiencing balanced strain, i.e., the person experiences neither overload nor underload. Meaningfulness is fostered by the feeling of having influence on the shaping of situations. According to Antonovsky, whether a strong or weak SOC develops, depends on the circumstances in society, that is, on the availability of generalised resistance resources (see Section 2.3.4.) (Antonovsky, 1993a). When generalised resistance resources are present which allow repeated, consistent experiences and permit participation in shaping outcome, as well as a balance between overload and underload, then a strong SOC will develop over time (Antonovsky, 1993a). Experiences that are predominantly characterised by unpredictability, uncontrollability and uncertainty will lead to a weak SOC. This does not mean, however, that a person must never experience uncertainty and unforeseen events in order to acquire a strong SOC. The development of a strong SOC requires a balance between consistency and surprise, between rewarding and frustrating events. Antonovsky considered a fundamental change in the SOC to be limited in adults. If at all, a radical change in the social or cultural influences or in the structural living conditions can lead to a significant change in the SOC. Examples of radical changes, which greatly change the resources and opportunities available up to that point or lead to many unexpected experiences, are emigration, a move to a new community, the birth of a child, changes in marital status or in employment. Psychotherapy might also induce a change, but this requires hard and continuous work (Antonovsky, 1979) “...it is utopian to expect that an encounter, or even a series of encounters, between client and clinician can significantly change the SOC” (Antonovsky 1987a, p. 118).

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2.3.2.

The Health Ease/Dis-ease Continuum

As mentioned above, Antonovsky criticised the common healthy/sick dichotomy (see Section 2.2), with which scientific medicine and the medical care system work; in particular, health insurance companies must orient themselves on these categories. Antonovsky juxtaposed this division with the conception of a continuum with the poles ease (health) and dis-ease (illness). The end poles, complete health or complete disease are not attainable for living organisms. Every person, even though he or she experiences himself or herself as healthy, also has unhealthy components and as long as a person is still alive, parts of him or her must be healthy: “We are all terminal cases. But so long as there is a breath of life in us, we are all in some measure healthy” (Antonovsky, 1987a, p. 50). The question is no longer whether one is healthy or ill, but how far or how close one is to one of the end poles of health ease and dis-ease. In addition, Antonovsky assumed that there are a number of other conditions or dimensions that can also be viewed as continuums and which correlate with the ease/dis-ease continuum. For his thesis question, it is important to distinguish between physical condition and these other dimensions of well-being/discomfort. He placed the aspect of physical health in the centre of his model (Antonovsky, 1979).

2.3.3.

Stressors and Tension

One problem germane to stress research is the definition of stressors: stressors are all stimuli which engender stress. Whether or not a stimulus is a stressor, can only be determined by its effect and thus cannot be predicted. To solve this problem, Antonovsky introduced a new element in the model. He postulated that stressors start out by simply causing a physiological state of tension (psychophysical activation), which can be traced back to the fact that individuals do not know how to react in a given situation. Stressors are defined as “...a demand made by the internal or external environment of an organism that upsets its homeostasis, restoration of which depends on a non-automatic and not readily available energy-expending action” (Antonovsky, 1979, p. 72). What Keeps People Healthy?

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For Antonovsky, the organism’s main task is coping with states of tension. Here, concepts of coping research play a key role. When the coping strategy succeeds, it has a healthmaintaining or health-promoting effect. When the coping strategy fails, then “stress” (strain and its consequences) or a situation that is a subjective or objective burden for the person arises. Since coping strategies cannot always succeed, stress reactions and stressful situations are a ubiquitous phenomenon. However, the ensuing stress reaction must not necessarily have negative consequences for health. The strain can have a neutral or even a health-promoting effect. It is the interaction with pathogenic agents, harmful substances and physical weak spots which lead the stress reaction to weaken physical health. Antonovsky distinguished between physical and biochemical stressors, i.e., the influence through force of arms, starvation, toxic substances or pathogens can be so strong that they have a direct effect on the state of health. In this case, the pathogenic orientation is called for, leading to the search for a means of eliminating the stressors. Since, however, the hazards of physical and biochemical stressors in industrialised nations have diminished, the focus has shifted to psychosocial stressors. This is where Antonovsky employed his SOC construct. On the one hand, a strong SOC enables a person to judge a particular stimulus to be neutral, which would cause tension in persons with a weak SOC. This is known as primary appraisal I. 1 However, when a person with a high SOC judges a stimulus to be a stressor, then he or she is in a position to determine whether the stressor is threatening, favourable or irrelevant (primary appraisal II). Classifying the stressor as favourable or irrelevant means that tension is perceived but, at the same time, the person expects the tension to cease without the activation of resources. The stressor that triggers tension is thus redefined as a non-stressor. Even when a stressor which engenders tension is defined as potentially threatening, people with a high SOC will not actually feel threatened. Their fundamental confidence that the situation will work out in the end protects them. Furthermore, Antonovsky contended that people with a high SOC tend to react to threatening situations with appropriate and directed feelings that can be influenced by actions, for example anger about a certain fact. In contrast, people with a weak SOC tend to react with diffuse emotions that are difficult to regulate, such as blind rage. They become paralysed, since they lack confidence in their ability to cope with the problem (primary appraisal III).

1 Antonovsky refers to “primary appraisal” as an element of the transactional model of stress (see p. 56).

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2.3.4.

Generalised Resistance Resources

For a long time, Antonovsky explored different factors which facilitate successful coping with tension and thus influence the maintenance or the improvement of health. He gathered a broad spectrum of factors and variables in epidemiological studies that correlate with the state of health. These variables are related to individual factors, such as physical characteristics, intelligence and coping strategies, as well as social and cultural factors like social support, financial power and cultural stability. Antonovsky calls these variables “generalised resistance resources”. The term “generalised” refers to the fact that they are effective in all kinds of situations. “Resistance” refers to the fact that the resources increase the resistance of the person. “What is common to all generalised resistance resources, I proposed, is that they help to make sense out of the countless stressors with which we are constantly bombarded” (Antonovsky, 1987b, p. 48). Resistance resources have two functions: they have a continuous impact on life experiences and enable us to make meaningful and coherent life experiences which in turn form the SOC. They function as a potential which can be activated when necessary for managing states of tension. In his second book (1987a), Antonovsky conceptualised stressors as generalised resistance deficits. It is thus possible to consider resistance resources and resistance deficits as continuous dimensions. The positive pole stands for the possibility of making life experiences which strengthen the SOC. The negative pole represents experiences that weaken the SOC. For example, a large amount of financial resources or cultural stability can be a resource, a lack thereof can be seen as a resistance deficit or as a stressor. Stressors or resistance deficits lead to entropy 2 . In contrast, resistance resources lead to negative entropy 3 in the human system. The SOC is the channel that “orchestrates this battleground of forces promoting order or disorder” (Antonovsky, 1987a, p. 164).

2 3

Entropy: The tendency to move towards states of growing disorder. See the definition on p. 23. Negative entropy: The capability of a system to retain order. See the definition on p. 23.

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2.3.5.

An Overview of the Salutogenic Model

Noack (1997) compared the basic aspects of the salutogenic model with the pathogenic model (see Table 1).

Basic Assumptions of the Pathogenic and the Salutogenic Model Assumption regarding

Pathogenic Model

Salutogenic Model

Self-regulation of the system

Homeostasis

Overcoming heterostasis*

Definition of health and disease

Dichotomy

Continuum

Scope of the concept of health

Pathology of disease, reductionist

Recovery resources, sense of coherence, holistic

Causes of health and disease

Risk factors, negative stressors

Patient’s history

Effect of stressors

Potentially promoting disease

Promoting disease and health

Intervention

Implementation of effective remedies (“magic bullets”)

Active adaption, risk reduction and resource development

*Heterostasis: Imbalance, instability, the opposite of homeostasis. (Source: Noack, 1997, p. 95)

Table 1

Now that the most important elements of the model of the emergence of health have been discussed, we will go on to describe the way in which these constructs fit together and how Antonovsky explained the improvement of the state of health within the framework of this model. Diagram 1 provides a brief summary of the most important points. The concept of the sense of coherence (SOC) is central to explaining health-maintaining or health-promoting processes. The SOC is 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, 1987a, p.19).

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Brief Summary of the Salutogenic Model (after Antonovsky, 1979, pp. 184–185) Stressors E

F Sources of generalised resistance resources

Generalised resistance resources

C

2

State of Tension

G D

B Life Experiences

Sense of Coherence (SOC)

A

H K

Tension Management

Successful

Unsuccessful

I J Healthy

Ill

Stress

Health Ease/Dis-ease Continuum

Diagram 1

Life experiences form the SOC (Arrow A). A pronounced SOC requires life experiences which are as consistent as possible, which the individual can effectively influence and which cause neither overload nor underload. Such experiences are made possible by so-called generalised resistance resources, such as physical factors, intelligence, coping strategies, social support, financial power or cultural factors (Arrow B). The emergence or the presence of resistance resources is contingent on the social, cultural and historical context and the predominating child-raising patterns and social roles. Finally, personal attitudes and random events can also have an influence on resistance resources (Arrow C). The extent to which these pre-existing generalised resistance resources can be mobilised depends on the strength of the SOC (Arrow D). There is a recursiveness which can quickly become a vicious circle. If there are too few resistance resources, then the emergence of the SOC will be negatively influenced. A weak SOC, on the other hand, prevents the optimum utilisation of the available resistance resources. Stressors which confront the organism with stimuli for which it has no automatic responses engender states of tension (Arrow E). The mobilised resistance resources inWhat Keeps People Healthy?

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fluence stressor management (Arrow F) and the state of tension (Arrow G). This is also recursive. The success of tension reduction acts to strengthen the SOC (Arrow H): “By overcoming a stressor, we learn that existence is neither shattering nor meaningless” (Antonovsky, 1979, p. 194). As a result of the successful tension reduction, the state of health or the position on the ease/dis-ease continuum is maintained or re-established (Arrow I). In turn, a favourable position on the ease/dis-ease continuum facilitates the acquisition of new resistance resources (Arrow K). Unsuccessful tension management, however, leads to a state of tension (Arrow J). This state of tension interacts with existing pathogenic influences and vulnerabilities and thus has a negative effect on the organism’s position on the ease/disease continuum.

The Influence of the Sense of Coherence on Health After describing the salutogenic model with its components and the SOC as its central construct, we will now turn to the question about the processes by which the SOC influences physical health. In general, Antonovsky agreed with stress researchers that an overload of constant or repeated experiences of stress in combination with physical weakness can be a detriment to the organism’s state of health. In his terminology, the most important thing is to prevent tension from becoming strain. According to Antonovsky, the following effects of the SOC can be assumed: 1. The SOC can have a direct influence on different systems of the organism, for example, the central nervous system, the immune system and the hormone system. It affects thinking processes, called cognitions, which determine whether a situation is dangerous, safe or welcome. Thus, there is a direct link between the SOC and the engendering of complex reactions on different levels. That is to say, the strength of the SOC influences not only the management of states of tension (buffers, see Item 2, below), but also acts as a direct filter in information processing. 2. The SOC mobilises existing resources. Successful implementation of these resources leads to a reduction of tension and thus indirectly affects the physiological systems involved in the processing of stress. Antonovsky did not regard short-term physiological stress actions (tension) to be detrimental as long as they are compensated for by an ensuing recovery phase. Damage occurs only when these self-regulating processes are disturbed. 3. People with a pronounced SOC are more likely to be in a position to make choices regarding behaviour that explicitly promotes health, for example, a nutritious diet, prompt medical attention, medical check-ups, and are able to avoid acting in ways that

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endanger their health. Thus, by way of affecting health-promoting behaviour, the SOC has an indirect influence on the state of health. Antonovsky considered his assumptions about the interactions between the SOC and health as confirmed by the relatively new interdisciplinary research field of psychoneuroimmunology. This research field focuses on the investigation of the complex interactions between the nervous system, the hormone system and the immune system and their effects on the human organism, that is on physical health or illness. Within the context of psychoneuroimmunology, Antonovsky saw his assumption confirmed that the cognitivemotivational construct of the SOC can have a direct influence on the organism.

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2

3

Current State of Research

3.

Current State of Research

This chapter examines the importance of the concept of the sense of coherence and the role it plays in research. First, the current state of research on the sense of coherence will be presented and elucidated. In the second section, the extent to which the sense of coherence can be distinguished from other health-psychological constructs will be discussed. The last section illustrates how the concept of the sense of coherence can be seen within the context of various research traditions which are also concerned with the preservation and maintenance of health.

3.1.

The Sense of Coherence: State of Empirical Foundation

The SOC-Scale Before discussing the current state of research on the central construct, the sense of coherence (SOC), we will address various means of measuring or registering it. In order to examine his theory empirically, Antonovsky developed a questionnaire, “The Orientation to Life Questionnaire” (SOC-scale, Antonovsky, 1983). This questionnaire is based on the data from 51 qualitative interviews in which the people questioned talked about their lives. The interviewees were people who had been subjected to severe trauma yet seemed to come to terms with their lives remarkably well. The statements identified as representing a general attitude toward life or life experiences were analysed. Using Guttman’s facettechnique (see Shye, 1978; Borg, 1993), 29 items were identified, which each had a corresponding seven-point assessment scale. There is also an abbreviated version which contains 13 items. This scale, which is designed to measure the SOC, contains the constructs of comprehensibility with eleven items, manageability with ten items, and meaningfulness with eight items. 1 The items are supposed to register a basic attitude in the sense of a dispositional orientation. The three theoretically formulated partial constructs could not be clearly confirmed by factor analysis. It is more plausible to assume a general factor (Antonovsky, 1993c; Frenz, Carey & Jorgensen, 1993). For this reason, it does not make sense to analyse and interpret the three scales individually. In the meantime, the SOC-scale has been 1

The complete questionnaire is in the Appendix, Section 6.5.

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translated into several languages. There is also a German version which, however, has not yet been standardised and normed (Noack, Bachmann & Oliveri, 1991). Antonovsky assumed that an extremely high score on the scale cannot be expected, or rather must be considered pathological, since a person who consistently perceives everything as being comprehensible and predictable is poorly adapted to reality. The scale is supposed to be applicable transculturally and was conceived for the life situation of adults. When developing an instrument of measurement, it is common practice to test it for various validity and reliability criteria. If these criteria are satisfied, the instrument can be considered to measure what it is supposed to measure both accurately and reliably. The SOC-scale is presumed to meet the demands of test theory. 2 Whether or not the instrument measures what it claims to measure is a matter of construct validity. There are different ways to establish this. In order to test the concept of the sense of coherence, it was mainly compared with similar constructs. High correlations are considered to confirm the similarity and thus the validity of the construct, whereas correlations which are too high may indicate that the construct lacks independence. As expected, the sense of coherence correlates highly with related concepts (see Section 3.2). Very high correlations with anxiety and depression raise the question as to whether the SOC-scale might simply represent the reverse of these two constructs. However, doubt has been cast on the procedure of correlative comparison itself as a means of testing construct validity (e.g. Siegrist, 1994). Few attempts have been made to validate the construct with non-correlative methods.

Empirical Studies on the Sense of Coherence The following discussion on the current state of research is based on approximately 50 empirical studies on the SOC-construct, which have been published since 1992. The emphasis is on recent publications, since Antonovsky himself culled the studies which had been published up to 1990 and critically examined their results (Antonovsky 1993c). The publications mentioned here consist of the literature on salutogenesis obtained with the help of CD-ROM literature databases in addition to other literature that was available to us (see the Introduction and Section 6.1. of the Appendix). We have not only reviewed the English and the German literature, but also that appearing in other European countries. The studies mentioned here are presented in an overview in Section 6.4 of the Appendix. To begin with, we can say that twenty years have gone by since Antonovsky presented his concept of the SOC in his book “Health, stress and coping” (1979). To date, not much 2

Internal consistency: Cronbach alpha .82 and higher; Test-retest-reliability at time intervals from 7–30 days, product-moment-coefficients of r=.92 and higher (Antonovsky, 1993c; Rimann & Udris, 1998).

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more than 200 studies on the SOC have been published. Franke (1997) came to the conclusion that the concept had stimulated a “tremendous” amount and that the spectrum of the areas in which salutogenesis had been researched was impressive. Our evaluation is less euphoric. The majority of these studies were conducted by a few working groups in Israel and Sweden. In contrast, very few were from the USA. This is surprising, because the neologism “salutogenesis” has gained a foothold in many areas of the health sciences and is en vogue. It can be assumed that the perspective underlying the construct of health and illness and the corresponding shift in perspective has gained significance. However, the actual value of the construct as a means of explaining health, as Antonovsky intended, has not been acknowledged to any considerable extent, not even after twenty years and especially not by the scientific “opinion-makers” in the USA. Despite the fact that a change in perspective is often propagated (some even speak of a paradigm shift), one can also observe that studies on health psychology that examine the prognostic value of other constructs continue to prefer a study design which is oriented on the deficit or risk model. Independent of the empirical evidence on the SOC, it can be established that, despite the international publications by the scientific community in the last twenty years, only a few have considered the SOC to be worth examining and those were mostly members of Antonovsky’s own research groups. Subject and Aims of the Studies Reviewed None of the studies available to us aimed at testing Antonovsky’s salutogenic model of health in its entirety (see Chapter 2). Such an attempt would have to fail because of the complexity of the model. The studies are mainly cross-sectional and measure the relationship between the SOC (rated according to the abbreviated and the complete versions of the SOCscale) and numerous parameters of mental and physical health and personality traits. These so-called correlations do not permit causal conclusions, but rather describe a relationship between two factors without explaining how this relationship came about. For example, one factor might cause the other, or both may be caused by a third factor. Therefore, if a significant correlation between a high SOC and a health variable can be found, it is not proof that the SOC is a cause of health. The following overview shows which relationships are commonly examined. Health: – General state of health – Physical health/complaints/symptoms/functional impairments – Mental health/complaints/symptoms/anxiety/depression – Life satisfaction/well-being

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Stress Perception and Coping: – Stress perception – Coping Social Environment: – Social support – Social activities – Family and marital satisfaction/communication Health Behaviour: – Utilisation of opportunities – Alcohol consumption – Sport and leisure

3

Personal Characteristics: – Age, gender, ethnic origin – Socio-economic status (income, social class, education) Other variables examined in individual studies: Self-esteem, inquisitiveness, emotionality, activity/flexibility and stability as personality traits, suicidal ideation, learned helplessness, defence mechanisms, Type-A behaviour pattern, physiological data, social desirability, intelligence, attitudes toward retirement, health beliefs, risk perception.

SOC and Health Antonovsky considered the strength of the SOC to be directly connected to health. Consequently, he postulated a biological substrate for the SOC or direct physiological consequences. The sequence SOC – health behaviour – health is not central to his thinking, although he assumed an indirect influence of health (see p. 34). Therefore, examining hypotheses regarding a direct relationship between the central construct of the model – the SOC – and health parameters conforms to the model. Surprisingly, in Antonovsky’s model, health is reduced to a physical or seemingly objective aspect. He emphasised a direct relationship between physical health and the SOC, whereas he was very sceptical about the relationship between the SOC and aspects of mental health, such as well-being and life satisfaction: “I would, of course, be flattered should other investigators report data linking the SOC to other aspects of well-being, but will not be too disappointed by limited results” (Antonovsky, 1987a, p. 182). The results discussed below indicate that relationships between the SOC and various aspects of mental health are closer than those between the SOC and physical health. In some cases, no direct influence of the SOC on physical health could be found, contradicting the hypotheses formulated in the examination. What Keeps People Healthy?

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SOC and Mental Health The studies we examined showed correlations between the SOC and measurements of mental health that were more or less high, yet nevertheless significant. Among other aspects, the relationships were confirmed on representative population samples. Thus, for a Swedish population sample (N=4390), Lundberg (1997) was able to establish that the risk of psychological problems in persons with a high SOC was 3.5 times lower than in persons with a low SOC. This relationship is independent of the variables of age and gender. Another representative study on a Swedish population sample with N=2003 subjects yielded similar results. Larsson and Kallenberg (1996) found significant correlations between the SOC and measurements of mental health, such as moodiness, restlessness, fatigue, concentration problems and so forth (between r=.18 and r=.53). The relationship between the SOC and psychological symptoms was confirmed in other studies 3 . Significant correlations could be found between positive aspects of mental health, such as well-being, life satisfaction, and the SOC (Anson et al., 1993a; 1993b; Chamberlain et al., 1992; Larsson & Kallenberg, 1996). The high correlations between the SOC and anxiety, as well as the SOC and depression, are striking. Various studies 4 show correlation coefficients as high as r=-.85. This legitimately raises the question as to whether the SOC can be characterised as a new dimension of mental health, or whether the known constructs as well as tried and true instruments can be maintained. However, this question cannot be answered completely on the basis of the current state of research. SOC and Physical Health As mentioned above, in contradiction to Antonovsky’s assumption, the relationship between the SOC and physical health is not very clear. Hood, Beaudet and Catlin (1996) examined the influence of the SOC on three different measures of health in a representative Canadian population sample (N=16291; adult men and women). In addition to a subjective assessment of general health, they presented a scale for the measurement of functional aspects of health, which not only questions physical functions, such as hearing and eyesight, mobility, pain, ability to concentrate and so on, but also emotional well-being. A third scale contains the number of chronic physical illnesses, such as cancer, high blood pressure, migraines and so forth. Weak correlations between the SOC and all three measures of health could be found (between r=-.10 and r=.31). The coefficients are significant, which is to be expected in view of the 3 See Anson, Paran, Neumann & Chernichovsky, 1993a; 1993b; Callahan & Pincus, 1995; Chamberlain, Petrie & Azariah, 1992; Dangoor & Florian, 1994; Gebert, Broda & Lauterbach, 1997; Korotkov, 1993; Sack, Künsebeck & Lamprecht, 1997; Sammallahti, Holi, Komulainen & Aalberg, 1996. 4 See Bowman, 1996; 1997; Coe, Miller & Flaherty, 1992; Collins, Hanson, Mulhern & Padberg, 1992; Flannery, Perry, Penk & Flannery, 1994; Frenz et al., 1993; Kravetz, Drory & Florian, 1993; Langius, Björvell & Antonovsky, 1992; McSherry & Holm, 1994; Petrie & Brook, 1992; Rena, Moshe & Abraham, 1996; Sack et al., 1997; Schmidt-Rathjens, Benz, Van Damme, Feldt & Amelang, 1997.

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size of the sample. The SOC can explain 10% of the variance of the functional state of health, but only 4% of the subjective appraisal of one’s own state of health. Used as a predictor of chronic illness, the SOC can only explain 1% of the variance and is thus extremely low. Bös and Woll (1994) found no relationship between the physician’s assessment of health and the SOC in a study of N=500 men and women. Dangoor and Florian (1994) also came to the conclusion that the medical diagnosis and functional limitations do not contribute to the prediction of the SOC. Langius and Björvell (1993) used the Sickness Impact Profile (SIP) to study a Swedish random sample of N=145 men and women. They found a significant correlation with the SOC of r=-.29. A more exact analysis, however, showed that this was only to be traced back to the “psychosocial complaints” sub-scale and otherwise no statistically significant relationship to physical complaints could be established. Nor could any relationship be found between pain and the SOC in a sample of N=57 patients before surgery. A second study after the operation showed, however, that patients with a higher SOC reported significantly less pain six weeks after the operation (Chamberlain et al., 1992). Becker, Bös and Woll (1994) found statistically significant correlations between the SOC and measures of physical health. However, in contradiction to Antonovsky’s hypotheses, there was no direct relationship in a path-analytical model between the SOC and physical health. This finding was also confirmed in another study with a path-analytical design by Williams (1990). It is clear in this case that the inferential or predictive value of correlation studies is not sufficient to study complex relationships and problems. Some studies found correlations between the SOC and measures of physical health which, seen together, are not very impressive. Callahan and Pincus (1995) examined N=828 rheumatism patients, the majority of whom were white and married. They found significant correlations between the SOC (assessed using both the complete and the abbreviated form) and Activities of Daily Living (ADL-scale), pain and general state of health. As in other studies, this finding is not especially meaningful, since the correlation coefficients between the SOC and measurements of physical health are relatively low. They are between r=-.10 and r=-.37 (Anson et al., 1993a; 1993b; Hood et al., 1996; Larsson & Kallenberg, 1996). For two patient samples, scales were used to measure physical health that also inquire about psychosomatic symptoms, such as loss of appetite, sleeping disorders, headaches, etc. In this case, statistically significant correlations around r=-.50 were found (Gebert et al., 1997; Rena et al., 1996). In the study mentioned above, Lundberg (1997) came to the conclusion that the relationship between the SOC and physical illness could be understood in terms of the complaints made by the patient. People with low SOC values might tend to complain more than those with higher SOC values. What Keeps People Healthy?

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SOC and Subjective Judgement of the General State of Health In some studies, the subjective judgement of the general state of health was assessed and related to the SOC. Exactly which subjective health definitions the subjects based their judgement of their health on, and whether the results can be classified as a physical, psychological or holistic conception of health, remains unclear. Because of the relatively low correlation coefficients between r=.21 and r=.37, it can be assumed that the subjects most likely rated their physical health rather than well-being or mental health. 5 Summary In summary, the state of research to date shows that SOC and mental health are closely related. The correlation between SOC and anxiety or depression is even so high that the question is raised whether the SOC-scale measures something else or something more than the germane instruments for assessing the above-mentioned dimensions of mental health or illness. The relationship between the SOC and measures of physical health or the subjective general state of health proved to be less clear. To be sure, further studies with a suitable research design are necessary to clarify this question.

SOC, Stress Management and Coping Some studies address the question whether the amount of SOC can influence the perception and evaluation of a stimulus as a stressor. In stress research, three types of stress stimuli are distinguished: chronic stress, daily hassles and critical live events. Antonovsky considered chronic stressors which characterise the life situation of a person to be the primary determinants of the SOC level. He assumes that they have a negative effect on the SOC. In contrast to Lazarus and Folkman (1984), Antonovsky doubted whether daily hassles can be considered to have a similar effect on the SOC (Antonovsky, 1987a). A conclusive evaluation regarding the accuracy of these theoretical assumptions is not possible based on the research findings currently available. On the one hand, correlation studies do not permit testing of causal relationships and, on the other hand, relatively low but nevertheless significant correlations between the SOC and daily hassles were found in the studies by Bishop (1993), Flannery et al. (1994) and Korotkov (1993). There is also evidence for a relationship between the amount of perceived stress and the SOC. McSherry and Holm (1994) were able to demonstrate on the basis of a sample of N=60 students that the subjects with high and medium SOC values felt significantly less “stressed” than those with low SOC values. Interestingly, the results can even be confirmed on a physiological level. High SOC values lower the physiological parameter towards the end of the confrontation with the stress stimulus, that is, although all three groups react to the stress stimulus, people with low SOC values begin and end the stress situation with higher stress values. Further studies also confirm that the SOC and the appraisal of a situation as stressful are related. 5

See Anson et al., 1993a, 1993b; Becker, Bös, Opper, Woll & Wustmann, 1996; Bös & Woll, 1994; Callahan & Pincus, 1995; Chamberlain et al., 1992; Hood et al., 1996; Langius et al., 1992; Larsson & Kallenberg, 1996.

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With regard to the relationship between the SOC and coping strategies, Antonovsky wrote: “Knowing what the SOC level of a person is, we cannot predict whether, in a given stressor situation, he or she will fight, freeze or flee, be quiet or speak up, seek to dominate or melt into the shadows, or whatever other categories of overt behaviour we may construct” (Antonovsky, 1987a, p. 187). However, he assumed that people with a high SOC value, in contrast to those with low values, perceive problems as being more comprehensible and manageable and more likely to be a challenge than to be a burden. The results of the above-mentioned study by McSherry and Holm confirmed this last assumption that persons with lower SOC values perceive themselves as having relatively less coping resources and less social, material and psychological resources. They have less confidence that they will be able to master situations than the students with a high SOC in the study. According to the studies to date, the SOC appears to facilitate adaptation to difficult life situations, such as taking care of an ill relative (Dangoor & Florian, 1994; Rena et al., 1996). Baro, Haepers, Wagenfeld and Gallagher (1996) examined N=126 relatives, mostly wives, who took care of demented and chronically physically ill people. A low SOC value was found to be related to a perceived overload due to the care-taking tasks and to unfavourable coping behaviour, such as social withdrawal and the consumption of medication. In contrast, people with a strong SOC seem to have a coping ability which allows them to attribute meaningfulness to their task. Antonovsky believed that the search for a “coping strategy that is universally effective in successful dealing with stressors” is useless (Antonovsky, 1987a, p. 144.). However, he felt that people with a high SOC have the required flexibility to select the appropriate coping strategy to meet situational demands, which need not necessarily be active and solution-oriented. At the same time, he mentioned that a person with a strong SOC is motivated to analyse a problem and to activate the most suitable resource he or she has available. This statement was confirmed by the studies we examined. Low SOC values correlated with depressive coping behaviour (Becker et al., 1996), defence mechanisms (Sammallahti et al., 1996), helplessness (Callahan & Pincus, 1995), and with palliative coping attempts and with resignation (Rimann & Udris, 1998) and active coping strategies. In contrast, high SOC values show a positive relation to situational control attempts (Rimann & Udris, 1998) and active coping strategies (Gallagher, Wagenfeld, Baro & Haepers, 1994; Margalit, Raviv & Ankonina, 1992; McSherry & Holm, 1994).

SOC and Social Environment According to Antonovsky, unfavourable life circumstances can impede optimum development of the SOC. People in unfavourable life situations – and that includes the absence of social support – do not have the same opportunity to develop their sense of coherence as do people who grow up in a social environment which is supportive from a developWhat Keeps People Healthy?

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mental psychological point of view. Antonovsky, however, did not regard the importance of social support as being very high. He considered it to be merely one of many general resistance resources. A few of the studies we reviewed dealt with the relationship between the SOC and different measures of social support. In their representative population sample, Larsson and Kallenberg (1996) found a relationship between the SOC and the number of friends – the higher a person’s SOC value, the more friends he or she had. In a sample of N=80 paralysed patients and their spouses, Rena et al. (1996) found that the SOC value corresponds to the amount of marital satisfaction. Becker et al. (1996) reported a correlation coefficient of r=.46 between social support and the SOC for N=863 women and men.

SOC and Health Behaviour Antonovsky did not regard the influence of the SOC on health-related behaviour or the avoidance of behaviour that is hazardous to health, such as cigarette smoking or poor eating habits, as being central to the problem of salutogenesis: “I make no claim that persons with a strong SOC are more likely to engage in those behaviours that evidence indicates are good for the health – not eating between meals, not smoking, regular physical activity, and so on. These behaviours are far more determined by social-structural and cultural factors than by the way one sees the world, and I do not wish to confuse the two” (Antonovsky, 1987a, p. 152–153). He qualified this statement, however, by stressing that people with a high SOC value have a lesser tendency to turn to inappropriate coping strategies, such as addictive drugs or noncompliance 6 , than people with low SOC values, since the former have diverse alternatives and thus can select coping behaviour which is more appropriate for the problem. “From this point of view, there is indeed a basis for anticipating a causal sequence between the SOC, health behaviours, and health” (Antonovsky, 1987a, p. 153). At the same time, he hypothesised that the strength of the SOC has direct physiological consequences and affects health status through the central pathways of the neuroimmunological and endocrine systems (Antonovsky, 1987a, p. 154). The few studies which have addressed the relationship between the SOC and behaviour relevant to health could not provide clear indications for such a relationship. Bös and Woll (1994) examined, among other things, the amount of exercise done by N=500 men and women. They found that older persons with a high SOC get more exercise that those with low SOC values. This finding could not be established for younger persons.

6

“Non-compliance” refers to the disregarding of therapeutic measures and agreements.

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Franke, Elsesser, Algermissen and Sitzler (1997) examined N=928 women with and without a history of substance abuse and reached the conclusion that the SOC values of normal women are significantly higher than those who have drug problems. In contrast to their hypothesis, Frenz et al. (1993) found no significant relationship between the SOC and alcohol consumption. Behaviour detrimental to health employed as a coping strategy in the face of a stressful home situation was demonstrated in the study by Gallagher et al. (1994) mentioned above in those caregivers that showed low SOC values. In an elaborate study, Becker et al. (1996) investigated the influence of numerous variables, including SOC, healthy eating habits, intensive exercise and restful sleep, on the habitual physical level of health of N=863 men and women. The SOC did not correlate with intensive exercise. Significant, yet not very pronounced correlation coefficients of r=.17, r=.13 and r=.23 were determined for the relationship between the SOC and healthy eating habits and between the SOC and exercise in stressful situations as well as restful sleep. Seen as a whole, the research findings are contradictory. Up to this point, the SOC cannot be considered to be a good predictor of health behaviour.

SOC and Personal Characteristics Antonovsky assumes that the strength of the SOC is independent of sociocultural and sociodemographic influences. However, he qualifies this statement by considering the criterion of participation in decision-making processes to be decisive for the development and maintenance of the SOC, while at the same time emphasising that the decision-making processes must be related to activities that are highly regarded by society (Antonovsky, 1987a). This, however, would imply an influence of gender, education, and so forth. At this point, it is not yet possible to make a conclusive statement about the above-mentioned remarks. Cultural Group The transcultural validity of the construct of the SOC has been the subject of several studies in different countries, which do not indicate any major deviation from the SOC values measured. Similar values have been obtained for populations of different ethnic groups. Bowman (1996), for example, was able to demonstrate that the pronouncement of the SOC in a group of Anglo-Americans was similar to that of a group of Native Americans, despite great differences in the socio-economic conditions between the two groups. Hood et. al (1996) also could not establish any differences between Canadians of European origin and immigrants from Asia. Seen as a whole, the cultural differences between countries like Sweden, the USA and Germany are not succinct enough to be able to speak of the transcultural validity of the construct. What Keeps People Healthy?

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Gender and Age With regard to the independence of the SOC value of gender and age, the results are heterogeneous. Anson et al. (1993a; 1993b) found, in contradiction of Antonovsky’s assumption, gender differences in N=238 men and women with mild hypertension. The women in the study exhibited a lower SOC value than the men. The authors considered female socialisation, which often still makes women financially dependent, to be a barrier to the development of a pronounced SOC. Larsson and Kallenberg (1996) also confirmed the low SOC values in women in their large-scale study in Sweden. Gender differences in the SOC values have also been established by Margalit et al. (1992) for the parents of handicapped children, by Coe et al. (1992) for caregivers, by George (1996) for social workers and by Schmidt-Rathjens et al. (1997) in a population sample of N=5133 men and women between the age of 40 and 65. In contrast, no gender differences were found by Callahan and Pincus (1995), Pasikowski, Sek and Scigala (1994), Hood et al. (1996) and Rimann and Udris (1998). Franke (1997) summarised that gender differences can be observed mainly in clinical samples. However, our analysis showed gender differences mainly in non-clinical samples, so that a direct influence of gender on the development of the SOC must at least be taken into consideration. Age Antonovsky contended that the SOC remains stable throughout adulthood. In contrast to this assumption, the studies we reviewed indicated that the strength of the SOC increases with age (Callahan & Pincus, 1995; Frenz et al., 1994, Larsson & Kallenberg, 1996; Rimann & Udris, 1998; Sack et al., 1997). However, well-founded statements about the stability of this construct cannot be made without long-term studies. Education/Socio-economic Status No conclusive judgement can be made with regard to the relationship between the SOC and education level and socio-economic status. A Polish study of N=523 pregnant women shortly before delivery showed no significant relationship between education level and the SOC value (Dudek & Makowska, 1993). Neither a relationship between the SOC and income, nor between the SOC and education, could be established in a Canadian study with a population sample of N=16,291 (Hood et al., 1996). A further representative study provided no indication of an influence of the level of education on the SOC (Larsson & Kallenberg, 1996). At the same time, however, the same study established a significant relationship between the type of employment, income and the SOC. Self-employed persons, white-collar salaried employees and people with higher incomes have higher SOC values than blue-collar workers and people with low incomes. These findings were confirmed by another large Swedish study (Lundberg, 1997) and the Swiss study by Rimann and Udris (1998). They found that larger professional realms of action and a higher position in the firm’s hierarchy correlate positively with the SOC. In

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comparison with other groups, staff of upper and middle management had the highest SOC values and unskilled labourers the lowest. However, Lundberg (1997) did find that social class and socio-economic status during childhood did not influence the extent of the SOC in adulthood. The results of the studies are difficult to interpret from the standpoint that education level, socio-economic status and type of employment or position in the firm’s hierarchy can be assumed to be confounded. Nevertheless, the studies did not demonstrate any consistent results regarding the relationship between the three criteria and the SOC.

3.2.

3

Sense of Coherence as Compared to Related Concepts

Parallel to Antonovsky’s SOC, influential psychological concepts have been developed in the past few years which attempt to explain how individual characteristics affect the emergence and the change of health and disease. These concepts are often subsumed under the category “internal or personal protective factors”. Internal protective factors are referred to as dispositional, though changeable personal characteristics, as well as cognitive or behavioural styles that are situational. Because specific health behaviours, such as taking advantage of the preventive checkups offered by the health care system, have been assumed to help maintain health, they can also be considered protective factors. Commonly cited personal protective factors include the concepts of “health locus of control” (Wallston & Wallston, 1978), “self-efficacy” (Bandura, 1977; 1982), “hardiness” (Kobasa, 1979; Kobasa, Maddi & Kahn, 1982), “optimism” (Scheier & Carver, 1985; 1987), “mental health as an attribute” (Becker, 1992) and perceived or expected “social support” (Cohen & Syme, 1985; Schwarzer & Leppin, 1989). The following constructs were examined regarding their correspondence to and divergence from the SOC: – – – –

Health locus of control, Self-efficacy, Hardiness, Optimism.

In Table 2 at the end of this section, the contextual components of the constructs mentioned are presented in an overview and the similarities and differences are illustrated once again. What Keeps People Healthy?

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Health Locus of Control (HLOC) The aspect of control is important in Antonovsky’s model of the SOC. On the one hand, it is included in the comprehensibility component. If events are predictable and can be explained, then cognitive or other kinds of control over these events are possible. On the other hand, control is central to the component of manageability. This refers to the motivational or action-related aspect, that is, the conviction that one has possibilities or resources available. If something bad or unexpected happens, people with a strong SOC have the certainty that they can handle it. Antonovsky explicitly stressed that manageability included not only the individual’s abilities, but also the aid and influence of other persons or institutions (Antonovsky, 1987a). Within the field of social psychology, there are different approaches which consider control to be the key to explaining behaviour. Common to these approaches is the assumption that individuals attempt to gain control over the events in their environment. In the field of health, this is represented by the health locus of control. This concept is based on the theories of a locus of control by Rotter, which are not specific to health (1966; 1975). Health locus of control refers to the expectations of the individual that health and illness can be influenced – independent of his or her actual objective ability to influence them (Wallston & Wallston, 1978). In contrast to Antonovsky, Wallston and Wallston regard the HLOC more as specific and situationally dependent than as stable, personally dependent factors. They distinguish between internal, external and fatalistic loci of control. Whereas people with an internal locus of control are convinced that their state of health can be influenced by their own behaviour, people with an external locus of control consider their state of health to be dependent on other individuals or external conditions, for example, on medicinal treatment. Persons with fatalistic convictions attribute their health to fate, luck or chance. Most of the hypotheses in studies on the HLOC assume that internal loci of control are better. Favouring internal loci of control contradicts the neutral assessment of the different loci of control made by Antonovsky. In his opinion, this placement might be culturally motivated, since western industrial societies value individuality and the idea that everyone is the master of his or her own fate. Originally, the predictive value of the HLOC was optimistically overestimated. This must be qualified with regard to the latest research. The contradictory findings make it difficult to conclusively evaluate this construct (Bengel, 1993). Following Antonovsky’s line of thinking, the results cannot be interpreted in the sense that an internal locus of control generally represents a factor which protects health. According to the situational context, those behaviours associated with external loci of control which might tend to be passive could well be adequate. They might also lead to emotional relief in the case of chronic illnesses, for example, and thus contribute to a subjective feeling of well-being.

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Self-efficacy Control is also a key aspect of another social-psychological construct, called self-efficacy (Bandura, 1972a; 1982). It is gaining in significance in health-psychological questions. In his self-efficacy theory, Bandura contended that the behaviour of a person is determined by expectations concerning his or her own efficacy (efficacy expectancy) and the outcome of a behaviour (outcome expectancy). Merely the anticipation of a positive result does not suffice to induce a change in behaviour. Indeed, the conviction that one can actually exercise a particular behaviour or successfully perform this behaviour is decisive. Self-efficacy is built up through the experiences an individual makes in situations that have been successfully mastered. This, in turn, leads to the establishment of suitable coping strategies. Self-efficacy appears to be fundamental to the motivation of behavioural change. (For an overview of the relationship between self-efficacy and health-related behaviour, see Schwarzer, 1992; Strecher, McEvos Develis, Becker & Rosenstock, 1986). Self-efficacy is a component of the individual appraisal of one’s own coping possibilities and thus contributes to coping with crises and to the construction of the individual’s personal environment (Rippetoe & Rogers, 1987). The empirically established relationship between the willingness to adopt preventive behaviours (for a summary, see O’Leary, 1985; Bandura, 1986), to maintain these behaviours in the face of temptation (DiClemente, 1981), and to implement situationally adequate coping strategies (Rippetoe & Rogers, 1987) indicates that self-efficacy influences health-related behaviours and in this indirect manner represents an important factor for health protection. Bandura originally conceived self-efficacy as situational beliefs and not as a stable personality trait. His theory differs from Antonovsky’s approach in this point. More recent ideas tend to consider self-efficacy both as a trait and as specific cognitions that are only valid for clearly defined situations (Schwarzer, 1992; 1994). Antonovsky did not distinguish between outcome and efficacy expectations. However, both aspects are implicit in the component of manageability – the confidence that one has the resources available that one needs to cope with events. When one compares the corresponding questionnaires, the similarity in the composition of the component of manageability and the construct of self-efficacy is obvious. For example, a question in the SOC-scale asks: “Do you have the feeling that you are in an unfamiliar situation and don’t know what to do?” In the scale for generalised self-efficacy, the question is: “In unexpected situations, I always/never know how to act.” Similar to the HLOC and the stress-coping theories, the self-efficacy theory is characterised by strong action orientation. Subjective assessments influence health-related behaviours and are thus buffers or mediators of health, or rather, of disease and risk factors.

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Hardiness Kobasa (1979; Kobasa, Maddi & Kahn, 1982) presented the construct of “hardiness” at the same time as Antonovsky coined the term “sense of coherence”. It is important to point out that Kobasa, too, was interested in the question of invulnerability and health resources, that is, she was a proponent of a salutogenic approach from the beginning, even though she did not use this term. In her opinion, it is the personality trait of hardiness which leads people to react differently to objectively identical stressors and stressful situations. Hardiness refers to the fact that individuals are resistant to the negative effects of stress and as a result do not develop any negative consequences. In contrast to Antonovsky, Kobasa does not view this trait as a static personal characteristic, whose development is completed early and is virtually fixed by adulthood. In her opinion, personality characteristics are personal styles that can develop dynamically as the individual interacts with the environment. Her standpoint allows for change and is thus not quite as pessimistic as that of Antonovsky. Hardiness contains three components that not only overlap with each other, but also show some very close parallels to the three components of the SOC: commitment, control and challenge. People having pronounced hardiness are curious about and active in all areas of their lives (commitment). On the one hand, this requires the individual to be convinced of his or her own importance, actions and good judgement. On the other hand, this characteristic also includes social action and engagement. Antonovsky felt that when Kobasa uses the term “commitment”, she means “exactly the same thing” as his term “meaningfulness” (Antonovsky, 1987a, p. 49). ”Control” is meant to be the opposite of “helplessness”. In other words, people with more pronounced hardiness are convinced that they can control and have influence on their surroundings. These persons emphasise the individual responsibility of their actions and the possibility of reducing the negative effects of stressors through self-determined activities. Kobasa distinguished between external control, where the source is outside the self, and internal, self-determined control. Internal control is meant to be synonymous with self-responsibility and active behaviour. As Antonovsky wrote: “Kobasa’s use of Rotter’s Internal-External Locus of Control Scale (...) is explicitly at variance with my approach. This culturally narrow scale posits only two alternatives: either I control matters or someone or something ‘out there’ does. It posits a fundamental mistrust in power being in the hands of anyone else” (Antonovsky, 1987a, p. 52). Furthermore, persons with high hardiness feel challenged by changes in life. They experience changes as normal and exciting, and as an opportunity for inner growth rather than as a threat. They actively seek new experiences and, in dealing with unexpected situations, show openness and cognitive flexibility. The last component bears a basic dif-

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ference to the SOC, since change rather than stability is considered to be the normative lifestyle. Kobasa names two different mechanisms of influence on health for the personality variable of hardiness. First, hardiness can serve as a buffer, which makes people experience stress differently and contributes to the fact that individuals employ successful coping strategies to solve their problems. In this case, hardiness has an indirect effect on health. It influences the perception and appraisal of a stressful event, and leads to successful, active coping with situations characterised by aversive stimuli (Ouellette-Kobasa & Puccetti, 1983). Second, like the SOC, hardiness is also thought to directly reduce tension. In the 1980’s, numerous studies investigated the relationship between hardiness and many different kinds of health parameters, such as state of health or symptoms of disease, health behaviour, coping with illness, social support, job satisfaction and personal well-being (see Maddi, 1990, for an overview). The inconsistency in the results can certainly be attributed to the lack of measuring tools which satisfy psychometric demands.

Dispositional Optimism Another approach from the field of personality psychology stems from Scheier and Carver (1985; 1987). They refer to dispositional optimism as being a characteristic that is relatively stable over time and across different situations and which enables persons to perceive their environment in a specific way. Such individuals tend to expect positive events and are hopeful and confident about their outcome. The authors view this characteristic as a generalised outcome expectancy which is not limited to a specific area of behaviour or to certain situations. Their theory has a much simpler structure than that of Antonovsky. However, the “generalised positive outcome expectancy” is identical to the SOC’s component of manageability. This concept also overlaps with the component of comprehensibility. However, Antonovsky did not claim that persons with a strong SOC frequently expect positive outcomes. The construct of “dispositional optimism” is based on a self-regulation model of behaviour (Scheier & Carver, 1990). This model proposes that, by means of self-attentiveness, discrepancies between momentary behaviour and behavioural goals will be perceived and will stimulate an analysis of the reasons for these discrepancies and the related barriers. In this analysis process, the probability of a reduction in discrepancy is assessed. The outcome expectancy influences subsequent behaviour. In the case of negative outcome, the behaviour will be discontinued or the amount of energy invested will be reduced. If a favourable outcome is expected, the efforts undertaken to reach the goal will be intensified. In this model, confidence as a generalised outcome expectancy is the best predictor of behaviour. Dispositional optimism is not considered to be a consequence of successful What Keeps People Healthy?

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action, but in fact, the reverse is true, in the sense that it is a cause of behaviour or relevant for action. In contrast to this individualist perspective, Antonovsky embedded his SOC concept much more deeply in the social and cultural context of life circumstances and the corresponding developmental possibilities. Exactly how dispositional optimism affects health has not yet been established. There is assumed to be a buffer effect or an indirect effect of disposition on health by way of coping mechanisms. Aversive events are assessed and perceived as being soluble, which leads to an active approach to problems. Optimists tend to exhibit problem-related coping and an active search for social support (Scheier, Weintraub & Carver, 1986). Successfully coping with stress should have a direct effect on physical complaints. A favourable outcome expectancy can lead to increased effort which, in the sense of a selffulfilling prophecy, can lead to successful attainment of the goal. The feeling of achievement makes symptoms have less of an impact. A further explanation appears to be the quick solution of problems, that is, the problems are not suppressed and thus do not reach the magnitude of those problems that are not promptly confronted. Several studies confirm the protective influence of dispositional optimism on physical health, psychological well-being, life satisfaction, coping behaviour and preventive health behaviour (Chamberlain et al., 1992; Scheier & Carver, 1987; Wieland-Eckelmann & Carver, 1990). The constructs discussed above are presented in the following table for comparison.

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What Keeps People Healthy?

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Sense of Coherence

Loci of control (LOC)

Self-efficacy

Generalised Outcome Expectancy: Things will turn out positively

Conviction that things will turn out well

Generalised expectancy as to whether events in an individual’s realm of life can be influenced or not

The expectancy that a specific behaviour will lead to a predictable result

Generalised Self-efficacy: The conviction of being able to carry out an action independently

Confidence in one’s ability to master life’s tasks (manageability)

Internal Locus of Control: Conviction of having an influence on events and actions

Resources that one has under control (manageability)

Especially internal LOC have a positive effect on health parameters

External Locus of Control: Conviction that others or a higher power will take care of things

Resources that can be controlled by legitimate others (manageability)

External LOC usually have a less positive effect on health parameters

Dealing with Change

Continuity, stability as a central orientation; the world is seen as ordered and predictable (comprehensibility)

Life changes as a challenge; normative lifestyle as an orientation towards change and not towards stability

Meaningfulness

Life is seen as being meaningful, problems are worth investing energy in (meaningfulness)

Curiosity in life, commitment in all areas of life

The expectancy that one will be able to perform the appropriate behaviour in a given situation

Hardiness

Dispositional Optimism Confidence, optimism

The ability to exercise control in one’s surroundings

Self-responsibility of action and the possibility of reducing the negative effects of stressors by selfdetermined activities

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3.3.

Stress and Resilience Research

How people deal with stress and stressful situations has long been a subject of interest in the health sciences. As a result of the so-called “cognitive turn” within psychology, there is general agreement today that subjective processes of appraisal are more significant than objective factors (Beutel, 1989).

Transactional Model of Stress Probably the most influential stress coping theory is the transactional model of stress (Lazarus, 1966; 1981; Lazarus & Folkman, 1987). It permits a change in perspective from the viewpoint of objective stress to the subjective coping process, that is, to those adjustments necessary for the individual to cope with stress (Koch & Heim, 1988). Stress is thus not a fixed dimension, but can be changed by the individual’s information processing abilities and by situational variables (Lazarus & Folkman, 1987). The transactional stress model distinguishes between two different appraisal processes. “Primary appraisal” refers to the appraisal of characteristics of a situation. In other words, stressful events can be judged as a threat, as a challenge or as irrelevant to one’s wellbeing. “Secondary appraisal” refers to the evaluation of personal and social resources, that is, of one’s own possibilities to cope with a stressful situation alone or with the support of others. Lazarus and Folkman differentiate between five coping reactions that fulfil problem-solving as well as emotion-regulating functions: – The search for information serves as a basis to select coping reactions or for the reappraisal of stressful situations. – Direct action as a coping reaction encompasses all behaviours with which a person attempts to gain control of stressful events. – The omission of action can also serve as a coping strategy. – Intrapsychic forms of coping include all cognitive processes that enable the regulation of emotions, such as defence mechanisms, avoidance, self-deception, etc. – The search for social support as a further coping behaviour refers to the active search for and the utilisation of help from others. Coping behaviour has also been categorised in other ways, for example, active-cognitions, active-behaviour, or avoidance behaviour (Billings & Moos, 1981), person-related coping (information search and avoidance, re-appraisal, reproaches towards self and others, palliation) and environmentally-related coping (withdrawal, avoidance, waiting-and-seeing, resignation, utilisation of support, active influence) (Perrez, 1988).

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Within the framework of stress and coping research, successful or appropriate coping strategies are considered to be health resources, since they lead to improved adaptation to life’s circumstances or demand a change away from aversive situations. According to Cohen and Lazarus (1979), appropriate coping strategies enable the reduction of destructive situational conditions, the maintenance of a positive self-image, the stability of emotional balance, and the establishment of satisfactory relationships. In addition, they influence well-being and the state of health (Lazarus, 1981). Active, problem-solving-oriented coping strategies tend to be considered as appropriate behaviour for managing stressful situations (Braukmann & Filipp, 1984; Heim, 1988). Less healthy persons tend to resign in problem situations, can deal less well with stressors that cannot be influenced and exhibit a higher tendency to take refuge in flight (Perrez, 1988). The most important requirement for effective coping, however, seems to be the flexible implementation of different behaviour patterns (Lazarus & Folkman, 1987).

Stress Research and the Sense of Coherence Stress research provided the framework within which Antonovsky developed his concept of the SOC (see Chapter 1). It is not always easy to understand the similarities and differences between the different approaches in stress research and the SOC. The most important approaches are those from Selye and Cannon, Holmes and Rahe, and Lazarus. Some of the fundamental theoretical ideas are very similar. Thus the concept of “primary appraisal” in Lazarus’ model is comparable to the SOC component of “meaningfulness”, whereas the concept of “secondary appraisal” has similarities with the component of “manageability”. Divergences have emerged mainly because, according to Antonovsky, the salutogenic perspective has been neglected in the traditional approaches of stress research: – Research hypotheses are formulated pathogenically and thus guide the epistemology and insight (e.g., depression as a predictor of cancer mortality. The probability that depressed patients will die of cancer is twice as high as that of patients who are not depressed. This statement ignores the fact that only very few of the depressed patients actually ever die of cancer). – Stressors are automatically defined as risk factors without further investigation of this assumption. Antonovsky regarded stressors as an omnipresent component of life that is detrimental to health only under certain circumstances. – The dependent variables that are examined are almost exclusively measurements of disease or risk factors, positive measures of health are not investigated. – Coping strategies are considered to be buffers, as mediators between disease and health. Factors that might directly contribute to health are not investigated. – The focus is usually on specific behaviour that acts as coping strategies. The SOC, however, refers to the individual belief system about the nature of things and not to what one does. The strength of the SOC does not permit the prediction of concrete behaviour. What Keeps People Healthy?

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– Judgements and expectations of a person are seen as situationally dependent. In contrast, Antonovsky sees them as a situationally-independent basic attitude (dispositional orientation). The interactional demands-resources model of health by Becker (1992) is another health-psychological model to explain health. It was also developed in the tradition of Lazarus’ transactional stress model, and Becker considers it to supplement the salutogenesis model. It attempts to explain the physical and psychological state of health. The model postulates that, in order to cope with internal and external demands, such as role expectations, physical and psychological needs, internal and external resources are used. The internal resource “Seelische Gesundheit als Eigenschaft”, or “SGE” (mental health as a characteristic), is a key factor in the behaviour and experiencing of a coping process that is taking place. Becker regards mental health as a characteristic that remains stable over time and that enables one to meet internal and external demands. The construct consists of the components psycho-physical well-being, self-actualisation and selfand other esteem. In keeping with Beck, these three factors constitute a type of cognitive triad, that is, the positive view of one’s self, one’s environment and one’s future. Mental health as a characteristic affects coping behaviour in progress, health behaviour and thus – indirectly – health. Since the emotions triggered by stressful events are less intense, it also affects health status. SGE is measured by the Trier Personality Inventory, which was developed by Becker (1989). In an overview, Becker (1992) reports positive relationships between habitual health behaviour, such as cautious, conformative behaviour, healthy eating habits and exercise, relaxation and recreation, and mental health in a sample of 148 adults (Strehler, 1990, quoted after Becker, 1992). In a study of intrafamiliar similarities, Becker demonstrated that psychologically healthy persons have access to better external resources (in this case a psychologically healthy spouse) than psychologically less healthy persons (Becker, 1991). Perrez (1988) found indications that psychologically healthy persons are less restless, depressed and anxious than psychologically less healthy patients when dealing with daily troubles. Common to both Becker’s and Antonovsky’s model is that, in the face of the complex interaction between internal and external demands and resources, they attribute a key role to stable cognitive-affective processing patterns for the emergence and maintenance of the state of health. In addition, because of their complexity, both models are prone to methodological difficulties when empirically tested.

Resilience and Invulnerability Research Like stress and coping research, resilience and invulnerability research looks for factors which maintain and protect psychological and physical health. The concepts of resilience

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and invulnerability originated in developmental psychology. They denote a stable and healthy personality and behavioural development which has emerged despite unfavourable experiences and stress in early childhood. The findings of resilience or invulnerability research are based on retrospective and prospective longitudinal studies that represent an extremely elaborate form of psychological research (Köferl, 1988). Characteristic of the research in this area is that it is often not based on an etiological model of resilience, that it lacks a conceptual framework or a theory with an explicit claim and, finally, that it examines more personal and less social risk factors. Moreover, Antonovsky’s criticism also applies to this area of research, i.e., that statements about the invulnerability of specific persons or groups of persons are based predominantly on risk studies that in turn stem from a deficit model of developmental processes. The results of resilience research are usually presented in the form of a catalogue containing variables of pathogenic or protective influences on child development. Lösel and Bender (1997) regard the following social and personal resources as having confirmed protective effects: – – – – –

Temperamental characteristics (e.g., a predominantly positive mood) Cognitive and social competence (e.g., effective problem-solving abilities) Self-reflective cognitions and emotions (e.g., positive self-esteem) An emotionally secure bond to one special other Characteristics of the child-raising environment (e.g., stimulating, emotionally warm) – Social support within and outside the family – The experience of meaning and structure in life (e.g., ethical value system) Within the framework of resilience or invulnerability research, the sense of coherence is regarded as one of many potential resources of favourable developmental processes (see Hurrelmann, 1988; Lösel & Bender, 1997; Köferl, 1988). Antonovsky himself never made reference to the models and approaches of resilience or invulnerability research. This research tradition was established at about the same time as the salutogenic model was developed. Since it is rooted in another scientific discipline, one can assume that Antonovsky was not very familiar with it. The significance of invulnerability research can be attributed mainly to its methodological approach of retrospective and prospective longitudinal studies. In this respect, resilience and invulnerability research, which tends to be methodology-oriented, can complement the model of salutogenesis. Within Antonovsky’s salutogenic model, longitudinal studies could contribute to the question as to which circumstances lead to the development of a strong SOC. Essential for the significance of the SOC as a central protective factor would be the proof that the different social and personal resources found in resilience research are a prerequisite for the development of the SOC, but later no longer independent of the What Keeps People Healthy?

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strength of the SOC. In other words, in the case of a weak SOC, objectively available resources are not perceived or are not utilised. Since multifactorial processes are involved, the proof of such relationships is hindered by significant methodical problems. The registration and description of relationships between personal and social factors that protect health appear to be more promising in the hands of resilience or invulnerability research. Prospective longitudinal studies are necessary to examine causal relationships between protective factors and health, which is not possible in primarily correlative studies, such as those mainly used to test the SOC concept.

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4

Importance and Utilisation of the Concept in Different Areas of Application

4.

Importance and Utilisation of the Concept in Different Areas of Application

This chapter of the expert report describes different areas of work and research in Germany in which salutogenic principles have been introduced and have gained scientific as well as practical importance. This report can only address published material or that otherwise known to us. Thus, this description of the usage and the significance of salutogenic principles in the areas selected must remain limited and refers only to the German public health system. Individual facilities devoted to prevention and health promotion, to rehabilitation and psychosocial care, as well as out-patient and in-patient medical care, have supplemented their concepts with salutogenic measures or retitled the names of their former services with salutogenic terms. Many of these approaches taken by facilities and organisations – especially in health promotion and rehabilitation – have not been documented or have only been registered for internal use, or are only available in the form of project reports that are difficult to acquire. The reports are not listed in the bibliographies of scientific literature. Many of the facilities have neither the time, nor the capacity, nor the access to the germane media and journals. Moreover, their work does not require documentation or legitimation by scientific publications and papers. Independent of the fact that this overview is incomplete, we assume that the treatment of salutogenic principles in health care facilities and organisations takes place in one of the following four ways: – There is no evidence of concern with the concept of salutogenesis (most frequent case). – The service is supplemented with salutogenically-oriented elements. – The previous services are relabeled “salutogenic”. – The philosophy and conception adhere to salutogenic principles. In our opinion, the areas of “Health Promotion and Prevention” (Section 4.1.), “Psychosomatics and Psychotherapy” (Section 4.2.) as well as “Rehabilitation” (Section 4.3.) are the only areas of application that merit thorough reviewing. In addition, ideas in a few other fields are discussed, for example: – Resource orientation in nursing (Artinian, 1991; 1997; Schachtner, 1996), – Physicians’ attention to patients’ health resources (Hollnagel & Malterud, 1995; a conference on the subject of “Salutogenesis in General Medicine” took place at the Institute for General Health in Frankfurt in July 1998), – Salutogenic factors in patients dependent on addictive substances (Fuchtmann, 1994).

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From a scientific perspective, the field of industrial psychology should be mentioned: the members of the working group headed by I. Udris (Switzerland) are proponents of a salutogenic approach in industrial psychological research (see, for example, Udris, Kraft & Mussmann, 1991; Udris, Kraft, Muheim, Mussmann & Rimann, 1992). In the research project “Personnel and Organisational Resources of Salutogenesis” (SALUTE), they examined the influence that personnel and organisational factors have on the maintenance of health in the context of employment. Their research is based on system theory and action theory models in which health or illness result from exchange and coping processes between internal and external resources and demands, similar to those of Antonovsky and Becker. Based on their research results, the working group formulated consequences for the design of working structures and for industrial preventive measures. Industrial health promotion should not only influence individual health behaviour, but also contain thorough and holistic measures for the design of work and organisational structures (Udris et al., 1992). Concrete applications of the salutogenic approach in the form of specific health-promoting programmes or measures in an industrial context are not known to us.

4.1.

Health Promotion and Prevention

The following section discusses the importance of the salutogenic model for the development, conception and design of preventive measures. This is based on the following material: – Implications that can be drawn directly from Antonovsky’s theories or that he formulated himself, – Contributions that contain the fundamental elaborations on the necessity of the integration of salutogenic approaches in prevention, as well as those that contain the key word “salutogenesis“, – Literature on health promotion as conceived by the WHO. Antonovsky’s principal thesis is that a strong sense of coherence is the decisive factor for successful coping with omnipresent stressors and thus for the maintenance of health (Antonovsky, 1987a). He regarded the SOC as a stable characteristic which is not only formed by individual factors, but also by historical, social and cultural conditions. The development of the SOC is completed by adulthood and can only be slightly or temporarily modified by critical events. However, the stability of the SOC has not been sufficiently clarified. Antonovsky himself said little about ways to change the SOC through planned, targeted measures and interventions. He pointed out that, in many situations, What Keeps People Healthy?

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slight and temporary changes may be significant, and that it could be important to assist people in critical life situations so that their SOC does not start to decline temporarily. Antonovsky considered structural and social measures that enable the individual to influence and participate in socially recognised decision processes to be the most promising way to positively influence the SOC. According to Antonovsky, it becomes more stable and thus more difficult to change as one gets older. The conclusion to be drawn from this is that it is important to create a world in which children and adolescents experience consistency, can recover from stress, and can participate in decision-making processes. All in all, the implications and consequences that can be drawn from Antonovsky’s theoretical elaborations on the practice of prevention tend to be rather sobering. Once adulthood is reached, the SOC can be changed only slightly or temporarily. If at all, changes can only be made by long-term assistance or intervention which results in “psychotherapying” preventive measures. Measures aimed at individuals can achieve only little if the structural and societal conditions are unfavourable. Therefore, health promotion and preventive measures must be geared to changing a broad spectrum of individual, social and cultural factors. Antonovsky himself stressed again and again that a strong SOC does not always result in socially acceptable behaviour and can be developed in contexts that are destructive to our Western democratic ideals: “I would like to say that the rigidity of an SOC that emerges in such a context inevitably makes it fragile, inauthentic, and doomed to shattering. But we must grant that the evidence is not at all clear” (Antonovsky, 1987a, p. 106). Despite Antonovsky’s pessimistic elaborations, the salutogenesis model has become important to the field of prevention. It serves as a meta-theory for the working field, as legitimation for conceptual ideas and for the planning of concrete measures. It provides a framework for preventive activities that often lack a clear theoretical foundation and are undertaken in an activistic, uncoordinated manner. This theoretical framework supports resource-oriented, competence-raising and non-specific preventive measures. The model also supports a critical view of the previous preventive measures taken in health education and confronts the risk factor model. In this context, the low success rate regarding the change in risk factors should be mentioned. It is also important that the model parries the puritanical aspects of “warnings”, “alarms” and “austerity” belonging to the risk factor model with a positive concept. The shift in perspective from risk factors to preventive factors is compatible with a modern concept of health which ranks the psychological and social dimensions on the same level as the physical dimension. The inception of the salutogenesis model occurred at about the same time as the community psychology movements that formulated the concept of empowerment and socialecological approaches. All these approaches stand for or have enabled a shift in perspective in prevention, which has had an impact on the Ottawa Charter of the WHO and the approach of health promotion. Even though the terms “salutogenesis” or “SOC” are not mentioned in the Ottawa Charter of the WHO of 1986, it subsequently placed the main

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concern of health promotion on the strengthening of the SOC and Antonovsky’s positive self-perception of action competence/self-efficacy as a major element of health (Kickbusch, 1992). Many authors seem to feel that putting the salutogenic model into practice in the field of prevention is equal to implementing the WHO concept of health promotion. For example, Freidl, Rásky and Noack (1995, p. 16) defined health promotion as “the initiation and support of salutogenic processes in social systems and the assistance in establishing the structures for them”. This equates health promotion with salutogenesis. According to Noack (1996a; 1996b), salutogenic resources, that is, the social, living and working environment, and individual characteristics, are areas of action for health-promoting measures. The meaning of the concept of health promotion and the related shift in perspective is also underlined by Antonovsky’s ideas. However, this also means that the sparse literature available on aspects of the application of salutogenesis does not go much further beyond the discussion on health promotion. For example, Renner (1997) mentioned several projects by the Hessian Working Group for Health Education, which were developed according to the WHO guidelines for health promotion and are aimed at strengthening salutogenic factors, such as “Healthy Cities”, “Make Children Strong”, “First Love and Sexuality” and so on. In contrast to classical risk-factor-oriented measures of health education, these concepts foster the active participation of non-professionals or the members of self-help groups and attempt to strengthen their resources and competence, while conveying positive forms of communication and interaction independent of their risk behaviour. Paulus (1995) distinguished between “health promotion in institutions”, such as schools (which have instituted programmes like “Make Children Strong” and anti-smoking campaigns), and “health-promoting institutions”. In keeping with the Ottawa Charter, salutogenic schools do not merely provide preventive measures periodically, but involve the entire school and all its members in a continuous health-related developmental process. The measures apply to very different areas and include social, ecological and communal aspects of school activities (Paulus, 1995). Other authors agree that the latter is essential in putting the WHO guidelines into practice adequately. Not everything we found that bore the name “salutogenesis” and “health promotion” actually put these concepts into use. For example, classical programmes on the avoidance of health risk factors are claimed to be based on the salutogenesis model, or a single event with the theme of social support or enjoyment training is considered, as far as the initiator is concerned, to suffice as having put Antonovsky’s model into practice. The current situation in health promotion is characterised by the fact that the information level of the providers of health-promoting services is very different. In many cases, What Keeps People Healthy?

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they appeal for a shift to salutogenesis without having true knowledge of the model. In other cases, previously introduced measures are continued but relabeled as “salutogenic”. All measures on the critical discussion and reception of the model should be encouraged and supported. The scientific and health-political benefits, as well as the gain in the fields of health promotion and prevention, are far from being conclusively determined.

4.2.

Psychosomatics and Psychotherapy

In addition to health promotion and prevention, psychosomatics and psychotherapy are further fields of application for the concept of salutogenesis. In the following, both areas will be discussed together since psychotherapy is a central method in psychosomatics. Psychosomatic medicine or psychosomatics is a specialised discipline in the canon of subjects in medicine. Psychosomatics is concerned with illnesses whose emergence and progression are significantly affected by the psychological processes and the psychosocial situation of the patient. However, it also encompasses physical symptoms without an organic substrate, frequently referred to as somatisation, vegetative or functional disorders. Psychosomatic medicine is also very important for primary physical illnesses. In this case, psychological processes influence the way the patient copes with the illness, as well as the course of the illness. The borders between psychosomatics and clinical psychology, psychiatry, medical psychology, and behavioural medicine are not clear-cut. Dialogue, psychotherapeutic individual and group treatment, and various exercises are methods used in psychosomatics. “Psychotherapy” is the generic term for a collection of different methods which aim to influence or improve behavioural or psychological disorders and other troubling conditions by communicative means, generally verbal. In general, the aim is to reduce the symptoms which disturb and restrict the patient, as well as to change his or her personality structure. Thus, the therapist and the patient must succeed in creating a supportive rapport, the therapist-patient relationship. Psychotherapy is predominantly conducted on an out-patient basis in private practices of psychotherapists, usually clinical psychologists or physicians, but also on an in-patient basis in psychiatric and psychosomatic clinics. There is some overlapping with the field of rehabilitation (Section 4.3), since a large portion of the in-patient treatment for psychosomatic illnesses takes place in medical rehabilitation centres.

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There are a number of psychotherapeutic schools. Most often, psychotherapy is performed on the basis of behavioural therapy, depth psychology (“Tiefenpsychologie”) or psychoanalysis and client-centred psychology (“Gesprächspsychologie”). Further psychotherapeutic schools are Gestalt therapy, systemic therapy and psychodrama. Psychotherapy is based on a theory of mental disorders and a theory of therapeutic change. The concept of salutogenesis rarely appears in the psychosomatic and psychotherapeutic literature. In psychosomatic and psychotherapeutic textbooks, the terms “salutogenesis” and “sense of coherence” are seldom mentioned. To give a few examples, one textbook from each of the fields of psychosomatics (Ahrens, 1997), psychoanalysis (Thomä & Kächele, 1996; 1997) and behavioural therapy (Margraf, 1997) will be discussed together with a so-called integrative textbook of psychotherapy (Senf & Broda, 1996). In the “Lehrbuch der psychotherapeutischen Medizin” (Textbook of Psychotherapeutic Medicine) by Ahrens (1997), salutogenesis is merely presented as an orientation in which the research for health protective factors has the same rank as pathogenically-oriented research. In the “Lehrbuch der Verhaltenstherapie” (Textbook of Behavioural Therapy) by Margraf (1997), salutogenesis is addressed in conjunction with the euthymic basis of behavioural therapy (Lutz, 1997). Euthymic experience and action encompasses anything that does the psyche good. For this reason, psychotherapy should also concentrate on positive feelings like fun, joy, relaxation, equilibrium and well-being – that is, they also take positive aspects of experience in psychotherapy into account. Neither in the “Lehrbuch der psychoanalytischen Therapie” (Textbook of Psychoanalytic Therapy) by Thomä and Kächele (1996; 1997), nor in the textbook “Praxis der Psychotherapie” (Practice of Psychotherapy) by Senf and Broda (1996), is the term “salutogenesis” listed in the index. It is remarkable that M. Broda, one of the German-speaking authors best acquainted with Antonovsky (see Section 4.3), did not integrate the concept of salutogenesis in his textbook. Most of the other textbooks on psychosomatics, medical psychology and clinical psychology do not address the subject of salutogenesis. If they do mention it, they only devote a few sentences or pages to it. (See, for example, Ahrens, 1997; Gerber, Basler & Tewes, 1994; Rösler, Szewczyk & Wildgrube, 1996; Siegrist, 1995; Tress, 1997; Wirsching, 1996.) In German-speaking countries, three conference proceedings have focused on the salutogenic approach in psychosomatics and psychotherapy (Franke & Broda, 1993; Lamprecht & Johnen, 1994; Lutz & Mark, 1995). Franke and Broda (1993) gave their anthology the title “Psychosomatische Gesundheit. Versuch einer Abkehr vom Pathogenese-Konzept” (Psychosomatic Health. An Attempt to Depart from the Concept of Pathogenesis). Their main thesis is “that pathology-oriented thinking and action in psychosomatics cannot contribute to a reduction in the incidence of psychosomatic illnesses” (p. 1). This book focuses on the definition of health. In the authors’ opinion, the salutogenic perspective supports the importance of subjecWhat Keeps People Healthy?

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tive concepts of health (Helfferich, 1993; see also Belz-Merk, Bengel & Strittmatter, 1992). Also treated are the fuzziness of the term, “health” (Franke), gender differences in the concepts of health (Helfferich), the protective effects of coping skills (Broda), the criticism of the risk factor model (Reye), public health care and the political and economic effects of the concept of pathogenesis (Franke, Huber, Glaeske, Reiners), and the scientific evaluation of convalescence criteria (Dahme). The conference proceedings plead against onesided pathology-oriented thinking and action in psychosomatics and psychotherapy. However, the discussion does not go decisively beyond describing the problems of the concept in psychotherapy and psychosomatics. In this case, Antonovsky’s ideas could provide a valuable framework for the discussion. In 1994, the “Deutsches Kollegium für Psychosomatische Medizin” (German College of Psychosomatic Medicine) held its 40th conference with the theme “Salutogenesis – a new concept in psychosomatics?” The conference proceedings, edited by Lamprecht and Johnen (1994; 3rd revised edition 1997), encompassed 32 contributions on the subject. Diverse areas of work and therapeutic strategies were presented. The contributions concentrated on the following questions: – How can salutogenic principles be integrated in psychosomatic-psychotherapeutic work? – Where are salutogenic principles already being implemented? – Is the sense of coherence suitable as a criterion for therapeutic success or should the sense of coherence be a psychotherapeutic goal? In this volume, Hellhammer and Buske-Kirschbaum made a fundamental contribution to “psychobiological aspects of protection and repair mechanisms”, addressing the question as to how the organism can mobilise additional strength when under stress. The book by Lutz and Mark (1995) entitled “Wie gesund sind Kranke?” (“How healthy are sick people?”) contains 24 contributions. It focuses on the debate regarding the definitions of health and illness. This is followed by studies and overviews or reports on different working areas and therapeutic approaches. Aside from the volumes and contributions, few studies on salutogenesis and psychotherapy can be found: – Broda et al. (1995): Therapieerfolg und Kohärenzgefühl (Therapeutic Success and the Sense of Coherence). – Broda et al. (1996): Selbstmanagement – Therapie und Gesundheitsressourcen (Self-management – Therapy and Health Resources). – Haltenhofer & Vossler (1997): Coping der Depression (Coping with Depression). – Plassmann & Färber (1997): Salutogenetische Therapieorganisation in der Psychosomatischen Klinik (Salutogenic Therapy Organisation in the Psychosomatic Clinic).

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– Sack et al. (1997): Kohärenzgefühl und psychosomatischer Behandlungserfolg (The Sense of Coherence and the Outcome of Psychosomatic Treatment). – Schulte-Cloos & Baisch (1996): Lebenskraft – Ressourcen im Umgang mit Belastungen (Life Strength – Resources in Coping with Stress). The concept of salutogenesis has had little impact on psychosomatics and psychotherapy. On the one hand, this is because the aspects of resource activation had already been discussed by different therapeutic schools independently of Antonovsky. The key construct – the sense of coherence – is defined by Antonovsky as one that is relatively stable and difficult to change. Thus, it is not well-suited as a criterion for denoting the success of psychotherapeutic treatment. In addition, it is in competition with numerous other empirically well-studied dimensions, such as neuroticism and depression. Even though, as a whole, psychotherapeutic and psychosomatic research has little honoured and integrated the concept of salutogenesis, we feel that the following aspects are relevant to the discourse: – – – –

The concept of health and illness, The goals of psychotherapy and treatment strategies, Preventive orientation and resource activation, Life situation and social environment.

The concept of health and disease is especially problematic in psychotherapy and psychosomatics. Who should and who must be diagnosed as exhibiting deviant behaviour, in need of treatment, ill or disturbed? Who defines the boundary between healthy and ill – the person in question, the physician, the psychologist or society? The criticism of a dichotomy between disease and health might well be relevant to the theory of mental disorders. However, the health care system requires a clear diagnosis, that is, “ill” or “healthy” (not in need of treatment) for patients with psychological complaints and symptoms. The concept of salutogenesis is helpful to the extent that it requires the different schools of psychotherapy to re-examine their theories and concepts. It forces them to answer the question whether they are sufficiently taking into consideration the role of factors that protect and maintain health in the practice of psychotherapy and in research on aetiology and therapy. Furthermore, it stimulates questions as to how much importance they attach to resource-activating methods and to the extent which they recognise and foster healthy aspects of the patient. Resource activation has long been a therapeutic principle of most therapies. Examples of resource activation are the inclusion of the patient’s partner in the therapy in a supportive role or the strengthening of his or her self-help skills. Previous research on a general model of psychotherapy attributes a key role to resource activation as a determinant for What Keeps People Healthy?

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the patient’s improvement. The concept is significant for the discussion regarding therapeutic goals, since it not only implies a focus on symptom reduction, but also aims at improving the healthy aspects and the skills of the patient. The discourse on the concept of salutogenesis in psychosomatics and psychotherapy is continued in two books: – Schüffel et al. (Eds.): Handbuch der Salutogenese. Konzept und Praxis. Berlin/Wiesbaden: Ullstein & Mosby (Handbook of Salutogenesis. Concepts and Implementation). – Margraf et al. (Eds.): Gesundheits- oder Krankheitstheorie? Berlin: Springer (Health or Illness Theory?).

4.3.

Rehabilitation

The illnesses most frequently diagnosed for rehabilitation are chronic physical illnesses, physical and sensory organ handicaps, mental disorders and mental retardation, as well as drug and alcohol dependence (Bundesarbeitsgemeinschaft für Rehabilitation, 1994). “Chronic illness” is a generic term for a number of very different illnesses of varying aetiology, pathogenesis, symptoms and prognosis. Common to all these syndromes is that they worsen continuously or in phases which can occur without warning. Frequently, causal therapy is not possible. The patients are dependent on the health care system and its specialists for long periods of time. The aetiology is generally assumed to be multifactorial, in which a particular disposition as well as habits or lifestyle play a role. Examples of chronic physical illnesses are: cardiovascular disease, cancer, chronic kidney disease, orthopaedic illnesses, illnesses of the digestive system or metabolism, HIV infection/AIDS, illnesses of the nervous system and of the skin. Coping with illness and the rehabilitation process are influenced by a number of factors: 1. Characteristics of the persons affected (e.g., sociodemographic characteristics, personality structure, comprehension of the illness and subjective theory of the illness), 2. Characteristics of health-related events and situations (intensity, duration, controllability, severity), 3. Psychosocial environment (family and significant others, professional situation, leisure activities), 4. Institutional environment (extent and type of the support experienced, atmosphere on the ward, self-help).

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The strength of the German rehabilitation system lies in the coordination of somatic, functional, professional and psychosocial measures. On the basis of the characteristics of chronic illnesses, the aims of rehabilitation and the therapeutic circumstances seem to provide favourable conditions for the integration of salutogenic principles. Nevertheless, salutogenic principles and the strategies derived from them have little impact on medical rehabilitation and the treatment of chronic illnesses. Exceptions are: – Psychosomatic rehabilitation, – Health education and health promotion in rehabilitation, – The rehabilitation of cancer patients. Psychosomatic care in Germany takes place to a great extent in rehabilitation facilities. Since, in this case, the focus is on psychotherapeutic measures, this aspect was discussed in Section 4.2., “Psychosomatics and Psychotherapy”. Although the topic of health promotion and prevention was treated in Section 4.1., the aspects specific to rehabilitation will also be discussed here. Measures taken concerning health promotion, health training and health education play an exceptional role in medical rehabilitation. Preventive measures are recognised as an overall equivalent dimension of treatment. Most programmes and measures aim at reducing health risk factors and behaviours and motivating the patient to take responsibility for his or her health. The conception and structure are mainly oriented on a medical concept of disease and rehabilitation, in which the reduction of risk factors is the principal goal of prevention. However, resource-oriented concepts, the consideration of protective factors and the emphasis of social resources have been receiving more and more attention (Liebing & Vogel, 1995; Broda & Dusi, 1996; Doubrawa, 1995). The review by Liebing and Vogel (1995) is based on a positive concept of health and does not only discuss physical skills, but also emphasises social and individual resources. The authors assert that in the future more attention should be paid to the question of healthmaintaining factors and conditions (see also Buschmann-Steinhage & Liebing, 1996). As Doubrawa (1995) sees it, in health promotion in the field of rehabilitation, the efforts of rehabilitation are based on a holistic and positive health concept which encompasses both physical as well as psychological well-being. Health is seen as a life-long process which is influenced by the individual’s biography and his or her social and ecological situation. Health promotion should not only aim at the individual behaviour of the patient, but also encourage him or her to make his or her life and environmental conditions healthy (see Section 4.1.). What Keeps People Healthy?

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Examples of Psychological Approaches of Health Promotion in the Rehabilitation Clinic Main Criteria of Health

Examples of Psychological Approaches of Health Promotion

Coping with roles

– Offers for the promotion of social and communication skills – Support in coping with specific personal problems, for example, marital counselling – Training in coping/stress management – Promotion of problem-solving and coping skills

Self-actualisation

– Life-planning group – Encouragement of interests, goal-setting, decision-making skills, social activities

Psychological well-being

– – – – –

Physical well-being

– Support of physical perceptive sensitivity and positive physical experiences – Support of coping with illness and handicaps – Reduction of health risks, for example, by non-smoking training, or “weight-watching”

Mini-course in enjoyment Autogenic training Support of realistic positive cognitions and expectations Adequate level of standards Support in the perception and expression of emotions

(Source: Doubrawa, 1995; p.20)

Table 3 In health promotion, the patient is seen as a responsible partner, who is offered knowledge on health and change, but who is left with the decision whether to put this knowledge into practice. Doubrawa compared this concept to health education that is influenced by the risk factor model. He points out the limitations of this approach in remarking that the principles of health promotion in rehabilitation must have limited effects when one considers the fact that a clinic stay of a few weeks is outweighed by very stable and influential social, economic and political influences. In the meantime, many conceptual descriptions of rehabilitation clinics include resourceoriented offers within the framework of health promotion, health training or health education. The programme of the Verband Deutscher Rentenversicherungsträger (Association of German Pension Insurance Institutions) entitled “Gesundheit selber machen” (“Do-it-yourself health”), which had been based on the classic risk factors, not only contains nutrition, exercise and physical training, exercises on the use of addictive substances, stress and coping, but also modules pertaining to protective factors and social support (Buschmann-Steinhage & Liebing, 1996).

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Doubrawa (1995) described approaches to health promotion which are exemplary for inpatient rehabilitation (see Table 3). Many of the approaches mentioned here are aimed at protective factors and the improvement of skills. They intend to improve well-being, problem-solving skills, the sense of enjoyment and the expression of emotions. However, the ideas and principles mentioned here have only just begun to be introduced in many rehabilitation clinics. The significance of salutogenesis for rehabilitation has been discussed most intensively in connection with oncological rehabilitation. The only review of the applications of salutogenic principles in oncological rehabilitation known to the authors is that in the anthology by Bartsch and Bengel (1997). Of particular interest here are the contributions by Weis (1997) and Bartsch and Mumm (1997). In Germany, the care of oncological patients takes places predominantly in specialised oncological rehabilitation clinics. In addition to medical and professional rehabilitation, psychosocial rehabilitation plays an important role (psycho-oncology). Psycho-oncology examines the psychosocial stressors caused by cancer and its effects on the quality of life and family relationships, for example, the possibility of psychological-psychotherapeutic treatment of the patient and its effects on the quality of life, employment and on the characteristics of the illness, such as relapses, metastases and life expectancy. The question as to whether the emergence and development of a tumour is influenced by psychological factors is one of the issues concerning psycho-oncology. Diverse psychosocial stressors are connected with falling ill with cancer: emotional problems, such as anxiety, depression, suicidal tendencies, hopelessness, pessimism and loss of meaningfulness, as well as ego and identity problems, partnership and family problems, for example, communication and relationship problems, changes in roles, sexual problems and employment problems (Weis, 1997). Weis contends that the goal of psychosocial rehabilitation in oncology is to convey methods of self-control to the patient, to strengthen and promote resources and to cope with the illness. Weis cites the following treatment goals: “strengthening the self-help potential, encouragement to openly express feelings, the reduction of anxiety, anger and other feelings, the improvement of self-esteem and the mental attitude towards the cancer illness, the promotion of the remaining health and personal resources, the improvement of communication between the patient, the partner and other relatives”. These goals parallel in part aspects of salutogenesis or the corresponding goals put forth by Antonovsky. Weis regards cognitive restructuring and reappraisal (patients change their assumptions about themselves, their environment and their illness) as the central issues common to both concepts. The types of treatment he recommends are behavioural therapy, art therapy, group therapy and imaginative exercises (procedures which work with the images and ideas of the patient). The significance of these kinds of treatment is reinforced by the concept of salutogenesis, yet aside from that they are relevant strategies in psychooncology. What Keeps People Healthy?

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Justifiably, Weis remarks that Antonovsky’s central issue revolves around preventing and maintaining health, whereas psycho-oncology mainly deals with patients who are severely or incurably ill. However, palliative treatment also has a use for salutogenic procedures. Palliative treatment is not designed to put an end to an illness, but rather to make living with it easier by reducing pain and maintaining the best possible quality of life. Its key component is the concept of a search for meaning that is based on inner psychological growth. Weis cites a major danger that can arise when the concept is implemented in an unreflected manner. The therapist, who is confronted with his or her own helplessness and impotence, points out positive aspects of the situation, resources and powers of selfhealing to the patient. This may be of help foremost to the therapist in repressing his or her helplessness. To date, there have been few studies or more theoretical papers on rehabilitative patient groups not belonging to oncological and psychosomatic rehabilitation. In most cases, previous rehabilitation concepts are revised “salutogenically”, that is, supplemented with lifestyle or resource-oriented services. As a result, behavioural medicine and rehabilitation psychological services are gaining in importance (for example, see Albus & Köhle, 1994). However, many of the offers have to be examined critically. Not every course in “well-being” is justified and necessary. The extent to which rehabilitation and follow-up care facilities have taken up salutogenically-oriented treatment and care concepts cannot be assessed conclusively in this report. It can be presumed, however, that in the field of health promotion in rehabilitation, and especially in the field of oncological rehabilitation, salutogenically-oriented measures are being increasingly developed and introduced and traditional strategies are being supplemented with salutogenic ones. The only advanced ideas to date which attempt to combine the concept of salutogenesis with a general theory of coping with illness are those formulated by Broda (1995). He calls for the development of competence-oriented rehabilitation that contrasts with the now dominant deficit-oriented rehabilitation. Competence-oriented rehabilitation encompasses emphasis on the responsibility of the patient, the discouraging of patient-role behaviour, as well as the strengthening of the patient’s resources. In summary, the future development of salutogenesis within the framework of rehabilitation is faced with the following tasks: 1. Integration of salutogenesis as a partial aspect of a theory of coping with illness and a theory of consequences of illness, 2. Analysis of the meaning of the sense of coherence in the course of the illness and its rehabilitation (see, for example, Collins, Hanson, Mulhern & Padberg, 1992), among other things, as a success criterion and a dimension to be influenced, 3. Development of salutogenic therapy principles for the promotion of health and coping with illness.

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Summary

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5.1.

Summary and Evaluation of the Scientific Discussion

This final chapter presents the central assumptions of the previous three chapters on the context, the theory formation and the current state of research of the salutogenic approach in distilled form. The concept will be evaluated from the perspective of health science below.

Historical Background The societal and scientific background on which Aaron Antonovsky developed his theory was influenced by growing concern about public health care and health and disease research. As early as the 1970’s, the traditional system of public health care was criticised for being based on a mechanistic view of disease and overemphasising organs and symptoms. The scientific discourse on the concepts of health and disease that followed illustrate that both are very complex phenomena that are difficult to define. Nevertheless, definitions are important, since they determine the conclusions that are drawn for the treatment of health and disease. A consequence of the criticism of the mechanistic view of disease was the development of a biopsychosocial model of disease. In this model, the explanation and treatment of disease not only takes into account somatic, but also psychological and social factors. Parallel to the development of the biopsychosocial model, increased efforts were made to prevent disease, originally exclusively on the basis of the risk factor model. This eventually led to the concept of health promotion. The development of an extended view of health and disease also led to an expansion and differentiation of the scientific subjects that dealt with the topic of health, such as social medicine, environmental medicine, medical psychology, psychosomatic medicine, psychoneuroimmunology, health psychology, behavioural medicine or public health.

The Concept of Salutogenesis Using the model of salutogenesis, Antonovsky intended to find an answer to his central thesis question: what keeps people healthy – despite the many potential noxious influences? The following characteristics denote the salutogenic approach. The human organism as a system is permanently exposed to natural and man-made influences and processes that upset its order, that is, its health. Health is not a state of stable

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homeostasis, but when confronted with detrimental influences must continuously be reestablished. Health and disease are not mutually exclusive states, but extreme poles on a continuum (the health ease/dis-ease continuum). In between are states of relative health and relative disease. The search for specific causes of disease, also referred to as the pathogenic approach, must be supplemented by the search for health-promoting or health-maintaining factors, known as the salutogenic approach. Antonovsky termed these factors “generalised resistance resources”. There are individual resistance resources, for example, physical factors, intelligence or coping strategies, as well as social and cultural resistance resources like social support, financial power or cultural stability. Asking about resistance resources places the focus on the whole person and his or her biography and not on his or her illness or symptoms only. Antonovsky’s model proceeds in the tradition of stress and coping research. According to this approach, health is endangered by the detrimental influence of different kinds of stressors. In contrast to other stress researchers, Antonovsky contends that stressors are omnipresent and that their effects are not necessarily hazardous to health. Antonovsky proposes a distinction between tension and stress. In his opinion, the first reaction to stress is physiological tension. Whether or not this results in stress and is followed by processes detrimental to health depends on the appraisal and the coping reactions of the individual. The most important dimension that determines the outcome of these appraisal and coping reactions, as Antonovsky sees it, is the sense of coherence. “The sense of coherence is 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, 1987a, p. 19). The stronger one’s sense of coherence, the more success one will have staying healthy. The SOC is made up of three components: – The feeling of comprehensibility, – The feeling of manageability, and – The feeling of meaningfulness. The feeling of comprehensibility refers to the ability to perceive the world as being ordered and structured and not as chaotic, arbitrary, random or inexplicable. The feeling of manageability concerns the conviction that problems have solutions and that one has What Keeps People Healthy?

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enough resources available to meet the demands of the situation. The feeling of meaningfulness describes the extent to which one experiences life as emotionally meaningful and that problems and challenges are worth investing energy in. The special thing about the SOC is its orchestrating function. According to Antonovsky, the strength of the SOC determines the flexible and appropriate implementation of generalised resistance resources which include the different coping styles. The SOC develops in the course of childhood and adolescence. This development is complete at about the age of 30 and remains relatively stable thereafter. Antonovsky thus describes the SOC as a dispositional orientation. However, it is not comparable to a personality trait. In Antonovsky’s opinion, whether a weak or a strong SOC develops depends on the social circumstances and the socialisation in the family. He feels that a fundamental change in adulthood is only possible to a limited extent. Altering the SOC by means of psychotherapy can only be accomplished by long, hard work. In order to measure the SOC, Antonovsky developed a questionnaire, the “Orientation to Life Questionnaire”, also called the SOC-scale, which is available in an abbreviated and in an extensive form. The empirical evidence from the examination of the questionnaire to date shows that the three dimensions of the SOC (comprehensibility, manageability, meaningfulness) cannot be observed individually, i.e., the scale measures only the total strength of the SOC. The instrument proves to have high reliability; in other words, it is an accurate measure.

Current State of Research Despite the popularity of the concept of salutogenesis, our research revealed that, in the twenty years since Antonovsky introduced his model, no more than 200 studies have been published which examine the empirical foundation of the model. This shows that the model has attracted little attention in the scientific community. Even in the USA, which leads research in the health sciences, only few studies have been conducted. The empirical foundation of the salutogenic model is limited to cross-sectional studies, which measure the relation between the SOC and diverse parameters of psychological and physical health and personality traits (e.g., physical complaints, anxiety, life satisfaction, stress perception, social support and health-related behaviour). These correlations do not allow conclusions to be drawn about causal relationships. If significant relationships between a high SOC and a health variable are established, it cannot be regarded as proof that the SOC is a causal factor (that is, a prerequisite or a cause) for health and health maintenance. The SOC shows a high negative correlation with measures of mental health, like anxiety and depression; e.g., people that have a high SOC value are less anxious and depressed than those with a lower SOC value.

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The relationship between the SOC and measures of physical health is less clear. This finding contradicts Antonovsky’s assumption that the SOC has a direct influence on physical health. The SOC seems to have an influence on the perception of stress and coping styles and can facilitate adaptation to difficult life situations. People with a high SOC tend to perceive events or demands as more of a challenge and less of a strain. When they do experience stress, they can recover from it more quickly. These premises made by Antonovsky have been confirmed by many empirical findings. Few studies focus on the relationship between the SOC and the different measures of social support. Individual results show a positive relationship between the SOC and the number of friends, marital satisfaction and social support. For the field of prevention, it is of importance whether the SOC has an effect on concrete health behaviour, such as getting regular exercise, or risk behaviour, like smoking. Because the few studies on this subject came to contradictory results, no clear conclusions can be drawn. As far as gender is concerned, women appear to have lower SOC scores on average than men. Female socialisation might be a barrier for the development of a strong SOC. In contrast to Antonovsky’s assumption that the SOC remains stable throughout adulthood, the studies reviewed indicate that the SOC does indeed increase with age. However, longitudinal studies must be conducted before any well-founded statements about the alterability of the construct can be made. Because of the contradictory findings, no clear statements can be made about the relationship between the SOC and education level, socio-economic status and employment.

Related Concepts Prior to and coinciding with the development of the notion of the SOC, constructs and concepts were developed that attempt to explain how individual characteristics and cognitive styles influence the emergence and change of health and disease, as well as coping with disease and health behaviour. Among the most well-known personal or internal protective factors are health locus of control, self-efficacy, optimism, hardiness and mental health, but also depression and anxiety. The current state of research varies greatly for the different constructs, that is, they differ as to the number of studies and the empirical evidence regarding the validity of the model. There are similarities between the SOC and optimism as well as between the SOC and hardiness. The relationship between the SOC and self-efficacy is less clear. What Keeps People Healthy?

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The constructs mentioned above and the salutogenesis model were developed within the context of stress research. For this reason, the fundamental theoretical ideas of more recent approaches in stress research often show close similarities to Antonovsky’s model. Cognitive appraisal processes are essential in evaluating and coping with stressors. One of the most well-known stress theories is Lazarus’ transactional stress model. He distinguished between two appraisal processes. First, events can be judged as being a threat, a challenge or as irrelevant for one’s own well-being. Second, the resources are appraised that one can employ or cannot employ to cope with the stressor. There are different coping strategies which are more or less appropriate to the adaptation to a changing life situation. Coping with stress seems to be most effective when different coping strategies are used flexibly. Antonovsky considers the fact that the salutogenic perspective was neglected in traditional approaches in stress research to differentiate it fundamentally. Like stress research, resilience or invulnerability research is merely the backdrop for diverse research directions. The concepts of “resilience” and “invulnerability” refer to stable and healthy personality and behavioural developments that have occurred despite unfavourable experiences and stress in early childhood. The research in this field often lacks a fundamental theory. As a result, potentially protective factors are often presented in the form of a catalogue of variables. In this context, the SOC is sometimes mentioned as one of the many factors, neglecting its assumed orchestrating function in the mobilisation of resistance resources. Characteristic for resilience research are longitudinal studies. They are superior to cross-sectional studies, since they are better suited to establishing a causal relationship between health and protective factors.

Evaluation Antonovsky formulated his salutogenic model at a time when the medical care system was being criticised, the research on disease and its causes was being broadened to include the psychosocial dimension, and the significance of environmental factors was being recognised. At the same time, preventive efforts were being strengthened and a holistic, not exclusively symptom-oriented procedure was in demand. The basic idea of the salutogenic approach is similar to the concept of lifestyles of the World Health Organization and the concept of health promotion as it was laid down in the 1986 Ottawa Charter. The basic ideas of the salutogenic approach are not new. Salutogenic recommendations and concepts can be traced back to medicine in ancient times. Since then, predecessors and related concepts have been developed. However, Antonovsky is the first that not only criticised the pathogenic model but also parried it with a salutogenic theory that he thoroughly described and tried to confirm with empirical evidence.

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The salutogenic model can be considered the first and the most advanced model on the explanation of health (Dlugosch, 1994; Faltermeier, 1994). It takes into account dimensions on a social, physiological, biochemical and cognitive level. Because it includes many variables, it has a high integrative value (Becker, 1992). The model corresponds to a complex, meta-theoretical and heuristic model of processing (Faltermaier, 1994; Jerusalem, 1997). That means it serves as a framework for orientation that can organise and illustrate complex relationships. Many of the assumptions that the model of salutogenesis makes are too complex to be easily empirically examined. As a model of processing, it unites several time dimensions that require different methodical approaches. It has two principle time levels: 1. The emergence of the SOC is explained by the model components of generalised resistance resources and their sources, life experience and the result of tension reduction. These are longitudinal processes since the development of the SOC takes place predominantly in the early years of life. 2. The current state of health, however, is explained by the components of stressors, SOC, generalised resistance resources (GRRs), states of tension and states of stress. These are short or medium-term processes. The GRRs that go into effect are not identical to those that contributed to the emergence of the SOC. The different levels of the model illustrate that only a partial aspect of it can be examined. For many of the assumptions, problems regarding their operationalisation have not been satisfactorily solved. The salutogenic model assumes an information transfer between the participating levels and subsystems. However, there is no means of explaining how this transfer takes place (Noack, 1997). Thus, Antonovsky repeatedly stresses the sociological character of his model, which can mainly be seen in the fact that the SOC is influenced by structural characteristics. However, the theory does not offer a sufficient explanation as to how sociostructural factors influence the strength of the SOC (Siegrist, 1993). In the same vein, genetic factors, among others, are not included. The idea that health and disease are to be conceived as two poles on a continuum enables a more differentiated evaluation of an individual’s state of health than would be the case with categorisation as either healthy or ill. A disadvantage of the one-dimensional view is that it assumes a linear relationship between the decrease in healthy and the increase in ill components. The less healthy components a person has, the more ill components he or she must have. It appears better to conceive of health and disease as two independent factors (see Lutz & Mark, 1995). Surprisingly, Antonovsky does not presume that there is a direct connection between the central variable, SOC, and the position on the health ease/dis-ease continuum. What Keeps People Healthy?

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A weakness of the model is its narrow focus on physical condition. Antonovsky’s line of argumentation on this issue is difficult to follow. Although he assumed a relationship between the SOC, physical state and psychological well-being, he refused to integrate it into his model. Yet, separating physical and psychological well-being builds up a dichotomy that defeats the efforts to assert an holistic view of the person. The characteristics of a very weak SOC are very similar to cognitive and emotional symptoms of depression: the individual overlooks his or her resources, cannot respond flexibly and appropriately to demands, and finds life meaningless. Antonovsky’s stress concept remains unclear on several points. For example, it does not describe what distinguishes a state of tension from a state of stress. The processes that make states of stress have a pathogenic effect also remain undefined. Although the connection between noxious factors and weak areas are cited as the causes of the emergence of health impairment, there is no differentiation between acute stress reactions and continuous stress. Siegrist (1993) points out that Antonovsky’s theory neglects the fundamentals of stress-physiological theory, and especially the emotional theory; in other words, it attaches too little weight to affective components. The selection of coping strategies and the implementation of resources is seen in Antonovsky’s model as being chiefly carried out rationally (Siegrist, 1993; 1994). A central issue is whether the SOC actually has a superordinate, directing function as Antonovsky contends. Noack (1997), for example, does not grant the concept this function, but places it alongside constructs like self-efficacy, self-esteem or optimism. Up to now, there have been few attempts to develop the model of salutogenesis on the theoretical level. This is the case although Antonovsky himself, as well as other authors, are of the opinion that the concept is incomplete and leaves many questions open (Franke, 1997; Noack, 1997). Becker (1992) presented an interactional demands-resources model that follows the tradition of the stress-coping paradigm as well as taking up Antonovsky’s salutogenic perspective. Physical and mental health or disease are explained as a result of individual efforts to cope with internal and external demands with the aid of internal and external resources. Noack (1997) calls for a further development of the salutogenic approach in order to explain prerequisites for positive health developments so that health-political and practical guidelines can be derived (see also “Theorie der Humanmedizin”, “Theory of Human Medicine” by Uexküll & Wesiack, 1988.). The entire model of salutogenesis is rarely, and has seldom been, the subject of empirical examination. This is not surprising considering the complexity of the model. On the one hand, we have a comprehensive model of health that eludes empirical testing, and on the other hand, studies on narrowly defined relationships between the central construct of the model, the SOC, and a long list of health, and especially disease parameters. The research

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results are contradictory for the most part. There is hardly any relationship that can currently be considered relatively certain, since in some cases only a few studies ever investigate the same relationship, or the studies contain contradictory results. Homogeneous results have mainly been established in relation to the SOC and measures of mental health, which Antonovsky did not take into consideration or expect. Here, especially high correlations between the SOC, anxiety and depression were found. Thus, the question is still open as to whether the measurement of the SOC, as opposed to constructs with a longer and more intensive research tradition, provides an additional information. The direct influence of the SOC on physical health as postulated by Antonovsky cannot be supported to the extent expected. Judging by the current state of research, the SOC-scale developed by Antonovsky produces only a total value of the SOC. The values of the three dimensions “comprehensibility”, “manageability” and “meaningfulness” cannot be individually measured by the SOCscale. Even though Antonovsky himself was not very surprised about this, it contradicts the theoretical assumptions and the corresponding empirical results. Antonovsky criticises the fact that the salutogenic perspective has gained little or no foothold in health science research. In his opinion, the research hypotheses are formulated pathogenically from the start, resulting in a search for the causes of disease, yet without explaining why people remain healthy in the face of critical life events or continuous stress. The dependent variables examined are almost exclusively parameters of disease. Positive measures of health are disregarded. In addition, without any further examination, stressors are simply presumed to be detrimental to health. The studies we surveyed are salutogenically oriented in the sense that they examine the SOC. However, few fundamental differences from previous theories and research could be determined, since they continue to focus on the relationships between the SOC and negative measures of health such as complaints, symptoms and illnesses. The assumption regarding the stability of the SOC has not been sufficiently confirmed, and the presumed intercultural or transcultural validity has not been tested. Researching health-protective factors is, of course, more difficult than researching risk factors. In summary, the SOC is one of many concepts that have been proposed and examined. In particular, its overlapping with other constructs and the difficulty in keeping its three components separate, a problem of construct validity and dimensionality, will hinder the further development of its empirical foundation. Aside from the integrative power of the salutogenic model, the main issues of criticism are: – – – –

The focus on cognitive and subjective dimensions (SOC) as decisive, The low status of mental health, The limited analysis of the interaction between physical and mental health, The unexplained interaction between the SOC and health or disease, that is, the con-

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tradiction between the model and empirical findings regarding the SOC and mental health, – The methodological problems posed by empirical testing of the model. We consider the significance of the concept for the health sciences to be twofold. First, it stimulates research in the health sciences on protective factors and resources, and second, it broadens the view to include relationships and interactions between health risks and protective health factors or protective health conditions. It confirms the importance of a framework theory of health or health maintenance, even though it cannot be empirically tested by today’s methods.

5.2.

Summary and Evaluation of the Importance and the Utilisation of the Concept

The model of salutogenesis is currently being discussed in three fields of application: health promotion and prevention, psychosomatics and psychotherapy, and rehabilitation. In other areas of work, the concept of salutogenesis plays only a minor role.

Salutogenesis in Health Promotion and Prevention Within the three fields mentioned above, salutogenesis has attained the greatest importance in health promotion and health education or prevention. Salutogenesis provides a theoretical framework for preventive activities in these fields that often lack a theoretical foundation and are merely one of an eclectic many. The salutogenic model serves as a meta-theory which legitimates conceptual ideas and measures to be taken. It supports a critical view of health education and preventive efforts to date, challenges the risk factor model, and stands for resource-oriented, competence-raising and unspecific preventive measures. It is also important that the model parries the puritanical aspects of “warnings”, “alarms” and “austerity” with a positive concept. The shift in perspective from risk factors to preventive factors is compatible with a modern, interactive concept of health, which ranks the psychological and social dimensions on the same level as the physical dimension. The inception of the salutogenesis model occurred about the same time as the community psychology movements that formulated the concept of empowerment and socialecological approaches. All these approaches stand for or have enabled a shift in perspective in prevention, which has had an impact on the Ottawa Charter of the WHO and the approach of health promotion. Even though the terms “salutogenesis” or “SOC” are not

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mentioned in the Ottawa Charter of the WHO of 1986, it subsequently placed the main concern of health promotion on the strengthening of the SOC and Antonovsky’s positive self-perception of self-efficacy as a major element of health. Many authors seem to feel that putting the salutogenic model into practice in the field of prevention is equal to implementing the WHO concept of health promotion. However, this also implies that the sparse literature available on the possible applications of salutogenesis has nothing new to say or offer which goes beyond the discussion on health promotion. Programmes such as “Healthy Cities”, “Make Children Strong”, “First Love and Sexuality”, and so on, foster the active participation of non-professionals or the members of self-help groups and attempt to strengthen their resources and competence, while conveying positive forms of communication and interaction independent of their risk behaviour. These measures cover very different areas and include social, ecological and communal aspects in the activities. The basic premises of Antonovsky’s model for health promotion and prevention imply the need to create an environment which offers children and adolescents enough resources to build a strong sense of coherence. The SOC does dominate as a personal resource in the model of salutogenesis; however, in order for it to develop, health-promoting and preventive measures must aim at fostering a broad spectrum of individual, social and cultural factors, such as intelligence, education, coping strategies, social support, financial opportunities and cultural stability. Measures in keeping with the salutogenic model should enable children to have repeated, consistent experiences, as well as a balance between overload and underload. However, it is quite probable that, in the future, the informative research findings on protective factors will not be presented within the context of salutogenesis, but in resilience research and research on the epidemiology of psychological and somatic disorders in childhood and adolescence. As far as efforts to promote health and prevent disease in adults are concerned, Antonovsky’s assumption of a stable SOC in adulthood paints a bleak picture. However, the stability of the SOC in adulthood has not been satisfactorily confirmed by empirical investigations. According to Antonovsky, the problem that arises in the face of health promoting interventions in adulthood is that adults would require very intensive measures to achieve a change. The publications and written documents we found on salutogenesis in the field of prevention could have been developed and introduced without Antonovsky’s theoretical ideas. However, we must qualify this remark by saying that many preventive concepts and measures are not available in written and evaluated form. The motivational and argumentational use of the salutogenic concept to plan and implement programmes, such as skill-improving programmes for pre-school children, for example, but also for the entire field of health promotion and prevention, is a matter of conjecture. What Keeps People Healthy?

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Despite criticism of the scientific value of the concept of salutogenesis, it will continue to play an important role, especially in prevention and health promotion. The salutogenic model comes closest to the intentions and goals of the actors in this field, albeit the information level differs among them. In many cases, they appeal for a shift to salutogenesis without having true knowledge of the model. In other cases, conventional measures are retained but relabeled as “salutogenic”.

Salutogenesis in Psychosomatics and Psychotherapy The overall low status of Antonovsky’s model in psychotherapy and psychosomatics is illustrated by the fact that, in more recent textbooks, the concept of salutogenesis is mentioned sparsely and then on a general level. Three conference proceedings discuss the importance of the SOC and salutogenesis in psychotherapy and psychosomatics. However, the critical discussion of the pathogenic and biomedical model devoted to the disease and health model dominates. “Salutogenesis” is seen here as a synonym for resource activation, whose importance, independent of Antonovsky, is underscored by most therapeutic schools. Yet, few studies have investigated the change in SOC as a result of psychotherapeutic treatment.

Salutogenesis in Medical Rehabilitation In the field of medical rehabilitation, the concept of salutogenesis has gained some significance, but only within the framework of health promotion. The measures provided by so-called health education are usually devoted to the medical disease concept and are geared to reducing health risk behaviour. However, resource-oriented approaches are gaining recognition, and the health promotion approach is being demanded by rehabilitation and implemented in part. The programmes known to us are being supplemented with modules like protective factors, social support or enjoyment training. However, these measures remain centred around the individual and the way they are put into practice deviates from the holistic concept of health promotion. The term “salutogenesis” is often used as a new name for old services or rehabilitation goals. However, it spurs one to rethink them. The integration of salutogenesis as a partial aspect of a theory of coping with disease and its consequences, the analysis of the significance of the SOC in the course of the disease and its rehabilitation, and the development of salutogenic therapy goals, are important tasks for rehabilitation.

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Summary Evaluation Antonovsky does not stop at a scientific analysis of health, but goes on to formulate consequences for public health and the health sciences. His concept of the health ease/disease continuum animates the discussion on the concept of disease and health. He makes an appeal for interdisciplinary research on health and disease and reinforces behavioural as well as behaviourally-oriented prevention. He thus stimulates a discussion on the importance of health care and the societal value of health. The construct of the SOC as a dimension of therapeutic and preventive measures has not been established and researched to a sufficient extent. From a scientific view, it is doubtful whether this construct can or will ever assert itself. The interest in the salutogenic model can be explained by the criticism of current research, the criticism of the pure pathological perspective, and the need for a theory of action, especially for health promotion and prevention.

5.3.

Outlook and Recommendations

This expert report presents the current state of discussion on the concept of salutogenesis. In this endeavour, we can only survey published material or that otherwise known to us, so that this review must remain selective and is by no means comprehensive. The evaluation represents the opinion of the authors. Since the reception and discussion of the concept in the health sciences began relatively late and continued rather haltingly, we believe that a general evaluation of the concept would not do it justice. For this reason, we would prefer to close this report by answering three key questions. These questions represent possible appraisal dimensions and confirm that the evaluation would or must reach a different conclusion according to the perspective under which it is carried out.

1. Why is the concept so attractive? Is this evidence for a paradigm change in health research and health care? The model criticises the pathogenic perspective and thus the health system exclusively focused on the elimination of symptoms, suffering and disease. Salutogenesis thus indirectly demands the acceptance of health processes and, according to Franke (1997), What Keeps People Healthy?

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offers at least the possibility of integrating dying and death as unchangeable components of human life. Despite its political implications, the model does not provide an answer to the question of an adequate concept for public health care. Salutogenesis criticises the fact that health care is one-sidedly focused on disease (“Wie das bestehende Gesundheitssystem kranke Anteile verstärkt und gesunde Anteile unterdrückt” [How the Present Health Care System Strengthens Ill Aspects and Represses Healthy Ones], Lutz & Mark, 1994) and asks the question whether a “salutodiagnostic” approach should not complement a “pathodiagnostic” approach. It could show the patients which healthy aspects they have apart from their symptoms and could encourage or tell them to work on strengthening them. It would also make clear to them that these resistance factors and resources are also of high value for the therapy of their symptoms and illnesses. On the other hand, the search for resources leads to an expansion of the diagnostic evaluation, which must remain unspecified, since the resources can be found in all areas of life and the physician or the patient might feel that their exploration is inappropriate or too invasive. Research in the health sciences is characterised by a number of experiments and studies that are often unrelated to each other and are difficult to place within a unified and action-oriented framework. Salutogenesis fulfils in part the desire and the need for a comprehensive, interdisciplinary and general theory of health and is compatible with the biopsychosocial model of health and disease. The biopsychosocial model, in which health and disease are viewed as dependent on biological, physical and psychological circumstances and processes, as well as social and societal influences, still plays a more significant role, both scientifically and practically, than does the model of Antonovsky. However, the former remains predominantly pathogenically oriented, whereas the salutogenesis model radically and more consistently takes and emphasises a health-oriented perspective. Thus, selecting this model fulfils two important needs of the scientist and the practitioner: it offers a critical evaluation of the predominant research and health care paradigm and provides a theoretical framework for its research and practice. At the same time, it criticises health research and health care which is one-sidedly oriented toward pathological processes. Salutogenesis will not replace or succeed the risk factor model, but it can be seen as a significant reminder not to concentrate exclusively on risk factors. By emphasising a continuum, salutogenesis makes a significant contribution to the discussion on the concepts of health and disease. Health and disease are not two mutually exclusive categories, but, according to Antonovsky, form the poles of a continuum. In further development, they can be considered to be parallel, measured next to each other, describable and subjectively experienceable units that, of course, are in relation to each other and interact. The ill person has healthy components and, inversely, most healthy persons have ill or less well-functioning components. Health and disease are not static

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dimensions, but are constantly undergoing change both in the individual and in society. One cannot say that Antonovsky’s model has launched a paradigm change. Too many things developed before or at the same time as it did: the critical discourse on the health care system, the discussion of the health and disease concepts, the development of the biopsychosocial models and the principles of health promotion.

2. Is the salutogenesis model scientific? This question is often posed by representatives of institutions involved in prevention, health care, rehabilitation, and by high-ranking politicians. What it really means is whether the concept can withstand a scientific analysis, or whether it is justified from a scientific point of view to plan or carry out measures based on this concept. Can the statements be confirmed scientifically or are efforts being made to confirm them, and can relevant and well-founded guidelines for fields of application be derived from them? Any study on the subject of salutogenesis and the SOC that is contextually and methodologically planned and conducted adequately is “scientific”. In this sense, the research and confirmation of the central construct of the SOC has begun, but in comparison to other constructs, it is still minimal and by no means completed. The construct has not been circumscribed precisely enough to set it off from other, similar constructs. The items it contains are difficult to measure and the findings are often contradictory. The question as to how one is to understand the conveyance or the mechanism by which the SOC influences health is still unanswered. Can the SOC be altered at all in adulthood? Does the construct fall too short? The model as a whole has not been tested and is not testable because of its complexity. The studies surveyed showed a high level of consistency between the SOC and similar constructs. The very relationship between the SOC and behaviour or physical health has only been postulated – not, however, empirically confirmed. In our opinion, the current state of research is not sufficient to allow the evaluation of the model it merits and leaves more questions open than it answers.

3. Which consequences result for practical work? Looking at the number of attempts made to put salutogenic principles into practice, one must draw the conclusion that it is at the beginning. This raises the question as to whether an intensive discussion about the model would or could yield something qualitatively different than what was already described and appealed for in the Ottawa Charter of the WHO for health promotion. The ideas set down in the Ottawa Charter can be transposed without any problems or contradictions to the salutogenesis model, and vice versa. What Keeps People Healthy?

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There is a potential danger in euphorically touting salutogenic principles. The structures of our public health care system should not be underestimated, nor should the expectations and the needs of the target group. The patients have been socialised according to the medical model (that is, predominantly pathogenic); they often only want their symptoms to be alleviated and not primarily offers to increase their competency and to strengthen their SOC. Of course, this automatically raises the question as to the quality of such services and their financing. Since measures aimed solely at the individual are not in keeping with the concept, structural and societal changes are necessary. The analysis of the fields of application shows that the concept has attained a certain amount of importance in three areas: in health promotion and prevention, in psychosomatics and psychotherapy, and in rehabilitation. In all of these areas, salutogenesis coincides with developments that can easily be combined with the assumptions and premises of salutogenesis: resource orientation, focus on health-maintaining factors, holism, concentration on the acquisition of skills, emphasis on environmental aspects, positive definition of health, and the criticism of the concept of pathology. In these cases, too, the providers of health-promoting services, psychotherapists and the providers of rehabilitation measures profit from the proposed conceptual framework of salutogenesis. Salutogenesis stresses positive aspects and positive experiences, preventing illness, and thus is quite compatible with many of the self-set goals in these fields of application. Here, too, it serves as a meta-theory. However, if one takes a closer look, one sees that the direct derivation of measures is problematic. For practical work, one aspect is especially important: Antonovsky emphasises the relevance of ethical questions. On the one hand, the definition of health is always attached to norms, and this poses the danger of discriminating against people on the basis of these moral or ethical principles. Since a salutogenic perspective entails the consideration of all areas of life, including very private ones, all salutogenic-oriented measures for the promotion of health also carry the danger of a totalitarian influence by the empowered institutions: “I am fully aware that one implication of the salutogenic approach or the institutional organisation of a society’s health care system is the endless expansion of social control in the hands of those who dominate this system. The direction of the answer, to the extent that there is one, lies precisely in the question of who dominates the system, on the institutional as well as on the immediate, interpersonal level of the doctor/patient relationship” (Antonovsky, 1987a, pp. 10–11). Antonovsky sees yet another danger in unjustified association of health promotion and ethical or moral behaviour. Not everything that is functional and positive for health is necessarily morally justified, and not everything that is morally or ethically just must also be good for health. Even people whose behaviour is considered unethical can be in the best of health (Antonovsky, 1995).

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The fascination of the concept also carries the danger of unreflected adoption of its principles and can hinder the necessary discussion on its scientific and practical significance. Many of those who plan measures and services in the public health care system, especially in prevention and health promotion, lack sufficient knowledge of salutogenesis or have unrealistic expectations of the concept. Employees of health promotion and prevention facilities, of rehabilitation clinics, of specialised psychosomatic clinics and other health care facilities, but also self-help groups, need information about the concept. They would like to discuss the current status and possible consequences for their field of work. Thus, the authors strongly urge the communication of the central assumptions of the concept and an exchange about the consequences for services and measures (contribution and limits of the concept, conceptual planning of the work, possibility of a service with salutogenic-based measures). Studying and discussing the model in the above-mentioned perspectives would be especially called for in the prevention and health promotion fields. Presentations, conferences or seminars on the subject of salutogenesis should not only be targeted at scientists, but also at those active in the fields of health promotion and prevention. Such presentations should serve to exchange information and discuss the fundamental ideas of the model. The discussion should include the possible consequences that can be drawn from system-induced and individual-oriented measures, and encourage thoughts on the ways in which salutogenic principles can be put into practice.

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Appendix

6

6.1.

Documentation of the Literature Search

The material for this expert report on salutogenesis was gathered in the course of an extensive literature research that we conducted. Among our sources are the germane literature databases as well as the Internet: Psyndex 1990–1998 Search words: Saluto, sense of coherence, Antonovsky Psyclit 1990–1998 Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky Medline 1990–1998 Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky Current Contents 1993–1997 Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky Dissertations Abstracts 1989–1997 WISO III, PAIS, Social Sciences Index, ERIC Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky Internet: Search words: Salutogenese, salutogenesis, Antonovsky Periodicals: Periodicals of Health Sciences 1990–1997 Textbooks: Medical Psychology and Sociology, Clinical Psychology, Psychosomatics and Psychotherapy, Health Psychology, Personality Psychology

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6.2.

Original Works by Antonovsky

Antonovsky, A. (Ed.) (1961): The early Jewish Labor Movement in the United States. New York: YIVO Institute of Jewish Research. Antonovsky, A. (1972): Breakdown: A needed fourth step in the conceptual armamentarium of modern medicine. Social Science & Medicine, 6, 537–544. Antonovsky, A. (1973): The utility of the breakdown concept. Social Science & Medicine, 7, 605–612. Antonovsky, A. (1976): Conceptual and methodological problems in the study of resistance resources and stressful life events. In: Dohrenwend, B. S. / Dohrenwend, B. P. (Eds.): Stressful life events: their nature and effects (pp. 245–258). New York: Wiles & Sons. Antonovsky, A. (1979): Health, stress, and coping: New perspectives on mental and physical well-being. San Francisco: Jossey-Bass. Antonovsky, A. (1983): The Sense of Coherence: Development of a Research Instrument. W. S. Schwartz Research Center for Behavioral Medicine, Tel Aviv University, Newsletter and Research Reports, 1, 1–11. Antonovsky, A. (1984a): A call for a new question – salutogenesis – and a proposed answer – the sense of coherence. Journal of Preventive Psychiatry, 2, 1–13. Antonovsky, A. (1984b): The sense of coherence as a determinant of health. In: Matarazzo, J. D. / Weiss, S. M./ Herd, J. A. / Miller, N. E. (Eds.): Behavioral health (pp. 144–129). New York: Wiley & Sons. Antonovsky, A. (1985): The life cycle, mental health, and the sense of coherence. Israel Journal of Psychiatry & Related Sciences, 22, 273–280. Antonovsky, A. (1986): Intergenerational networks and transmitting the Sense of Coherence. In: Datan, N. / Greene, A. L. / Reese, H. W. (Eds.): Life-span developmental psychology. Intergenerational relations (pp. 211–222). Hillsdale, NJ: Lawrence Erlbaum Associates. Antonovsky, A. (1987a): Unraveling the mystery of health. How people manage stress and stay well. San Francisco: Jossey-Bass. Antonovsky, A. (1987b): The salutogenic perspective: toward a new view of health and illness. Advances. The Journal of Mind-Body Health, 4, 47–55. Antonovsky, A. (1989): Die salutogenetische Perspektive: Zu einer neuen Sicht von Gesundheit und Krankheit. Meducs, 2, 51–57. Antonovsky, A. (1990a): Personality and health: Testing the Sense of Coherence Model. In: Friedman, H. S. (Ed.): Personality and Disease (pp. 155–177). New York: Wiley & Sons. Antonovsky, A. (1990b): Pathways leading to successful coping and health. In: Rosenbaum, M. (Ed.): Learned resourcefulness: on coping skills, self-control, and adaptive behavior (pp. 31–63). New York: Springer. Antonovsky, A. (1991a): Meine Odyssee als Stressforscher. In: Anonymous (Ed.): Jahrbuch für Kritische Medizin (pp. 112–130). Hamburg: Argument Verlag. Antonovsky, A. (1991b): The structural sources of salutogenic strengths. In: Cooper, C. L. / Payne, R. (Eds.): Personality and stress: Individual differences in the stress process (pp. 67–103). Chichester, UK: John Wiley & Sons. Antonovsky, A. (1992a): The behavioral sciences and academic family medicine: An alternative view. Family Systems Medicine, 10, 283–291. Antonovsky, A. (1992b): Can attitudes contribute to health? Advances. The Journal of Mind-Body Health, 8, 33–49. Antonovsky, A. (1993a): Gesundheitsforschung versus Krankheitsforschung. In: Franke, A. / Broda, M. (Eds.): Psychosomatische Gesundheit. Versuch einer Abkehr vom Pathogenese-Konzept (pp. 3–14). Tübingen: dgvt.

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Antonovsky, A. (1993b): The implications of salutogenesis. An outsider’s view. In: Turnbull, A. P. / Patterson, J. M. / Behr, S. K. / Murphy, D. L. / Marquis, J. G. / Blue-Banning, M. J. (Eds.): Cognitive coping, families, and disability (pp. 111–122). Baltimore: Brooks. Antonovsky, A. (1993c): The structure and properties of the Sense of Coherence Scale. Social Science & Medicine, 36, 725–733. Antonovsky, A. (1993d): Complexity, conflict, chaos, coherence, coercion and civility. Social Science & Medicine, 37, 969–981. Antonovsky, A. (1994): A sociological critique of the “Well-Being” Movement. Advances. The Journal of MindBody Health, 10, 6–12. Antonovsky, A. (1995): The moral and the healthy: Identical, overlapping or orthogonal? Israel Journal of Psychiatry & Related Sciences, 32, 5–13. Antonovsky, A. (1996): The sense of coherence. An historical and future perspective. Israel Journal of Medical Sciences, 32, 170–178. Antonovsky, A. (1997): Salutogenese. Zur Entmystifizierung der Gesundheit. Expanded German edition by A. Franke. Tübingen: dgvt. Antonovsky, A. / Maoz, B. / Dowty, N. / Wijsenbeek, H. (1971): Twenty-five years later. A limited study of the sequelae of the Concentration Camp experience. Social Psychiatry, 6, 186–193. Antonovsky, A. / Sagy, S. (1986): The development of a sense of coherence and its impact on responses to stress situations. Journal of Social Psychology, 126, 213–225. Antonovsky, A. / Sourani, T. (1988): Family sense of coherence and family adaption. Journal of Marriage and the Family, 50, 79–92. Antonovsky, A. / Sagy, S. (1990): Confronting developmental tasks in the retirement transition. The Gerontologist, 30, 362–368. Antonovsky, A. / Sagy, S. / Adler, I. / Visel, R. (1990): Attitudes toward retirement in an Israeli cohort. International Journal of Aging and Human Development, 31, 57–77. Antonovsky, H. / Antonovsky, A. (1974): Commitment in an Israeli Kibbutz. Human Relations, 27, 303–319. Anson, O. / Antonovsky, A. / Sagy, S. (1990): Religiosity and well-being among retirees: A question of causality. Behavior, Health, and Aging, 1, 85–97. Dahlin, L. / Cederblad, M. / Antonovsky, A. / Hagnell, O. (1990): Childhood vulnerability and adult invincibility. Acta Psychiatrica Scandinavica, 82, 228–232. Langius, A. / Björvell, H. / Antonovsky, A. (1992): The sense of coherence concept and its relation to personality traits in Swedish samples. Scandinavian Journal of Caring Sciences, 6, 165–171. Sagy, S. / Antonovsky, A. (1992): The family sense of coherence and the retirement transition. Journal of Marriage and the Family, 54, 983–993. Sagy, S. / Antonovsky, A. / Adler, I. (1990): Explaining life satisfaction in later life: The sense of coherence model and activity theory. Behavior, Health, and Aging, 1, 11–25.

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6.3.

References

Ahrens, S. (Ed.) (1997): Lehrbuch der Psychotherapeutischen Medizin. Stuttgart: Schattauer. Albus, C. / Köhle, K. (1994): Gesundheit wiedergewinnen. Konzept für eine salutogenetisch orientierte, ambulante Behandlung von Koronarkranken. In: Lamprecht, F. / Johnen, R. (Eds.): Salutogenese. Ein neues Konzept in der Psychosomatik? (S. 130–139). Frankfurt: VAS. Anson, O. / Carmel, S. / Levenson, A. / Bonneh, D. / Maoz, B. (1993): Coping with recent life events: The interplay of personal and collective resources. Behavioral Medicine, 18, 159–166. Anson, O. / Paran, E. / Neumann, L. / Chernichovsky, D. (1993a): Psychological state and health experiences: Gender and social class. International Journal of Health Sciences, 4, 143–149. Anson, O. / Paran, E. / Neumann, L. / Chernichovsky, D. (1993b): Gender differences in health perceptions and their predictors. Social Science & Medicine, 36, 419–427. Anson, O. / Rosenzweig, A. / Shwarzmann, P. (1993): The health of women married to men in regular army service: Women who cannot afford to be ill. Women & Health, 20, 33–45. Antonovsky, A. (1972): Breakdown: A needed fourth step in the conceptual armamentarium of modern medicine. Social Science & Medicine, 6, 537–544. Antonovsky, A. (1979): Health, stress, and coping: New perspectives on mental and physical well-being. San Francisco: Jossey-Bass. Antonovsky, A. (1983): The Sense of Coherence: Development of a research instrument. W. S. Schwartz Research Center for Behavioral Medicine, Tel Aviv University, Newsletter and Research Reports, 1, 1–11. Antonovsky, A. (1987a): Unraveling the mystery of health. How people manage stress and stay well. San Francisco: Jossey-Bass. Antonovsky, A. (1987b): The salutogenic perspective: toward a new view of health and illness. Advances. The Journal of Mind-Body Health, 4, 47–55. Antonovsky, A. (1993a): Gesundheitsforschung versus Krankheitsforschung. In: Franke, A. / Broda, M. (Eds.): Psychosomatische Gesundheit. Versuch einer Abkehr vom Pathogenese-Konzept (S. 3–14). Tübingen: dgvt. Antonovsky, A. (1993b): The implications of salutogenesis. An outsider’s view. In: Turnbull, A. P. / Patterson, J. M. / Behr, S. K. / Murphy, D. L. / Marquis, J. G. / Blue-Banning, M. J. (Eds.): Cognitive coping, families, and disability (pp. 111–122). Baltimore: Brooks. Antonovsky, A. (1993c): The structure and properties of the Sense of Coherence Scale. Social Science & Medicine, 36, 725–733. Antonovsky, A. (1993d): Complexity, conflict, chaos, coherence, coercion and civility. Social Science & Medicine, 37, 969–981. Antonovsky, A. (1995): The moral and the healthy: Identical, overlapping or orthogonal? Israel Journal of Psychiatry & Related Sciences, 32, 5–13. Antonovsky, A. (1997): Salutogenese. Zur Entmystifizierung der Gesundheit. Expanded German edition by A. Franke. Tübingen: dgvt. Antonovsky, A. / Sagy, S. (1990): Confronting developmental tasks in the retirement transition. The Gerontologist, 30, 362–368. Antonovsky, A. / Sourani, T. (1988): Family sense of coherence and family adaption. Journal of Marriage and the Family, 50, 79–92. Antonovsky, H. / Sagy, S. (1986): The development of a sense of coherence scale and its impact on responses to stress situations. Journal of Social Psychology, 126, 213–225.

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6.4.

Overview of the Studies on the Sense of Coherence

Author/Year

Country

Sample

Variables Examined

Instruments

Anson, Paran, Neumann & Chernichovsky (1993a; 1993b)

Israel

N=238 men and women with mild hypertension

SOC education employment marital status happiness distress satisfaction with family relations subjective evaluation of health symptom perception

SOC-scale Memorial University of New Foundland Scale of Happiness Psychological Distress Scale Measure Family Functioning self-developed scales

Results Gender differences were established in the sense that women have a much lower SOC score than men. Women have greater risks: They are more likely to lose their jobs and have less education. Less women are married; women are unhappier; they experience less mental wellbeing, are less satisfied with the atmosphere in the family and perceive themselves as being unhealthier. The higher the SOC score, the better the questionee estimated his or her own health to be (r=-.23) and the less symptoms of illness were reported (r=-.24).

Author/Year

Country

Sample

Variables Examined

Instrumentes

Anson, Rosenzweig & Shwarzmann, (1993)

Israel

N=97 women, of which N=44 were married to army members and N=53 to civilians

SOC availability of social support residential mobility labour force participation health distress utilisation of health services

SOC-scale, short form Scale of Psychological Distress self-developed scales

Results As a result of frequent moving, wives of army members have less psychosocial resources available related to inconsistency in social contacts, worse job opportunities and more worries. The SOC value of wives of army members was lower than that of the control group. Thus, the unfavourable living conditions are presumed to hinder the development of the SOC. Surprisingly, however, no differences between the state of physical health and psychological well-being was determined in both samples.

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Author/Year

Country

Sample

Variables Examined

Instruments

Becker, Bös, Opper, Woll & Wustmann (1996)

Germany

N=863 men and women of varying states of health a non-representative sample

SOC age gender mental health internal health locus of control exercise under stress conditions depressive coping style healthy nourishment intensive exercise good sleep social support (total=health-related variables, “gesundheitsrelevante Variablen”, “GRV”) habitual physical health level, i.e., high health, low health, normal health

Trierer Persönlichkeitsfragebogen (Trier Personality Inventory) SOC-scale Fragebogen zur sozialen Unterstützung (questionnaire of social support) self-developed scales

Results The authors differentiate between three research perspectives and thus pose three corresponding research questions reflecting the salutogenic, the pathogenic, and a comprehensive health psychological perspective. To test the first question, the high health group was compared to the rest of the sample. The SOC did not distinguish this group from the other two. The low health group, however, had significantly lower SOC scores than the rest of the sample. The SOC correlated with all GRVs (health-related variables) in the expected direction with the exception of intensive exercise. Of all GRVs, only mental health, SOC, exercise and restful sleep were predictive of the habitual level of health. However, this variable explained only 19% of the variance.

Author/Year

Country

Sample

Variables Examined

Instruments

Bös & Woll (1994)

Germany

N=500 men and women

SOC gender age internal locus of control health rating by physician self-rating of health exercise

SOC-scale Trierer Persönlichkeitsfragebogen (Trier Personality Inventory) I-Skala der körperbezogenen Kontrollüberzeugunge n (I-Scale of Physically-Related Locus of Control) self-developed scales

Results The SOC correlates in the expected direction with mental health, internal locus of control, and self-evaluation of health. No relationship could be established, however, between the SOC and the rating of the state of health by physician. Older persons with a high SOC score get more exercise. This relationship is not significant for younger persons.

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Author/Year

Country

Sample

Variables Examined

Instruments

Bowman (1996; 1997)

USA

N=186 psychology students

SOC ethnic origin: Native American (associated with larger families and lower SES) vs. Anglo-American depression anxiety physical health

SOC-scale Beck Depression Inventory State-Trait Personality Inventory Wahler Physical Symptom Inventory

Results No differences in the SOC score could be found in persons of different ethnic origin, socioeconomic status and family size. Negative correlations were established between the SOC and depression (r=-.49 in Native Americans, r=-.66 in Anglo-Americans), anxiety (r=-.43 and r=-.64, respectively), and physical health (r=-.29 and r=-.41, respectively).

Author/Year

Country

Sample

Variables Examined

Instruments

Callahan & Pincus (1995)

USA

N=828 rheumatism patients, predominately white, female, and married

SOC pain functional limitations learned helplessness general state of health

SOC-scale, long and short form MHAQ-Activity of Daily Living Difficulty Scale Arthritis Helplessness-Scale self-developed scales

Results In contrast to Antonovsky, the authors did not find a three-factor solution but only one factor. The short form is as reliable as the long form. Patients with lower ADL status, more pain, worse state of general health, and more helplessness with respect to their illness have lower SOC scores. The correlation coefficients, r=-.25 and r=-.42, are however relatively low. The duration of the illness, sex, ethnic origin, and education level had no influence on these relationships. There is a low, but significant relationship between the SOC and age.

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Author/Year

Country

Sample

Variables Examined

Instruments

Chamberlain, Petrie & Azariah (1992)

New Zealand

N=57 male and female, mostly older patients before and after a surgical operation

SOC gender surgical operation optimism as a personality trait pain state of health life satisfaction positive well-being psychological distress

Life Orientation Test SOC-scale Mental Health Inventory self-developed scales

Results Optimism and the SOC correlate positively (r=.62), but they correlate to varying degrees with the dependent variables. The SOC correlates in the expected direction with life satisfaction, well-being, psychological symptoms, and state of health, but not, however, with pain before the operation. When the preoperative values of the dependent variables are controlled, the SOC has a predictive value for positive health measures, but not for the negative ones (pain and psychological symptoms); in contrast, there is no longer a predictive value for optimism.

Author/Year

Country

Sample

Variables Examined

Instruments

Coe, Miller & Flaherty (1992)

USA

N=148 caregivers to chronically ill elderly persons (with Alzheimer, incontinence, etc.), most of whom white, female, and married to the patients

SOC sociodemographic characteristics relationship to the patient type of patient’s illness caregiving tasks time required employment status perceived burden of caregiving tasks physical and mental health status utilisation of health services received or desired help

SOC-scale, short form Geriatric Depression Scale no further information

Results Caregivers with high SOC scores were compared to those with low scores. Caregivers with a pronounced SOC perceived themselves as having less stress by their partners’ illness, have better mental health, i.e., lower depression values, etc., feel they have better support from friends and relatives and require less aid. Age, employment, health status, extent of the caregiving activities, and severity of the illness do not correlate significantly with the SOC. In contrast, the relationship between the SOC and depression (r=-.49) and mental health (r=.36) is significant. The SOC values of men are higher than those of women.

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Author/Year

Country

Sample

Variables Examined

Instruments

Dangoor & Florian (1994)

Israel

N=88 physically disabled married younger women

SOC medical diagnosis (neurological disease, skeletal-muscular disease, inner chronic illness) age socio-economic status functional handicaps effects of the handicap mental health family adaptation to the illness

SOC-scale Mental Health Inventory Evaluating and Nurturing Relationship Issues Communication and Happiness Scale self-developed scales

Results The SOC correlates high with mental health (r=.80) and family adaptation to the illness (r=.53) and correlates negatively (r=-.23) with the effects of the handicap. Not the objective aspects of the handicap but the extent of the SOC appears to be decisive for the adaptation to the illness. Medical diagnosis and functional handicaps have no predictive value. The high correlation between mental health and SOC can possibly be attributed to confounding between the MHI and the SOC-scale.

Author/Year

Country

Sample

Variables Examined

Instruments

Dudek & Makowska (1993)

Poland

N=523 pregnant women in hospital for delivery

SOC age education employment

SOC-Scale

6

Results The authors found high item intercorrelations and high correlations between the sub-scales. Manageability explains 80% of the variance of the complete SOC-scale. The scale has high reliability (split-half method r=.91). The authors found a five-factor-solution: Meaningfulness and Comprehensibility – the latter consisted of 3 sub-scales. No relationship could be established between age and education level and the SOC. Low correlations (r=.11 and .14, respectively) between comprehensibility and age/education level.

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Author/Year

Country

Sample

Variables Examined

Instruments

Flannery & Flannery (1990)

USA

N=95 adult students attending night school, predominately women

SOC life stress psychological distress anxiety depression

SOC-scale Hassles Scale Taylor Manifest Anxiety Scale Beck Depression Inventory

Flannery, Perry, Penk & Flannery (1994)

Results High negative correlations between the SOC and the independent variables were established. The same results hold for all the sub-scales of the SOC-scale. There are high intercorrelations of the sub-scales of the SOC-scale. A factor analysis indicates a one-factor solution.

Author/Year

Country

Sample

Variables Examined

Instruments

Frenz, Carey & Jorgensen (1993)

USA

N=374 healthy men and women, and psychotherapy patients

SOC patient/non-patient status age gender perceived stress anxiety depression alcohol consumption social desirability intelligence

SOC-scale Perceived Stress Scale State-Trait Anxiety Inventory-Trait Beck Depression Inventory QuantityFrequencyVariability Questionnaire Social Desirability Scale Shipley Institute of Living Scale

Results The authors found a one-factor solution for the SOC-scale and a high retest-reliability. Age and SOC correlated significantly in the expected direction. Patients have lower SOC values than healthy persons. In contrast to the expectations there was no significant relationship found between the SOC and alcohol consumption. There was a high negative relationship (r=-.73) between the SOC and perceived stress in both groups. There was a correlation of r=-.85 between the SOC and anxiety in the patient groups, which raises the question, whether these are two distinct constructs. As well, a high correlation of r=-.60 between the SOC and depression in patients was found; and r=-.39 between the SOC and social desirability. There was no relationship found between the SOC and intelligence.

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Author/Year

Country

Sample

Variables Examined

Instruments

Gallagher, Wagenfeld, Baro & Haepers (1994)

Belgium

N=126 caregivers (predominately women) of demented and chronically ill persons

SOC type of illness role overload coping responses

SOC-scale Activity of Daily Living self-developed scales

Baro, Haepers, Wagenfeld & Gallagher (1996)

Results Negative correlations between the SOC and perceived feelings of role overload. The higher the SOC, the greater the ability to attribute meaning to the caretaking activity (in the sense of a coping strategy). Negative correlations also between the SOC and active coping strategies, as well as between the SOC and coping strategies such as social withdrawal, smoking, and the consumption of medication.

Author/Year

Country

Sample

Variables Examined

Instruments

Gebert, Broda & Lauterbach (1997)

Germany

N=250 patients of a psychosomatic clinic

SOC constructive thinking – the ability to solve every day problems with a minimal amount of stress physical symptoms psychological symptoms gender patient/non-patient status age education

SOC-scale Constructive Thinking Inventory Gießener Beschwerdebogen (Gießener Complaints Questionaire) Kieler Änderungssensitive Symptomliste (Kieler Symptomlist Sensitive to Change)

control group: N=121 clinically asymptomatic persons

Results No gender differences, when age was controlled for. No relationship between age, education level and the SOC. Significant correlations between physical complaints and the SOC (r=-.54). High significant correlations between the SOC and constructive thinking (r=.82). Significant correlations between psychological complaints and the SOC (r=-.68). Significant differences between patient and control group concerning the SOC, i.e., patients with psychosomatic illnesses have a lower SOC value than healthy persons.

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Author/Year

Country

Sample

Variables Examined

Instruments

George (1996)

USA

N=653 field-workers, predominately female, that make house calls or do home health care for health organisations

SOC perception of risk to their own health by their profession (home health care) age education years of employment gender

SOC-scale Home Health Care Perception of Risk Questionnaire

Results Weak but significant correlations: Men have higher SOC-values than women. Older persons and those with many years of professional experience have higher SOC values than younger persons and those with less professional experience. The estimated risk to their own health by there profession is lower the higher the SOC. High SOC values correlate with the capability of refusing to make house calls perceived to be hazardous to their health. The use of self-defence methods (an accompanying person, tear gas, etc.) is not influenced by the strength of the SOC. The SOC correlates with cognitions, but not with behaviours: Cognitions about one’s own risk and about the possibilities of controlling them (refusing to make dangerous house calls).

Author/Year

Country

Sample

Variables Examined

Instruments

Gibson & Cook (1997)

USA

N=306 Open University students (N=67 male, N=239 female)

SOC personality traits general state of health gender

SOC-scale Dispositional Resilience Scale Eysenck Personality Inventory General Health Questionnaire

Results Significant negative correlations between general health and the SOC (r=-.26) for women; in contrast, hardiness correlates negatively with general health for men (r=-.33). Women have higher values in the meaningfulness scale than do men.

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Author/Year

Country

Sample

Variables Examined

Instruments

Hood, Beaudet & Catlin (1996)

Canada

N=16,291 Adults (National Population Health Survey)

SOC gender age income education ethnic origin family status employment traumatic events recent life events functional level of health subjective level of health chronic illnesses

SOC-scale, short form self-developed scales

Results Weak, but significant correlations with the three dependent variables in the expected direction (correlation between r=-.10 for chronic illnesses and r=.31 for functional aspects of health). SOC explains 10% of the variance for functional level of health, 4% for subjective level of health, and 1% for chronic illnesses. The other independent variables each explained 15% of the variance. No gender differences. Persons with traumatic experiences have lower SOC-values than those without traumatic experiences.

Author/Year

Country

Sample

Variables Examined

Instruments

Korotkov (1993)

Canada

N=712 Students

SOC daily stress perceived physical symptomatology emotionality

SOC-scale, short form Hassles and Uplifts Scale, revised version Symptom Checklist, revised version self-developed scales

Results The author found evidence for the hypothesis that the SOC and emotionality are confounded. Face validity: 11 of 13 items refer to feelings (according to two independent raters). Construct validity: Authors found three factors: Symptomatology, chronic stress, and as a third factor all items of the SOC and the emotionality scale. Predictive value of the SOC score low, if age, gender, and emotionality are partialled out (3% of the variance explained for physical health). No variance explained for physical health by the SOC at the second measurement (4 weeks following the first).

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6

Author/Year

Country

Sample

Variables Examined

Instruments

Kravetz, Drory & Florian (1993)

Israel

N=164 patients with coronary heart disease

SOC hardiness Locus of Control anger depression anxiety

SOC-scale Hardiness Scale Rotter’s I-E Locus of Control Scale State-Trait Anxiety Scale Beck Depression Inventory Anger Arousal Scale

Results The authors found two factors: negative affect and health proneness. Hardiness and Locus of Control load on the factor health proneness, which in turn, correlates negatively with the second factor, “negative affect” (anger, depression, anxiety). The SOC correlates with the factor “negative affect” to the same extent as it correlates positively with the factor “health proneness”. The authors regard this as calling to question the discriminative validity of the SOC-construct. They point out that the SOC encompasses many aspects of anxiety, depression, and anger. This can be seen on the level of the items that very often address the questionees negative feelings.

Author/Year

Country

Langius, Björvell & Antonovsky (1992)

Sweden

Sample N=97 nurses N=166 male and female patients

Variables Examined

Instruments

SOC self-motivation anxiety hostility

SOC-scale Self-Motivation Inventory Karolinska Scales of Personality

N=155 men and women of the normal population

Results The groups showed no differences in their SOC scores. Low SOC scores correlated with increased (somatic and psychological) anxiety and hostility. No correlations between the SOC and extraversion or aggression. High negative correlations with self-motivation in all groups examined.

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Author/Year

Country

Sample

Variables Examined

Instruments

Langius & Björvell (1993)

Sweden

N=145 men and women of three different age groups

SOC general health physical and psychological health age

SOC-scale, short and long form Sickness Impact Profile self-developed scales

Results Relationship between the SOC and the SIP-total scale r=-.29; a more exact analysis revealed however, that the relationship stems from significant correlations between the score on the psychosocial scales and the SOC and here only with the sub-scales sleep and recreation. Significant correlations between the SOC and general health (r=-.32 for the long form and r=-.21 for the short form). Hardly any differences between the short and the long form of the SOC-scale.

Author/Year

Country

Sample

Variables Examined

Instruments

Larrson & Kallenberg (1996)

Sweden

N=2003 men and women of a representative population sample

SOC age gender education employment income size of household number of friends general physical health psychological well-being physical and psychological symptoms

SOC-scale, short form Stress Profile Life Style Profile self-developed scales

Results Men have higher SOC scores than women. SOC scores increase with age. Education and the SOC do not correlate. Self-employed, salaried employees, higher income, larger household, and greater number of friends correlates significantly with the SOC. The higher the SOC the healthier the person. Relationships between the SOC and psychological well-being and psychological symptoms are larger (r= .18 to r=.53) than between the SOC and general physical state of health and physical symptoms (r=.13 to r=.31). The influence of the SOC on health is higher for women than for men. The SOC is the best predictor of all the independent variables examined.

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Author/Year

Country

Sample

Variables Examined

Instruments

Lundberg (1997)

Sweden

N=4390 persons of a representative population sample (predominately participants in a longitudinal study)

SOC age gender social class Indicators of childhood conditions Illness Indicators

SOC-scale, short form self-developed scales

Lundberg & Nynström Peck (1994)

Results Social class and socio-economic status during childhood have no influence on the SOC in adulthood. Family conflicts in childhood appear to have a slight effect on the SOC in adulthood. The SOC and social class in adulthood correlate, i.e., blue collar workers have a lower SOC than self-employed and salaried workers. Low SOC scores correlate with poor psychological and physical health, even when controlled for age, gender, and childhood situation, i.e., the risk of psychological distress for a person with a weak SOC is 3.5 times higher than that of persons with an average or high SOC score. The SOC and social circumstances in childhood are independent influential factors on the health of the adult.

Author/Year

Country

Sample

Variables Examined

Instruments

Margalit, Raviv & Ankonina (1992)

Israel

N=161 pairs of parents of either handicapped or non-handicapped children

SOC parent’s gender handicapped child or nonhandicapped child coping behaviour perceived family environment perceived abnormal behaviour of child

SOC Coping Scale Family Environment Scale Child Behaviour Checklist

Results Parents of handicapped children exhibit lower SOC scores than those without a handicapped child, i.e., the handicap makes the parents feel that the world is less controllable and comprehensible. Gender differences could be found in the sense that fathers had higher SOC scores than mothers.

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Author/Year

Country

Sample

Variables Examined

Instruments

McSherry & Holm (1994)

USA

N=60 students with high, middle, and low SOC scores

different strengths of the SOC anxiety anger curiosity stress perceptions coping behaviour pulse rate skin resistance

State-Trait Personality Inventory Stress Arousal Checklist Dakota Cognitive Appraisal Inventory Dimensional Coping Checklist physiological data with the aid of the necessary equipment

Results The subjects were exposed to a stress situation. Time of measurement was before and after the stress stimulus. It could be demonstrated that subjects with high and average SOC scores were significantly less stressed, anxious, and angry than those with low SOC scores. There were also differences in the expected direction regarding the estimation of the own coping ability and coping strategies, i.e., people with low SOC scores make use of less coping resources, less social, material, and psychological resources and have less confidence in their ability to master the situation. The authors found relationships between the SOC and self-efficacy as well as Locus of Control. High SOC scores lead to a reduction in the physiological parameters toward the end of the confrontation with the stress stimulus, i.e., although all three groups showed a reaction to stress, those with lower SOC scores begin and end the stress situation with higher stress measurements.

Author/Year

Country

Sample

Variables Examined

Instruments

Pasikowski, Sek & Scigala (1994)

Poland

N=60 men and women

SOC gender education place of residence Health Locus of Control (holistic-functional or biomedical health models)

SOC-scale Health Belief Scale

6

Results No differences between men and women, persons with higher or lower education and persons from rural or urban areas regarding the SOC scores. The “meaningfulness” scale correlates with a holistic-functional model of health.

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Author/Year

Country

Petrie & Brook (1992)

New Zealand

Sample N= 150 parasuicidal male patients (N=39) and (N=111) female patients

Variables Examined

Instruments

SOC depression hopelessness self-esteem suicidal ideation

SOC-scale Hopelessness Scale Self-Rating Depression Scale Coopersmith Self-Esteem Inventory Paykel et al. Scale

Results Correlations between the SOC sub-scales and the other variables were significant in the expected direction (between r=.65 and r=.76). Sub-scale meaningfulness the best predictor variable for suicidal ideation during hospitalisation. Six months later the SOC sub-scales comprehensibility and manageability the best predictor variables. The SOC better predictor for suicide risk than depression, etc.

Author/Year

Country

Sample

Variables Examined

Instruments

Rena, Moshe & Abraham (1996)

Israel

N=80 paralysed patients and their N=72 spouses

SOC severity of disability acceptance of disability anxiety health relative vulnerability marital satisfaction social activities work and study hours

SOC-scale Acceptance of Disability Scale State-Trait Anxiety Inventory Relative Vulnerability in Couples Relationship Index of Marital Satisfaction Questionnaire self-developed scales

Results High, significant correlations between the SOC and anxiety, psychosomatic complaints, and acceptance of the handicap. Significant correlations also between the SOC and perceived dependence, marital satisfaction, and work schedule. Results were similar for the disabled persons as well as for the healthy spouses. All three sub-scales of the SOC-scale have a significant predictive value. The SOC is a better predictor of the adaptation to the illness than the severity of the illness.

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Author/Year

Country

Sample

Variables Examined

Instruments

Rimann & Udris (1998)

Switzerland

N=559 male and female salaried employees

SOC stress at work and at home social and organisational resources mental health as a personality trait as coined by Becker Health Locus of Control value orientations coping styles age gender profession position in the company’s hierarchy

SOC-scale, short form coping questionnaire self-developed questionnaires no information on further instruments

Results The SOC short form is multi-dimensional, the authors did not succeed in discriminating the components postulated. Significant correlations with related constructs, the coefficients were however not substantial (18–34% common variance). The correlation of SOC and mental health is r=.58. The SOC correlates most strongly and inversely with resignation (r=-.37). Mildly positive correlations are found between SOC and attempts of situational control as well as palliative coping attempts. Gender differences are not clearly identifiable. Relationship to age in the expected direction. Professional action area and position in the company’s hierarchy correlate with the SOC – management had the highest scores compared to other groups, unskilled workers the lowest.

Author/Year

Country

Sample

Variables Examined

Instruments

Sammallahti, Holi, Komulainen & Aalberg (1996)

Finland

N=122 psychiatric patients and N=334 persons of the normal population as a control group

SOC psychiatric illness mental health defence styles

Defence Style Questionnaire General Health Questionnaire Symptom Checklist 90

Results Two-factor-solution: 1st factor items of the SOC-scale, meaningfulness, 2nd factor, “feelings”, encompasses the scales comprehensibility and manageability. The SOC correlates high with SCL-90 (r=-.83), GHQ (r=-.66), i.e., the severity of the psychiatric symptoms and mental health. The SOC correlates with all the sub-scales of the SCL-90 like somatisation, depression, anxiety, anger, hostility, psychoticism, etc. Immature Defences Style (a sub-scale of the DSQ) and the SOC correlate at r=-.78.

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6

Author/Year

Country

Sample

Variables Examined

Instruments

Scherwitz & Ornish (1994)

USA

N=48 older patients scheduled for angiography; control group design: Lifestyle Change Intervention – participants and patients on the waiting list

SOC psychophysiological measurements Type A behavior patterns participation/non-participation in the intervention

not reported

Results One year later, the SOC score was higher in the intervention group than in the control group.

Author/Year

Country

Sample

Variables Examined

Instruments

SchmidtRathjens, Benz, Van Damme, Feldt & Amelang (1997)

Germany

N=5133 men and women between the ages of 40 and 65

SOC personality type (cancer personality, heart-circulatory personality as coined by Grossarth-Maticek) dispositional optimism health beliefs time urgency and perpetual activation anger hostility psychoticism personality traits as conceptualised by Eysenck exaggerated social control critical life events social support physical health gender

SOC-scale measurement of the behaviour typology (Grossarth-Maticek) Life Orientation Test Fragebogen zur Erfassung gesundheitsbezogener Kontrollüberzeugungen (Questionnaire to measure health beliefs) Time Urgency and Perceptual Activation Scale State-Trait-Anger-Expression Inventory Depressivitäts Skala (Depression Scale) Eysenck Persönlichkeits Inventar (Eysenck Personality Inventory) Way of Life Scale List of Critical Life Events Questionnaire of Social Support

Results Healthy persons have higher SOC scores than ill persons, independent of gender. Women have lower scores than men – differences are, however, slight when compared numerically. Correlations with dispositional optimism (r=.53), depression (r=-.63) , and neuroticism (r=-.61). Mean differences on the SOC-scale between healthy persons, cancer patients, and patients with cardiovascular disease disappear when depression and neuroticism are controlled for. They therefore can be explained by the last two variables.

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Studies Mentioned in Antonovsky’s Review Article 1 Author/Year

Country

Sample

Variables Examined

Instruments

Antonovsky & Sagy (1990)

Israel

N=805 adults shortly before retirement

SOC socio-economic status gender attitude towards retirement

SOC-scale Attitude towards Retirement-Scale

Sagy, Antonovsky & Adler (1990)

Results The higher the SOC score, the less likely the subject was to perceive the impending retirement as a loss, rather the more likely he or she was to experience it as a gain. This result was found for all the social classes examined and for men as well as women; it is thus independent of socio-economic status and gender.

Author/Year

Country

Sample

Variables Examined

Instruments

Antonovsky, H. & Sagy (1986)

Israel

N=418 students of different ages, N=63 of which before and after the evacuation of the Sinai

SOC emotional closeness with parents communication with parents age gender stability of the community anxiety

SOC-scale State-Trait Anxiety Inventory self-developed scales

6

Results Boys have higher SOC scores than girls. Older students have a higher SOC than younger students. No influence could be determined of the emotional bond and communication with parents on the SOC score. The more unstable the environment, the lower the SOC score. Contrary to the hypothesis the quality of the parent-child relationship had no effect on the SOC score. The variable examined explained only 8% of the variance. The higher the SOC score the lower the anxiety score (trait). No relationship could be established between SOC and anxiety (state) in an acute crisis (one week before the evacuation). However, the correlation is significant six weeks after the evacuation, i.e., when the crisis situation got back to normal, youths with a higher SOC score showed a lower anxiety score (state).

1

Antonovsky, A. (1993c): The structure and properties of the Sense of Coherence Scale. Social Science & Medicine, 36, 725–733.

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Author/Year

Country

Antonovsky & Sourani (1988)

Israel

Sample N=60 handicapped men and their wives, working class

Variables Examined

Instruments

FSOC (Family Sense of Coherence) Perceived family satisfaction

Family Sense of Coherence Scale Family Adaptation Scale

Results Families with a high SOC score perceived their families to be better adapted to the father’s handicap and are more satisfied with the family environment.

Author/Year

Country

Sample

Variables Examined

Instruments

Carmel, Anson, Levenson, Bonneh & Maoz (1991)

Israel

N=230 male and female members of two kibbutzim

SOC age gender recent life events psychological well-being physical well-being functional ability

SOC-scale The Social Readjustment Rating Scale Scale of Psychological Distress Quality of Wellbeing Scale self-developed scales

Anson, Carmel, Levenson, Bonneh & Maoz (1993)

Results The SOC correlates positively with health measurements (r=.12 to r=.23). When gender is controlled for, however, this correlation is only valid for men. The SOC correlates more with psychological and physical well-being than with productivity. Slight (but significant) negative relationship between SOC and critical life events, i.e., either the SOC prevents critical life events or the experiencing of critical life events reduces the SOC. No gender differences could be found regarding the SOC scores.

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Author/Year

Country

Sample

Variables Examined

Instruments

Cederblad & Hansson (1996)

Sweden

N=148 persons belonging to psychiatric risk groups

SOC intelligence activity, flexibility and stability as personality traits Locus of Control coping strategies quality of life physical and mental health

SOC-scale Symptom Checklist 90 Quality of Life Scale Health Sickness Rating Scale Ways of Coping Checklist Locus of Control Sjobring Model of Personality Dimensions

Cederblad, Dahlin & Hagnell (1993) Cederblad, Dahlin, Hagnell & Hannson (1995) Dahlin, Cederblad, Antonovsky & Hagnell (1990)

Results In addition to the SOC, 8 further personality dimensions were examined. A multiple regression analysis revealed that the SOC was the best predictor for the outcome variables quality of life and physical and mental health. The SOC correlates significantly with SCL-90 (r=.72), QOL (r=.77), perceived health (r=.46) and HSRS (r=.51).

6 Author/Year

Country

Sample

Variables Examined

Instruments

Hart, Hittner & Paras (1991)

USA

N=59 College students

SOC anxiety social support

SOC-scale, short form Trait Anxiety Inventory Interpersonal Support Evaluation List

Results High correlations between anxiety and the SOC. No relationship between the SOC and social support.

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6.5.

Orientation to Life Questionnaire (SOC-Scale)

Source: Antonovsky, A. (1987): Unraveling the mystery of health. How people manage stress and stay well. Orientation to Life Questionnaire Here is a series of questions relating to various aspects of our lives. Each question has seven possible answers. Please mark the number which expresses your answer, with numbers 1 and 7 being the extreme answers. If the words under 1 are right for you, circle 1; if the words under 7 are right for you, circle 7. If you feel differently, circle the number which best expresses your feelings. Please give only one answer to each question.

1. When you talk to people, do you have the feeling that they don’t understand you? never have this feeling

1

2

3

4

5

6

7

always have this feeling

2. In the past, when you had to do something which depended upon cooperation with others, did you have the feeling that it: surely wouldn’t get done

1

2

3

4

5

6

7

surely would get done

3. Think of the people with whom you come into contact daily, aside from the ones to whom you feel closest. How well do you know most of them? you feel that they’re strangers

1

2

3

4

5

6

7

you know them very well

4. Do you have the feeling that you don’t really care about what goes on around you? very seldom or never

1

2

3

4

5

6

7

very often

5. Has it happened in the past that you were surprised by the behaviour of people whom you thought you knew well? never happened

1

2

3

4

5

6

7

always happened

6. Has it happened that people whom you counted on disappointed you? never happened

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1

2

3

4

5

6

7

always happened

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7. Life is: full of interest

1

2

3

4

5

6

7

completely routine

2

3

4

5

6

7

very clear goals and purpose

8. Until now your life has had: no clear goals or purpose at all

1

9. Do you often have the feeling you’re being treated unfairly? very often

1

2

3

4

5

6

7

very seldom or never

4

5

6

7

completely consistent and clear

7

deadly boring

10. In the past ten years your life has been: full of changes without your knowing what will happen next

1

2

3

11. Most of the things you do in the future will probably be: completely fascinating

1

2

3

4

5

6

12. Do you have the feeling that you are in an unfamiliar situation and don’t know what to do? very often

1

2

3

4

5

6

7

very seldom or never

4

5

6

7

there is no solution to painful things in life

5

6

7

ask yourself why you exist at all

13. What best describes how you see life: one can always find a solution to painful things in life

1

2

3

14. When you think about your life, you very often: feel how good it is to be alive

1

2

3

4

15. When you face a difficult problem, the choice of a solution is: always confusing and hard to find

What Keeps People Healthy?

1

2

3

4

5

6

7

always completely clear

125

6

16. Doing the things you do every day is: a source of deep pleasure and satisfaction

1

2

3

4

5

6

7

a source of pain and boredom

4

5

6

7

completely consistent and clear

17. Your life in the future will probably be: full of changes without your knowing what will happen next

1

2

3

18. When something unpleasant happened in the past, your tendency was: “to eat yourself up” about it

1

2

3

4

5

6

7

to say “ok, that’s that, I have to live with it”, and go on

5

6

7

very seldom or never

7

it’s certain that something will happen to spoil the feeling

19. Do you have very mixed up feelings and ideas? very often

1

2

3

4

20. When you do something that gives you a good feeling: it’s certain that you’ll go on feeling good

1

2

3

4

5

6

21. Does it happen that you have feelings inside that you would rather not feel? very often

1

2

3

4

5

6

7

very seldom or never

22. Do you anticipate that your personal life in the future will be: totally without meaning or purpose

1

2

3

4

5

6

7

full of meaning and purpose

23. Do you think that there will always be people whom you’ll be able to count on in the future? you’re certain there will be

1

2

3

4

5

6

7

you doubt there will be

24. Does it happen that you have the feeling that you don’t know exactly what’s about to happen? very often

126

1

2

3

4

5

6

7

very seldom or never

Research and Practice of Health Promotion, Volume 4

25. Many people – even those with a strong character – sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past? never

1

2

3

4

5

6

7

very often

7

you saw things in the right proportion

26. When something happened, have you generally found that: you overestimated or underestimated its importance

1

2

3

4

5

6

27. When you think of difficulties you are likely to face in important aspects of your life, do you have the feeling that: you will always succeed in overcoming the difficulties

1

2

3

4

5

6

7

you won’t succeed in overcoming the difficulties

28. How often do you have the feeling that there’s little meaning in the things you do in your daily life? very often

1

2

3

4

5

6

7

very seldom or never

29. How often do you have feelings that you’re not sure you can keep under control? very often

1

2

3

4

5

6

7

very seldom or never

6

What Keeps People Healthy?

127

Codification of the Items The table on this page shows which item is attributed to which sub-scale of the SOC: C=Comprehensibility, MA=Manageability, ME=Meaningfulness. The score for a sub-scale and the total score for SOC as a whole can be calculated by adding the points marked for each item in the questionnaire. Care, however, must be taken regarding the item scoring. If the item is positively scored, then the rating value marked is taken at face value: for example, a positively scored item which the questionee rates at “2”, is then scored with two points. However, if the item is reverse scored, the lowest value marked (i.e., 1) must be converted to the highest value (i.e., 7). In keeping with this procedure, a 2 would get 6 points, a 3 would get 5 points and so on.

Item Number

128

SOC Sub-scale

Item Scoring

Short Form

1

C

2

MA

reverse scoring positive scoring

3

C

positive scoring

4

ME

reverse scoring

5

C

reverse scoring

S

6

MA

reverse scoring

S

7

ME

reverse scoring

8

ME

positive scoring

S

9

MA

positive scoring

S

10

C

positive scoring

11

ME

reverse scoring

12

C

positive scoring

13

MA

reverse scoring

14

ME

reverse scoring

15

C

positive scoring

16

ME

reverse scoring

17

C

positive scoring

18

MA

positive scoring

19

C

positive scoring

20

MA

reverse scoring

21

C

positive scoring

22

ME

positive scoring

23

MA

reverse scoring

24

C

positive scoring

25

MA

reverse scoring

S

26

C

positive scoring

S

27

MA

reverse scoring

28

ME

positive scoring

S

29

MA

positive scoring

S

S

S

S

S S

Research and Practice of Health Promotion, Volume 4

In the specialist booklet series "Research and Practice of Health Promotion" has been published previously: Volume 1 – Gender-related Drug Prevention for Youths Practical Approaches and Theory Development. Final report of a research project by Peter Franzkowiak, Cornelia Helfferich and Eva Weise commissioned by the FCHE. Order No. 60 802 070

Volume 2 – Ecstasy: Use and Prevention Empirical Research Results and Guidelines. Documentation of a FCHE status seminar held in Bad Honnef from 15 to 17 September 1997. Order No. 60 801 070

Volume 3 – Quality Assurance in AIDS Prevention Report of the Expert Conference from 13 to 15 November 1995 in Cologne. A conference in cooperation with the World Health Organization, Regional Office for Europe, Copenhagen. Order No. 60 803 070

Volume 5 – Child Health Epidemiological Foundations. Order No. 60 805 070

To be published shortly: Volume 6 – Evaluation as a Quality Assurance Tool in Health Promotion A project commissioned by the European Commission. Order No. 60 806 070

schwarz, HKS67, HKS43, Pfeile = 100% aus HKS 44

WHAT KEEPS PEOPLE HEALTHY? ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

RESEARCH AND PRACTICE OF HEALTH PROMOTION

BZgA ISBN 3-933191-20-3

THE CURRENT STATE OF DISCUSSION AND THE RELEVANCE OF ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

VOLUME 4 Volume 4

Bundeszentrale für gesundheitliche Aufklärung

WHAT KEEPS PEOPLE HEALTHY?

Publisher: Federal Centre for Health Education