51776969 antonovsky what keeps people healthy

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Publisher: Federal Centre for Health Education

VOLUME 4

RESEARCH AND PRACTICE OF HEALTH PROMOTION

ISBN 3-933191-20-3

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

BZgABundeszentralefürgesundheitlicheAufklärung

WHAT KEEPS

PEOPLE HEALTHY?

THE CURRENT STATE OF DISCUSSION AND THE RELEVANCE OF ANTONOVSKY’SSALUTOGENETIC MODEL OF HEALTH

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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 measuresaimed at maintaining and promoting health.

It develops campaign concepts and strategies,produces summaries of media and methods,cooperates with a variety of workers andagencies in the health education field, andcarries out education measures both for thepopulation as a whole and covering selectedtopics for specific target groups.

The FCHE uses research results to plan andimplement its work, as well as to evaluate itseffectiveness and efficiency. This researchincludes projects on selected individual topics,evaluation studies, and the commissioning ofrepresentative repeat surveys. In order topromote an exchange of information andexperience between theory and practice theFCHE holds national and internationalconferences.

These studies and assessments, along with theresults of specialist meetings, are published bythe FCHE in its specialist booklet series on“Research and Practice of Health Promotion”.This is to be seen as a forum for scientificdiscussion. The aim of the series – like theexisting series on sex education and familyplanning – is to further extend the dialoguebetween theory and practice.

What Keeps People Healthy?The Current State of Discussion and the Relevanceof Antonovsky’s Salutogenic Model of Health

Jürgen Bengel, Regine Strittmatter and Hildegard Willmann

Expert report commissioned by the Federal Centre for Health Education

Research and Practice of Health PromotionVolume 4

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 fordiscussion. The opinions expressed in this series are those of the respective authors, which are not necessarily shared by the publisher.

Published by the Bundeszentrale für gesundheitliche Aufklärung(Federal Centre for Health Education - FCHE)Ostmerheimer Str. 220, D-51109 Köln, GermanyTel.: +49(0)221/89 92–0 Fax: +49(0)221/89 92–3 00E-Mail: [email protected]

All rights reserved.

Editors: Stephan Blümel, Katharina Salice-StephanTranslated by Debbie Johnson

Composition: Salice-Stephan, ColognePrinted 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, Germanyor on the Internet at http://www.bzga.de

Order No. 60 804 070

This volume is a translation of the German edition:

Bengel, Jürgen / Strittmatter, Regine / Willmann, HildegardWas 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 3-933191-10-6Order No. 60 606 000

3What Keeps People Healthy?

Preface

An important task of the Federal Centre for Health Education (FCHE) is to investigate theextent to which new health concepts and models can contribute to the further develop-ment of strategies and methods of health promotion.

The salutogenesis model conceived by the American-Israeli medical sociologist, Aaron An-tonovsky, belongs to the most influential health concepts of the last few years and thushas met with growing interest in persons active in health promotion. For this reason, theFCHE commissioned an expert’s report with the goal of examining the utilisation of thisconcept for health promotion.

In this expert’s report, Jürgen Bengel, Regine Strittmatter and Hildegard Willmann fromthe University of Freiburg, Germany, present the concept of salutogenesis and compare itto related concepts. They elucidate the current state of empirical foundation, give an over-view of the importance and utilisation in diverse areas of application, and conclude withtheir recommendations.

The FCHE presents this booklet, the fourth in the series “Research and Practice of HealthPromotion”, as an additional contribution to the discussion on suitable concepts andstrategies for the promotion of health and their continuous increase in quality.

Cologne, November 1998 Dr. Elisabeth PottDirector of the Federal Centrefor Health Education


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 monographsJournalsTextbooks

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 theUniversity of Freiburg, Dept. of Rehabilitation PsychologyBelfortstrasse 16D-79085 FreiburgTel.: +49(0)7 61/2 03 30 46Fax: +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. 220D-51109 KölnTel.: +49(0)221/89 92-3 28Fax: +49(0)221/89 92-3 00

Project management: Stephan Blümel


Contents

Introduction 9

Historical Background 13

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

3.1. The Sense of Coherence:

State of Empirical Foundation 38

3.2. Sense of Coherence as Compared

to Related Concepts 49

3.3. Stress and Resilience Research 56

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8 Research and Practice of Health Promotion, Volume 4

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

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

5.3. 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

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Introduction

The subject of salutogenesis has attracted a lot of attention in the social sciences and inmedicine recently, especially in the fields of prevention and health promotion. TheAmerican-Israeli medical sociologist, Aaron Antonovsky (1923–1994), introduced thisconcept to the health sciences and public health care. He criticised an exclusively patho-genic-curative approach and juxtaposed it against a salutogenic orientation arguing thatthe question, why people stay healthy, should have priority over the question of the causesof disease and their risk factors. The salutogenic orientation primarily explores the con-ditions of health and the factors that protect health and contribute to invulnerability. Itfocuses on the factors which maintain health. In part, one is beginning to speak of aparadigm 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 peoplemanage 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-Ver-lag), H. H. Bartsch & J. Bengel (Eds.), “Salutogenese in der Onkologie” (Salutogenesisin Oncology) (Basel, Karger), and F. Lamprecht & R. Johnen (Eds.), “Salutogenese – Einneues Konzept in der Psychosomatik?” (Salutogenesis – a New Concept in Psycho-somatics?) (Frankfurt, VAS). In 1998, two additional books followed: W. Schüffel et al.(Eds.), “Handbuch der Salutogenese. Konzept und Praxis” (Handbook of Salutogene-sis. Concepts and Application) (Berlin/Wiesbaden, Ullstein & Mosby), and J. Margraf, J.Siegrist & S. Neumer (Eds.), “Gesundheits- oder Krankheitstheorie?” (Health or DiseaseTheory?) (Berlin, Springer).

It is remarkable that Antonovsky’s views on salutogenesis were not taken up in the healthcare discussion until some time after the publication of his two main books on the sub-ject in 1979 and 1987. Put simply, two general tendencies can be observed in the recep-tion of his ideas and theses: Some authors as well as critics of the health care systemaddress 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 innovativepreventive measures. Other authors conduct empirical studies specifically on the sense ofcoherence. They examine the extent to which the concept can be investigated methodi-cally, the particular interactions that coincide with characteristics of mental and physi-cal health and disease, or whether it can be used as an indication of success in the fieldsof psychotherapy and psychosomatic medicine.


The Federal Centre for Health Education planned to examine the extent to which a sa-lutogenic orientation can open new opportunities for intervention and action in the pro-motion of health. For this purpose, it advertised an expert report on the subject ofsalutogenesis to discuss the status of the salutogenic model and its possible consequencesfor the practice of health care: “The expert report should provide an overview and anevaluation of the writings with respect to the concept’s application to the promotion ofhealth.”This report by our working group describes Antonovsky’s concept of salutogenesis anddocuments its scientific treatment. We have attempted to make the basic ideas of theconcept understandable and present them within the context of the historical developmentof the health sciences. The report was written to provide a clear, concise answer to the fol-lowing 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 checkin germane data banks as well as in the Internet: The following sources were examinedunder 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 Indexand ERIC. In addition, we looked through health science journals and textbooks underthe entry “salutogenesis”.

The report is divided into a main text and a documentation of the sources. The first threechapters of the text are dedicated to the formulation of the theoretical background andthe current research. Chapter 1 depicts the historical background of the salutogenicmodel. Chapter 2 introduces the concept of salutogenesis and Chapter 3 describes the cur-rent state of research. With respect to the status and the application of the concept (Chap-ter 4), three different applications are introduced: health promotion and prevention(Section 4.1.), psychosomatic medicine and psychotherapy (Section 4.2.) and reha-bilitation (Section 4.3.).

The last chapter, Chapter 5, contains a summary of the expert report and an evaluationof the concept. It summarises the discussion introduced in the first three chapters as wellas the status and the merits of the concept and concludes with an outlook and recom-mendations. A bibliography of the literature used for the expert report can be found inChapter 6 along with a bibliography of the works by Antonovsky. In addition, the empiricalstudies cited in Chapter 3 on the sense of coherence are presented in a table. The ques-tionnaire on life-orientation (SOC-scale) appears in the final section.


The authors have attempted to make the material easily understandable to the targetaudience. Technical terms have been explained where necessary. Chapter 3 on “CurrentResearch” could not quite meet this demand, since in this case research methodologicalterms and jargon had to be used which were indispensable in describing and discussingthe 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. UlrikeFrank, cand. phil. Marcus Majumdar and cand. phil. Christian Schleier (all in Freiburg)for important additions and comments.

1Historical Background


Before we illustrate the concept of salutogenesis in Chapter 2, we will first describe thehistorical background and the context in which Aaron Antonovsky formulated his delib-erations and conducted his research. The model of salutogenesis and Antonovsky’s thesescan only be understood when viewed against the background of the developments andtrends in health care and in the health sciences of the past 50 years. To this end, thefollowing 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 ofthe 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 actionswhich are often characterised as a pathogenic orientation: this view focuses on the pa-tient’s complaints, symptoms or pain. All efforts made by the medical system, the physi-cians and the therapists are aimed at eliminating the symptoms and the complaints asquickly as possible. Patients expect a great deal from the possibilities of the medical caresystem. In the past decades, impressive achievements in the diagnosis and therapy of manyillnesses have been made. Nevertheless, the criticism of the technological institutionali-sation of medicine and the primary focus on the symptoms of disease have increased inthe past few years. As the field of medicine becomes increasingly technical, it has beendeplored as being impersonal, that is, accused of neglecting the whole person. Further-more, critics consider our health care system to be too expensive, feel that it cannot handlethe increase in chronic illnesses, and is not sufficiently concerned with ethical questions.“Communicative medicine” is in demand, which is not only oriented toward disease andhandicaps diagnosed at high technical expense. The field of medicine should attachmore importance to the dialogue between the physician and the patient, while devotingattention and support to the patient’s healthy components. In addition to the results ofmedical tests on organs, those psychosocial aspects of importance to the adjustment to theillness 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-

1. Historical Background

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What Keeps People Healthy?

cepts of health and illness and an understanding of the causes of disease, its cure or alle-viation. 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 per-sonally 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 thecapability of the organism to cope with stress and strain. These subjective notions developin the course of the socialisation of every individual within a specific social context andclimate. The perception of physical complaints is influenced by social and individualjudgements. 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 subjectivecondition and the health-related behaviour of the individual.

Definitions of HealthThere are a number of approaches to defining health and disease. They are oriented ondifferent health norms. The particular definitions of health and disease have a significantinfluence on which means are considered appropriate and necessary for the restoration,the maintenance and the promotion of health. This is essential, since these specificationsdetermine the amount and type of influence and responsibility for the emergence of thedisease and its cure that can or should be attributed to the patient (extent of self-responsibility). An ideal norm of health depicts a state of perfection, whose attainment isdesirable or valuable. By defining health as a state of complete psychological and physi-cal 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 ab-solute states are not attainable.

The statistical norm of health is determined by the frequency of a characteristic of theorganism: whatever holds for the majority of humanity is defined as healthy. Deviationsfrom these average values are considered to indicate disease. The classification of a per-son as either ill or healthy thus requires a reference group, for factors as age and genderas well as the predetermined value ranges. “Health” as a functional norm is based on theperson’s ability to fulfil his or her role in society. In turn, the determination of functionalnorms 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


complaints and symptoms are present. This concept shared by experts, physicians andtherapists collides with the ideas of health and disease of so-called laypersons, namely thepatient. A pure biomedical perspective neglects important dimensions of the patient’scondition, such as life satisfaction and well-being. Persons with physical injuries can alsobe 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 difficultto grasp and to describe. In the social sciences and the medicine of today, it is unanimousthat 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 psychologicalwell-being (e.g. joy, happiness and life satisfaction), but also performance, self-realisa-tion and a sense of meaningfulness. Health depends on the existence, on the perceptionand on the means of dealing with stress and strain, on risks and on hazards in the socialand ecological environment, on the existence, on the perception, on the tapping and onthe use of resources. The proposals now being made by the social sciences to define thephenomenon of health are distinguished by a complexity that can be considered new.

The Development of the Biopsychosocial Model of Disease

The Biomedical Model of DiseaseAt the outset of the 19th century, under the influence of the thoughts of the natural scien-ces, a concept of disease emerged that is called the biomedical model of disease (see Fal-termaier, 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 andstructures as well as the physiological processes are analysed as precisely as possible.Symptoms of disease (physical complaints, physical changes but also psychological irreg-ularities) can be explained by organic defects. These anatomical or physiological defectsmake up the actual illness. The source of the defect was thought to originate from a lim-ited number of causes as it is the case of viruses or bacteria. Decisive is the recognition ofthe defect and the search for a means to reverse or “repair” it. These assumptions de-termine the treatment of physical symptoms. The definition according to which a personcould be classified as ill or not depends on whether anatomical or physiological changescan be determined. The ill person in the form of a subject and an agent is virtually ex-cluded. He or she is a passive object of physiological processes, over which his or her psy-chological and social reality has no influence.

Medical research which adheres to this model concentrates on the discovery of yet un-known defects and the proof that they are the cause of the disease. The medical treatmentaims at repairing the defect. This concept of disease led to great medical progress in manyareas, such as the treatment of metabolic disorders or the battle against infectious ill-nesses.

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Broadening the Biomedical ModelCriticism of the biomedical model of disease was raised quite early and triggered heateddebates in the 1970’s. The social medical scientist, Engel (1979), contrasted this modelwith an expanded biopsychosocial model, in which both somatic as well as psychosocialfactors were used to explain the origin and the progression of disease. Research in thesocial sciences, psychology and psychosomatics demonstrates that psychological andsocial factors are relevant to the emergence and the progression of disease. They also in-fluence the diagnosis and the treatment of disease. Even the perception of symptoms, theexperiencing of pain, the decision to undergo medical treatment, and to follow doctor’sorders, to name only a few examples, are significantly influenced by psychological andsocial 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 stressfulconditions. It does not follow a pure vulnerability concept which examines how psycho-logical stressors become detrimental under psychophysiological processes. Nowadays, inthe interdisciplinary field of the health sciences, many disciplines such as medicalpsychology, the psychology of health, behavioural medicine and psychoneuroimmunologyare involved. Psychoneuroimmunology is a relatively new field of research that integratesthe knowledge and the methodology of psychology and different medical subdisciplinesto examine which interactions between different systems of the body exist, such as the cen-tral 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. In-deed, the phrasing of biopsychosocial models is often oriented on a deficit model ofhumans as well. This tendency becomes apparent in the face of the political demandsmade regarding prevention concepts and the measures taken by health policies. At firstglance, 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 sub-sumed under the concepts of early detection and health education have been shaped bymedical thinking, even though health education in particular requires knowledge of psy-chology (Borgers, 1981; Oyen & Feser, 1982). Despite the diverse criticism and the fact thatthe importance of psychosocial and cultural factors has been established, the biomedicalmodel 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. Measurestaken to improve hygienic conditions and large-scale immunisation programmes, suchas those introduced following World War II, are of great importance for the development


of society. In the meantime, preventive measures focus on the prevention of chronic de-generative disease and so-called civilisational disease.

The Risk Factor ModelThe basis for preventive measures is still the risk factor model. This model was developedin the 1950’s in conjunction with the results of epidemiological studies and statistics fromlife insurance agencies in connection with coronary heart disease. Correlations betweenrisk factors such as high lipid levels, tobacco consumption, obesity, psychological stres-sors and the incidence of coronary heart disease were demonstrated. The chance of hav-ing 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 certainpercentage of the persons examined. In other words, the coincidence (the correlation be-tween risk factors and disease) does not allow a causal interpretation or prediction to bemade for a given individual as to the morbidity (the frequency or chance of getting a cer-tain disease) or the mortality (the frequency or the chance of dying from a certain dis-ease). The effects of risk factors are not compulsory for each individual; they merelyindicate an increased chance of developing the disease. Some research results on the sig-nificance of different risk factors and their interactions as well as the determination of cri-tical 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 con-centrate on the avoidance of risk factors and on individual changes in behaviour. Thusfar, 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 ProgrammeSince 1978, when the WHO Conference in Alma Alta ambitiously proclaimed “Health forall by the year 2000”, the aim to supplement the biomedical risk factor model and allit implies has been part of the agenda.

The WHO introduced the Health Promotion Programme in the Ottawa Charter, whose keyfeatures 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 viewhealth as a goal, but rather as a means of enabling positive shaping of individual and so-cial life. Preventive measures are thus not prescribed by the professional system. They aretargeted at active and responsible participation of the layperson in the establishment ofhealth-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 personsor groups. In this way, the promotion of health is a task which changes politics and so-ciety, which however does not make implementing the goals any easier.

The health promotional approach continues the above-mentioned developments in theunderstanding of health and disease. It is based on a complex, multidimensional conceptof health and is founded on a biopsychosocial model of disease. In addition to individual-related approaches, this concept of health promotion primarily stresses the necessity ofstructural changes. Broadening the classic risk factor model to include psychosocialdeterminants as well as surroundings and circumstances, and developing a theory of thecombined effects of risk and protective factors, fit the demands of health promotion andthe 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 militaryservice in World War II, he completed his doctoral thesis in sociology. At this time, he wasinterested 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 theIsrael Institute for Applied Social Research in Jerusalem. Rather accidentally, he becameinterested in medical sociology by taking part in several different research projects in thisfield, including an epidemiological study on multiple sclerosis. In the course of the yearsfollowing, he taught in the department of social medicine and worked on differentresearch projects on the connection between stress factors and health or disease.

In keeping with Lazarus (1966), Antonovsky began to support a stress concept in whichstressors are not automatically considered to lead to disease. In his concept, stressors areviewed as stimuli that can trigger a state of tension which must not necessarily lead tostress. Thus Antonovsky's social epidemiological research was a preliminary for his psy-chological examination of individual processing patterns in the face of tension. In thiscontext, Antonovsky rejected the idea of a specific effect of stressors and supported theopinion that the type of disease is determined by individual dispositional vulnerability andnot by the profile of the stressful influences.

Decisive for his further research were ideas that Antonovsky developed on the basis of astudy of adaptation to climacterium in women of different ethnic groups. One of thesegroups consisted of women who had been born between 1914 and 1923 in central Europeand some of them were interned in concentration camps. As expected, the group of con-


centration camp survivors exhibited significantly more signs of ill health than the womenin the control group. However, as many as 29%(!) of the former prisoners claimed to bein relatively good mental health despite these traumatic experiences. Antonovsky won-dered 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. Par-ticularly noteworthy are two books which he wrote in 1979 and 1987.

In addition to his research, Antonovsky helped to found a community-oriented school ofmedicine in Beer Sheba, Israel. He returned to the USA twice as a visiting professor, from1977 to 1978 and from 1983 to 1984. Antonovsky died at the age of 71 in 1994.

2The Concept of Salutogenesis


The goal of this chapter is to illustrate the basic ideas of salutogenesis and the salutogenicmodel of health. For this purpose, we will focus on Antonovsky’s original literature. Unlessotherwise 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 con-struct of “the sense of coherence”.

2. The Concept of Salutogenesis

2.1. The Salutogenic Problem

Why do people stay healthy despite so many detrimental influences? How do they manageto recover from illnesses? What is special about people who do not get ill despite the mostextreme strain?

These are the central questions that served as the point of departure for Antonovsky's theo-retical and empirical work. Antonovsky coined the term, “salutogenesis” (salus, Latin for “invincibility”, “well-being”, “happiness“; genese, Greek for “genesis”, “origin”) toemphasise its distinction from “pathogenesis” which has dominated the biomedicalapproach, 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 pathogenically-oriented perspective (Antonovsky, 1989). Thinking pathogenically means examining theorigin and the treatment of disease. Salutogenesis does not refer to the opposite in thesense 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 whileat the same time being more or less ill. Thus the question here is: How does a personbecome healthier and less ill?

Antonovsky used a metaphor to compare the predominant thinking and action premisesof medicine with the salutogenic perspective. The pathogenic approach is aimed at res-cuing people at great expense from a raging river, without taking into consideration howthey got in there and why they are not better swimmers. In contrast, seen from the per-spective 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 metaphorto describe salutogenesis:

“... my fundamental philosophical assumption is that the river is the streamof life. None walks the shore safely. Moreover, it is clear to me that much ofthe river is polluted, literally and figuratively. There are forks in the riverthat lead to gentle streams or to dangerous rapids and whirlpools. My workhas been devoted to confronting the question: ‘Wherever one is in the stream– whose nature is determined by historical, social-cultural, and physicalenvironmental conditions – what shapes one’s ability to swim well?’” (Antonovsky, 1987a, p. 90).

These images illustrate the different levels that characterise Antonovsky’s work and alsothe discourse on his ideas. The metaphor of the river as a symbol for life, and the idea thata person is always swimming in a more or less dangerous river, reflects his philosophicalviews. Research questions can be posed and phrased very differently depending on whetherone intends to examine who will drown first, what is necessary to rescue someone fromdrowning or whether one asks which factors facilitate swimming. Whether people arerescued shortly before drowning or the course of the river is tamed or the people are taughtto swim all depends on the public health care policies. The individual ability to swim isanalogous 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 variouscharacteristics of the river and the people swimming in it.

Antonovsky’s views on the origin of health were influenced by systems theoretical consid-erations. Health is not a normal, passive state of balance, but rather an unstable, activeand dynamic self-regulating process. The basic principle of human existence is notbalance and health but imbalance, disease and suffering. Disorganisation and thetendency toward entropy is omnipresent. “The human organism is a system and, likeall systems, it is at the mercy of the power of entropy” (Antonovsky 1993a, p. 7). Theconcept of entropy is borrowed from thermodynamics and refers to the tendency ofelementary particles to move to a state of increasing disorder. The lesser this tendency, themore order and organisation the system possesses. This capacity of a system towardorganisation is termed negative entropy. In a figurative sense, Antonovsky employed theconcept of entropy as an expression for the ubiquitous tendency of human organisms tolose their organised structure, but also the ability to reorder it again. Applied to one’s stateof health, this means that health must constantly be re-established and that at the sametime the loss of health is a natural and ubiquitous process. “The salutogenic approachregards the battle towards health as permanent and never quite successful” (Anto-novsky, 1993a, p. 10). Antonovsky admitted that his weltanschauung tends to be pessi-mistic in this context (Antonovsky, 1987b).


Antonovsky criticised the basic assumptions of western medical research and practice andcontrasted them with the fundamentals of his salutogenic views. Nevertheless, he did notintend to dispense with pathogenically-oriented questions of medical research, but ratherhe 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. Thisassumption is not tenable, or at least is not valid as the sole standard for the definition ofhealth. Epidemiological data demonstrate that at least a third, perhaps even the majorityof 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 aremutually 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 madeaccording to a physician’s diagnosis, who finds a specific illness, or by the patient him-self or herself and his or her environment. People who are classified as healthy are leftunnoticed by the public health care system, after medical check-ups and early detectionexaminations. 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 orhealthy (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 well-directed treatment. In this approach, disease is generally seen on the level of specificpathological processes. In the pathogenic paradigm, there are specific pathogenic con-ditions and agents for each illness, such as bacteria, viruses, etc., but also stressors andrisk factors. The treatment consists largely of combating them.

Antonovsky, however, directed his interest not toward specific symptoms, but rather towardthe fact that an organism can no longer retain its order. He was not concerned with theexact type of disorder in this case and, with this in mind, coined the term organism “break-down” (Antonovsky, 1972). Instead of exclusively combating pathogenic agents, thesalutogenic approach aims at strengthening resources to make the organism more re-sistant to weakening influences. This resource-oriented thinking calls for taking intoconsideration the entire person with all of his or her life experience as well as the entiresystem in which the person lives (Antonovsky, 1993b). A person’s individual story isimportant because only in the awareness of a person’s life situation can the resources thatcontribute to recovery be found and fostered.

2.2. Criticism of Health Research and Health Care

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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 forthe answers” (Antonovsky, 1979, p. 12). These two statements point out that his scien-tific work distinguishes itself from others mainly by the formulation of the thesis and theperspective taken. The concept of salutogenesis represents a criticism of a one-sidedorientation of the research on detrimental living conditions and pathogenic factors. Herepeatedly demonstrates that questions posed within the framework of pathogenically-oriented research have “blind spots”.

Salutogenically-oriented research examines questions such as, “Who are the Type A’s whodo not get coronary disease? Who are the smokers who do not get lung cancer?”(Antonovsky, 1987a, p. 10). Pathogenically-oriented research compares patients withcontrol groups that can be considered healthy, since they do not have a certain illness (seeSection 3.3.). However, they might suffer from other illnesses that go undetected. Incontrast, a salutogenic approach considers illnesses to be non-specific and asks why peoplestay healthy and which characteristics and skills distinguish them from others. For this pur-pose, 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 theorigin or maintenance of health. The striking thing about his model of health is that hedid not formulate a definition of health. He claimed that he is not interested in explain-ing health either as an absolute or an ideal concept, since this does not correspond to thetrue conditions (Antonovsky, 1979). Furthermore, as he saw it, a definition of healthalways requires the establishment of norms and thus risks judging others according tovalues 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 andstates 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.


According to Antonovsky, a person’s state of health or disease is determined to a significantextent by an individual, psychological factor: an individual’s general attitude toward theworld and his or her own life – a weltanschauung, as he once put it using the Germanword (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 ex-posed 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 ofhealth depends on how pronounced one’s cognitive and affective-motivational outlook onlife is, which in turn influences the extent to which one is in a position to utilise the re-sources available to maintain one’s health and well-being. Antonovsky termed this basicoutlook on life sense of coherence (SOC). “Coherence” means consistency, congruenceand harmony. The more pronounced a person’s sense of coherence, the healthier he or sheshould be and the more quickly will that person regain health and remain healthy. In hisfirst 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 andexternal environments are predictable and that there is a high probabilitythat 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 encoun-tering new life experiences and is influenced by them. In turn, the degree of SOC in-fluences the kind of life experiences. As a result, life experiences tend to confirm the basicorientation to life, which thus becomes stable and enduring. The strength of the SOC isindependent of the circumstances, the social roles that one currently fulfils or is expectedto fulfil. For this reason, Antonovsky referred to this outlook on life as a dispositionalorientation (a relatively enduring characteristic). It does not, however, stand for anyparticular personality trait.

According to Antonovsky, this basic attitude of experiencing the world as coherent andmeaningful is made up of three components:

1. The sense of comprehensibilityThis component describes the expectation or the ability of the person to process bothfamiliar and unfamiliar stimuli as ordered, consistent, structured information and notto be confronted with stimuli that are chaotic, random, accidental and inexplicable.The term “comprehensibility” is used in the sense of a cognitive processing pattern.

2.3.1. The Sense of Coherence

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2. The sense of manageabilityThis component describes a person’s conviction that difficulties are soluble. Antonov-sky also called this “instrumental confidence” and defined it as “...the extent to whichone perceives that resources are at one’s disposal which are adequate to meet thedemands 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 ownresources and competencies. It also subsumes the belief that other people or a higherpower will help one to overcome difficulties. Someone who lacks this conviction is likea “sad sack” or “shlimazl” who invariably experiences unfortunate events withoutbeing able to do anything about them. Antonovsky considered the sense of manage-ability as a cognitive-emotional processing pattern.

3. The sense of meaningfulnessThis dimension describes “...the extent to which one feels that life makes sense emo-tionally, that at least some of the problems and demands posed by living are worthinvesting energy in, are worthy of commitment and engagement, are challengesthat are ‘welcome’ rather than burdens that one would much rather do without”(Antonovsky, 1987a, p. 18). Antonovsky considered this motivational component to bethe most important. Without the experience of meaningfulness and without positiveexpectations towards life, there will not be a high SOC value despite the pronounce-ment of the other two components. A person who does not experience meaningfulnesswill 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 ofthe SOC:

“The sense of coherence is a global orientation that expresses the extent towhich one has a pervasive, enduring though dynamic feeling of confidencethat (1) the stimuli deriving from one’s internal and external environmentsin the course of living are structured, predictable, and explicable; (2) theresources 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 shecan activate the appropriate resources for specific situations. In contrast, a person with aweakly developed SOC would react to demands in a strong and rigid manner, since he orshe perceives himself or herself as having less coping resources.

The SOC works as a flexible directing principle, as a conductor who orchestrates theimplementation of different coping styles according to the demands to be met. “What theperson with a strong SOC does is to select the particular coping strategy that seems mostappropriate to deal with the stressors being confronted” (Antonovsky 1987a, p. 138).


The SOC is thus not a particular coping style, but rather is situated higher up in the hier-archy 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 in-fluenced by the experiences gathered. In adolescence, greater changes are still possible, sincethe 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 withPiaget’s (1969) principles of assimilation and accommodation: external changes influ-ence and modify internal perceptions. On the other hand, because of the pre-existing lifeviews, familiar realms of experiences are preferably sought, so that these tend to confirmthe pre-existing.

The comprehensibility component is formed by experiences of consistency. Since stimuliand experiences do not occur in an arbitrary, contradictory and unpredictable manner,they can be classified, categorised and structured. Manageability develops throughexperiencing 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 circum-stances in society, that is, on the availability of generalised resistance resources (seeSection 2.3.4.) (Antonovsky, 1993a). When generalised resistance resources are presentwhich 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 overtime (Antonovsky, 1993a). Experiences that are predominantly characterised byunpredictability, uncontrollability and uncertainty will lead to a weak SOC. This does notmean, however, that a person must never experience uncertainty and unforeseen eventsin order to acquire a strong SOC. The development of a strong SOC requires a balance be-tween 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 conditionscan lead to a significant change in the SOC. Examples of radical changes, which greatlychange the resources and opportunities available up to that point or lead to many un-expected 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 expectthat an encounter, or even a series of encounters, between client and clinician cansignificantly 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 Sec-tion 2.2), with which scientific medicine and the medical care system work; in particular,health insurance companies must orient themselves on these categories. Antonovsky jux-taposed this division with the conception of a continuum with the poles ease (health) anddis-ease (illness).

The end poles, complete health or complete disease are not attainable for living or-ganisms. 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 hermust be healthy: “We are all terminal cases. But so long as there is a breath of life inus, we are all in some measure healthy” (Antonovsky, 1987a, p. 50). The question is nolonger whether one is healthy or ill, but how far or how close one is to one of the end polesof health ease and dis-ease.

In addition, Antonovsky assumed that there are a number of other conditions or dimen-sions that can also be viewed as continuums and which correlate with the ease/dis-easecontinuum. For his thesis question, it is important to distinguish between physicalcondition and these other dimensions of well-being/discomfort. He placed the aspect ofphysical 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 allstimuli which engender stress. Whether or not a stimulus is a stressor, can only be deter-mined by its effect and thus cannot be predicted.

To solve this problem, Antonovsky introduced a new element in the model. He postulatedthat stressors start out by simply causing a physiological state of tension (psychophysicalactivation), which can be traced back to the fact that individuals do not know how to reactin a given situation. Stressors are defined as “...a demand made by the internal orexternal environment of an organism that upsets its homeostasis, restoration of whichdepends on a non-automatic and not readily available energy-expending action”(Antonovsky, 1979, p. 72).

For Antonovsky, the organism’s main task is coping with states of tension. Here, conceptsof coping research play a key role. When the coping strategy succeeds, it has a health-maintaining 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 theperson arises. Since coping strategies cannot always succeed, stress reactions and stress-ful situations are a ubiquitous phenomenon. However, the ensuing stress reaction mustnot necessarily have negative consequences for health. The strain can have a neutral oreven a health-promoting effect. It is the interaction with pathogenic agents, harmful sub-stances and physical weak spots which lead the stress reaction to weaken physical health.

Antonovsky distinguished between physical and biochemical stressors, i.e., the influencethrough force of arms, starvation, toxic substances or pathogens can be so strong that theyhave a direct effect on the state of health. In this case, the pathogenic orientation is calledfor, leading to the search for a means of eliminating the stressors. Since, however, thehazards of physical and biochemical stressors in industrialised nations have diminished,the focus has shifted to psychosocial stressors. This is where Antonovsky employed his SOCconstruct.

On the one hand, a strong SOC enables a person to judge a particular stimulus to beneutral, which would cause tension in persons with a weak SOC. This is known as primaryappraisal 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, favour-able or irrelevant (primary appraisal II). Classifying the stressor as favourable or ir-relevant 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, peoplewith a high SOC will not actually feel threatened. Their fundamental confidence that thesituation will work out in the end protects them. Furthermore, Antonovsky contended thatpeople with a high SOC tend to react to threatening situations with appropriate anddirected 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 difficultto regulate, such as blind rage. They become paralysed, since they lack confidence in theirability 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 copingwith tension and thus influence the maintenance or the improvement of health. Hegathered a broad spectrum of factors and variables in epidemiological studies thatcorrelate with the state of health. These variables are related to individual factors, suchas physical characteristics, intelligence and coping strategies, as well as social andcultural factors like social support, financial power and cultural stability. Antonovskycalls these variables “generalised resistance resources”. The term “generalised” refersto the fact that they are effective in all kinds of situations. “Resistance” refers to thefact that the resources increase the resistance of the person. “What is common to allgeneralised resistance resources, I proposed, is that they help to make sense out ofthe countless stressors with which we are constantly bombarded” (Antonovsky,1987b, p. 48).

Resistance resources have two functions: they have a continuous impact on life experi-ences and enable us to make meaningful and coherent life experiences which in turn formthe SOC. They function as a potential which can be activated when necessary for manag-ing states of tension.

In his second book (1987a), Antonovsky conceptualised stressors as generalised resistancedeficits. It is thus possible to consider resistance resources and resistance deficits ascontinuous dimensions. The positive pole stands for the possibility of making life ex-periences which strengthen the SOC. The negative pole represents experiences that weakenthe SOC. For example, a large amount of financial resources or cultural stability can bea resource, a lack thereof can be seen as a resistance deficit or as a stressor. Stressors orresistance deficits lead to entropy2. In contrast, resistance resources lead to negativeentropy3 in the human system. The SOC is the channel that “orchestrates this battle-ground of forces promoting order or disorder” (Antonovsky, 1987a, p. 164).

2 Entropy: The tendency to move towards states of growing disorder. See the definition on p. 23.3 Negative entropy: The capability of a system to retain order. See the definition on p. 23.


2.3.5. An Overview of the Salutogenic Model

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, Recovery resources, reductionist sense of coherence, holistic

Causes of health and disease Risk factors, Patient’s historynegative stressors

Effect of stressors Potentially promoting Promoting disease disease and health

Intervention Implementation of effective Active adaption, risk remedies (“magic bullets”) reduction and resource

development

*Heterostasis: Imbalance, instability, the opposite of homeostasis.

Now that the most important elements of the model of the emergence of health have beendiscussed, we will go on to describe the way in which these constructs fit together and howAntonovsky explained the improvement of the state of health within the framework of thismodel. Diagram 1 provides a brief summary of the most important points.

The concept of the sense of coherence (SOC) is central to explaining health-maintainingor health-promoting processes. The SOC is a global orientation that expresses the extentto which one has a pervasive, enduring though dynamic feeling of confidence that (1) thestimuli deriving from one’s internal and external environments in the course of living arestructured, predictable and explicable; (2) the resources are available to one to meet thedemands posed by these stimuli; and (3) these demands are challenges worthy of invest-ment and engagement (Antonovsky, 1987a, p.19).

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

(Source: Noack, 1997, p. 95)

Table 1

Diagram 1

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

Sources of generalised resistance resources

Sense of Coherence

(SOC)

StressHealthy Ill

Health Ease/Dis-ease Continuum

Successful

Generalisedresistanceresources

Life Experiences

Stressors

State ofTension

TensionManagement

Unsuccessful

EF

G

D

A

B

K

C

H

J

I

Life experiences form the SOC (Arrow A). A pronounced SOC requires life experienceswhich are as consistent as possible, which the individual can effectively influence andwhich cause neither overload nor underload.

Such experiences are made possible by so-called generalised resistance resources, such asphysical factors, intelligence, coping strategies, social support, financial power or culturalfactors (Arrow B). The emergence or the presence of resistance resources is contingent onthe social, cultural and historical context and the predominating child-raising patternsand social roles. Finally, personal attitudes and random events can also have an influenceon resistance resources (Arrow C).

The extent to which these pre-existing generalised resistance resources can be mobiliseddepends on the strength of the SOC (Arrow D). There is a recursiveness which can quicklybecome a vicious circle. If there are too few resistance resources, then the emergence ofthe SOC will be negatively influenced. A weak SOC, on the other hand, prevents theoptimum utilisation of the available resistance resources.

Stressors which confront the organism with stimuli for which it has no automaticresponses engender states of tension (Arrow E). The mobilised resistance resources in-


fluence stressor management (Arrow F) and the state of tension (Arrow G). This is alsorecursive. The success of tension reduction acts to strengthen the SOC (Arrow H): “Byovercoming 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 theease/dis-ease continuum is maintained or re-established (Arrow I). In turn, a favourableposition on the ease/dis-ease continuum facilitates the acquisition of new resistanceresources (Arrow K). Unsuccessful tension management, however, leads to a state oftension (Arrow J). This state of tension interacts with existing pathogenic influences andvulnerabilities and thus has a negative effect on the organism’s position on the ease/dis-ease continuum.

The Influence of the Sense of Coherence on Health

After describing the salutogenic model with its components and the SOC as its central con-struct, we will now turn to the question about the processes by which the SOC influencesphysical health. In general, Antonovsky agreed with stress researchers that an overload ofconstant or repeated experiences of stress in combination with physical weakness can bea detriment to the organism’s state of health. In his terminology, the most important thingis 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 exam-ple, the central nervous system, the immune system and the hormone system. It affectsthinking processes, called cognitions, which determine whether a situation isdangerous, safe or welcome. Thus, there is a direct link between the SOC and theengendering of complex reactions on different levels. That is to say, the strength of theSOC 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 resourcesleads to a reduction of tension and thus indirectly affects the physiological systemsinvolved in the processing of stress. Antonovsky did not regard short-term physiologi-cal stress actions (tension) to be detrimental as long as they are compensated for byan ensuing recovery phase. Damage occurs only when these self-regulating processesare disturbed.

3. People with a pronounced SOC are more likely to be in a position to make choicesregarding 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 SOChas an indirect influence on the state of health.

Antonovsky considered his assumptions about the interactions between the SOC and healthas confirmed by the relatively new interdisciplinary research field of psychoneuro-immunology. This research field focuses on the investigation of the complex interactionsbetween the nervous system, the hormone system and the immune system and their effectson the human organism, that is on physical health or illness. Within the context ofpsychoneuroimmunology, Antonovsky saw his assumption confirmed that the cognitive-motivational construct of the SOC can have a direct influence on the organism.

Current State of Research3


The SOC-Scale

Before discussing the current state of research on the central construct, the sense of co-herence (SOC), we will address various means of measuring or registering it. In order toexamine his theory empirically, Antonovsky developed a questionnaire, “The Orientationto Life Questionnaire” (SOC-scale, Antonovsky, 1983). This questionnaire is based on thedata 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 cometo terms with their lives remarkably well. The statements identified as representing ageneral attitude toward life or life experiences were analysed. Using Guttman’s facet-technique (see Shye, 1978; Borg, 1993), 29 items were identified, which each had a cor-responding seven-point assessment scale. There is also an abbreviated version whichcontains 13 items.

This scale, which is designed to measure the SOC, contains the constructs of comprehen-sibility with eleven items, manageability with ten items, and meaningfulness with eightitems.1 The items are supposed to register a basic attitude in the sense of a dispositionalorientation. The three theoretically formulated partial constructs could not be clearly con-firmed 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 ana-lyse and interpret the three scales individually. In the meantime, the SOC-scale has been

3.1. The Sense of Coherence: State of Empirical Foundation

This chapter examines the importance of the concept of the sense of coherence and therole it plays in research. First, the current state of research on the sense of coherence willbe presented and elucidated. In the second section, the extent to which the sense of coher-ence 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 withinthe context of various research traditions which are also concerned with the preservationand maintenance of health.

3. Current State of Research

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 notyet been standardised and normed (Noack, Bachmann & Oliveri, 1991).

Antonovsky assumed that an extremely high score on the scale cannot be expected, orrather must be considered pathological, since a person who consistently perceives every-thing as being comprehensible and predictable is poorly adapted to reality. The scale issupposed 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 vari-ous validity and reliability criteria. If these criteria are satisfied, the instrument can beconsidered to measure what it is supposed to measure both accurately and reliably. TheSOC-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 constructvalidity. There are different ways to establish this. In order to test the concept of the senseof coherence, it was mainly compared with similar constructs. High correlations areconsidered to confirm the similarity and thus the validity of the construct, whereascorrelations which are too high may indicate that the construct lacks independence. Asexpected, 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 theSOC-scale might simply represent the reverse of these two constructs. However, doubt hasbeen cast on the procedure of correlative comparison itself as a means of testing constructvalidity (e.g. Siegrist, 1994). Few attempts have been made to validate the construct withnon-correlative methods.

Empirical Studies on the Sense of Coherence

The following discussion on the current state of research is based on approximately 50 em-pirical studies on the SOC-construct, which have been published since 1992. The empha-sis is on recent publications, since Antonovsky himself culled the studies which had beenpublished up to 1990 and critically examined their results (Antonovsky 1993c). The pub-lications mentioned here consist of the literature on salutogenesis obtained with the helpof 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 theEnglish 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 hisconcept 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-coeffi-cients of r=.92 and higher (Antonovsky, 1993c; Rimann & Udris, 1998).


more than 200 studies on the SOC have been published. Franke (1997) came to the con-clusion that the concept had stimulated a “tremendous” amount and that the spectrumof the areas in which salutogenesis had been researched was impressive. Our evaluationis less euphoric.

The majority of these studies were conducted by a few working groups in Israel and Swe-den. 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 envogue. It can be assumed that the perspective underlying the construct of health and ill-ness and the corresponding shift in perspective has gained significance. However, theactual 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 andespecially not by the scientific “opinion-makers” in the USA.

Despite the fact that a change in perspective is often propagated (some even speak of aparadigm shift), one can also observe that studies on health psychology that examine theprognostic value of other constructs continue to prefer a study design which is orientedon the deficit or risk model.

Independent of the empirical evidence on the SOC, it can be established that, despite theinternational publications by the scientific community in the last twenty years, only a fewhave considered the SOC to be worth examining and those were mostly members of Anto-novsky’s own research groups.

Subject and Aims of the Studies ReviewedNone of the studies available to us aimed at testing Antonovsky’s salutogenic model ofhealth in its entirety (see Chapter 2). Such an attempt would have to fail because of thecomplexity of the model. The studies are mainly cross-sectional and measure the relationshipbetween the SOC (rated according to the abbreviated and the complete versions of the SOC-scale) and numerous parameters of mental and physical health and personality traits.These so-called correlations do not permit causal conclusions, but rather describe a rela-tionship between two factors without explaining how this relationship came about. Forexample, one factor might cause the other, or both may be caused by a third factor. There-fore, 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

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 personalitytraits, suicidal ideation, learned helplessness, defence mechanisms, Type-A behaviourpattern, 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. Con-sequently, he postulated a biological substrate for the SOC or direct physiological con-sequences. The sequence SOC – health behaviour – health is not central to his thinking,although he assumed an indirect influence of health (see p. 34). Therefore, examininghypotheses 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 objec-tive 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 ofmental health, such as well-being and life satisfaction: “I would, of course, be flatteredshould 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). Theresults discussed below indicate that relationships between the SOC and various aspectsof 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 thehypotheses formulated in the examination.


SOC and Mental HealthThe studies we examined showed correlations between the SOC and measurements ofmental health that were more or less high, yet nevertheless significant. Among otheraspects, the relationships were confirmed on representative population samples.

Thus, for a Swedish population sample (N=4390), Lundberg (1997) was able to establishthat the risk of psychological problems in persons with a high SOC was 3.5 times lowerthan in persons with a low SOC. This relationship is independent of the variables of ageand gender.Another representative study on a Swedish population sample with N=2003 subjectsyielded similar results. Larsson and Kallenberg (1996) found significant correlationsbetween 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 otherstudies3. Significant correlations could be found between positive aspects of mentalhealth, 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, arestriking. Various studies4 show correlation coefficients as high as r=-.85. This legitimatelyraises the question as to whether the SOC can be characterised as a new dimension ofmental health, or whether the known constructs as well as tried and true instruments canbe maintained. However, this question cannot be answered completely on the basis of thecurrent state of research.

SOC and Physical HealthAs mentioned above, in contradiction to Antonovsky’s assumption, the relationshipbetween the SOC and physical health is not very clear.

Hood, Beaudet and Catlin (1996) examined the influence of the SOC on three differentmeasures of health in a representative Canadian population sample (N=16291; adult menand women). In addition to a subjective assessment of general health, they presented ascale for the measurement of functional aspects of health, which not only questionsphysical functions, such as hearing and eyesight, mobility, pain, ability to concentrate andso on, but also emotional well-being. A third scale contains the number of chronicphysical illnesses, such as cancer, high blood pressure, migraines and so forth. Weakcorrelations between the SOC and all three measures of health could be found (betweenr=-.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 ofhealth, but only 4% of the subjective appraisal of one’s own state of health. Used as apredictor of chronic illness, the SOC can only explain 1% of the variance and is thusextremely low.Bös and Woll (1994) found no relationship between the physician’s assessment of healthand the SOC in a study of N=500 men and women. Dangoor and Florian (1994) also came to the conclusion that the medical diagnosis andfunctional limitations do not contribute to the prediction of the SOC. Langius and Björvell (1993) used the Sickness Impact Profile (SIP) to study a Swedishrandom sample of N=145 men and women. They found a significant correlation with theSOC of r=-.29. A more exact analysis, however, showed that this was only to be traced backto the “psychosocial complaints” sub-scale and otherwise no statistically significantrelationship to physical complaints could be established.Nor could any relationship be found between pain and the SOC in a sample of N=57patients before surgery. A second study after the operation showed, however, that patientswith a higher SOC reported significantly less pain six weeks after the operation (Chamber-lain et al., 1992).Becker, Bös and Woll (1994) found statistically significant correlations between the SOCand 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 physi-cal health. This finding was also confirmed in another study with a path-analytical design byWilliams (1990). It is clear in this case that the inferential or predictive value of correla-tion 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 ofwhom 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 es-pecially meaningful, since the correlation coefficients between the SOC and measurementsof 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 inquireabout psychosomatic symptoms, such as loss of appetite, sleeping disorders, headaches,etc. In this case, statistically significant correlations around r=-.50 were found (Gebertet al., 1997; Rena et al., 1996).

In the study mentioned above, Lundberg (1997) came to the conclusion that the relation-ship between the SOC and physical illness could be understood in terms of the complaintsmade by the patient. People with low SOC values might tend to complain more than thosewith higher SOC values.


SOC and Subjective Judgement of the General State of HealthIn some studies, the subjective judgement of the general state of health was assessed andrelated to the SOC. Exactly which subjective health definitions the subjects based theirjudgement 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 relativelylow correlation coefficients between r=.21 and r=.37, it can be assumed that the subjectsmost likely rated their physical health rather than well-being or mental health.5

SummaryIn summary, the state of research to date shows that SOC and mental health are closelyrelated. The correlation between SOC and anxiety or depression is even so high that thequestion is raised whether the SOC-scale measures something else or something more thanthe germane instruments for assessing the above-mentioned dimensions of mental healthor illness. The relationship between the SOC and measures of physical health or thesubjective general state of health proved to be less clear. To be sure, further studies with asuitable 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 percep-tion and evaluation of a stimulus as a stressor. In stress research, three types of stressstimuli are distinguished: chronic stress, daily hassles and critical live events. Antonov-sky considered chronic stressors which characterise the life situation of a person to be theprimary determinants of the SOC level. He assumes that they have a negative effect on theSOC. In contrast to Lazarus and Folkman (1984), Antonovsky doubted whether dailyhassles can be considered to have a similar effect on the SOC (Antonovsky, 1987a). Aconclusive evaluation regarding the accuracy of these theoretical assumptions is notpossible based on the research findings currently available. On the one hand, correlationstudies do not permit testing of causal relationships and, on the other hand, relatively lowbut nevertheless significant correlations between the SOC and daily hassles were found inthe 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 theSOC. McSherry and Holm (1994) were able to demonstrate on the basis of a sample ofN=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 confirmedon a physiological level. High SOC values lower the physiological parameter towards theend of the confrontation with the stress stimulus, that is, although all three groups reactto the stress stimulus, people with low SOC values begin and end the stress situation withhigher stress values. Further studies also confirm that the SOC and the appraisal of asituation as stressful are related.

5 See Anson et al., 1993a, 1993b; Becker, Bös, Opper, Woll & Wustmann, 1996; Bös & Woll, 1994; Callahan & Pincus, 1995; Chamberlainet 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 givenstressor situation, he or she will fight, freeze or flee, be quiet or speak up, seek todominate or melt into the shadows, or whatever other categories of overt behaviourwe may construct” (Antonovsky, 1987a, p. 187). However, he assumed that people witha high SOC value, in contrast to those with low values, perceive problems as being morecomprehensible 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 lastassumption that persons with lower SOC values perceive themselves as having relativelyless coping resources and less social, material and psychological resources. They have lessconfidence that they will be able to master situations than the students with a high SOCin the study.

According to the studies to date, the SOC appears to facilitate adaptation to difficult lifesituations, 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 wasfound to be related to a perceived overload due to the care-taking tasks and to un-favourable coping behaviour, such as social withdrawal and the consumption of medi-cation. In contrast, people with a strong SOC seem to have a coping ability which allowsthem to attribute meaningfulness to their task. Antonovsky believed that the search for a“coping strategy that is universally effective in successful dealing with stressors” isuseless (Antonovsky, 1987a, p. 144.). However, he felt that people with a high SOC havethe required flexibility to select the appropriate coping strategy to meet situationaldemands, 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 toactivate the most suitable resource he or she has available. This statement was confirmedby 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 showa positive relation to situational control attempts (Rimann & Udris, 1998) and activecoping strategies (Gallagher, Wagenfeld, Baro & Haepers, 1994; Margalit, Raviv & Anko-nina, 1992; McSherry & Holm, 1994).

SOC and Social Environment

According to Antonovsky, unfavourable life circumstances can impede optimum develop-ment of the SOC. People in unfavourable life situations – and that includes the absenceof social support – do not have the same opportunity to develop their sense of coherenceas do people who grow up in a social environment which is supportive from a develop-


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

SOC and Health Behaviour

Antonovsky did not regard the influence of the SOC on health-related behaviour or theavoidance of behaviour that is hazardous to health, such as cigarette smoking or pooreating habits, as being central to the problem of salutogenesis:

“I make no claim that persons with a strong SOC are more likely to engagein those behaviours that evidence indicates are good for the health – noteating between meals, not smoking, regular physical activity, and so on.These behaviours are far more determined by social-structural and culturalfactors than by the way one sees the world, and I do not wish to confuse thetwo” (Antonovsky, 1987a, p. 152–153).

He qualified this statement, however, by stressing that people with a high SOC value havea lesser tendency to turn to inappropriate coping strategies, such as addictive drugs or non-compliance6, than people with low SOC values, since the former have diverse alternativesand thus can select coping behaviour which is more appropriate for the problem. “Fromthis point of view, there is indeed a basis for anticipating a causal sequence betweenthe 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 andaffects health status through the central pathways of the neuroimmunological andendocrine systems (Antonovsky, 1987a, p. 154).

The few studies which have addressed the relationship between the SOC and behaviourrelevant to health could not provide clear indications for such a relationship.Bös and Woll (1994) examined, among other things, the amount of exercise done byN=500 men and women. They found that older persons with a high SOC get more exercisethat 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 with-out a history of substance abuse and reached the conclusion that the SOC values of normalwomen are significantly higher than those who have drug problems. In contrast to theirhypothesis, Frenz et al. (1993) found no significant relationship between the SOC andalcohol consumption.Behaviour detrimental to health employed as a coping strategy in the face of a stressfulhome situation was demonstrated in the study by Gallagher et al. (1994) mentioned abovein those caregivers that showed low SOC values.In an elaborate study, Becker et al. (1996) investigated the influence of numerous vari-ables, including SOC, healthy eating habits, intensive exercise and restful sleep, on thehabitual physical level of health of N=863 men and women. The SOC did not correlatewith 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 andhealthy eating habits and between the SOC and exercise in stressful situations as well asrestful sleep.

Seen as a whole, the research findings are contradictory. Up to this point, the SOC cannotbe 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 andsociodemographic influences. However, he qualifies this statement by considering thecriterion of participation in decision-making processes to be decisive for the developmentand maintenance of the SOC, while at the same time emphasising that the decision-mak-ing 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. Atthis point, it is not yet possible to make a conclusive statement about the above-mentionedremarks.

Cultural GroupThe transcultural validity of the construct of the SOC has been the subject of several studiesin different countries, which do not indicate any major deviation from the SOC valuesmeasured. Similar values have been obtained for populations of different ethnic groups.Bowman (1996), for example, was able to demonstrate that the pronouncement of the SOCin a group of Anglo-Americans was similar to that of a group of Native Americans, despitegreat differences in the socio-economic conditions between the two groups. Hood et. al (1996) also could not establish any differences between Canadians of Euro-pean origin and immigrants from Asia. Seen as a whole, the cultural differences between countries like Sweden, the USA andGermany are not succinct enough to be able to speak of the transcultural validity of theconstruct.


Gender and AgeWith regard to the independence of the SOC value of gender and age, the results are hetero-geneous. 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 thestudy exhibited a lower SOC value than the men. The authors considered female social-isation, which often still makes women financially dependent, to be a barrier to the de-velopment of a pronounced SOC. Larsson and Kallenberg (1996) also confirmed the low SOC values in women in theirlarge-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 sampleof N=5133 men and women between the age of 40 and 65. In contrast, no gender differ-ences 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 clinicalsamples. 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 takeninto consideration.

AgeAntonovsky contended that the SOC remains stable throughout adulthood. In contrast tothis assumption, the studies we reviewed indicated that the strength of the SOC increaseswith age (Callahan & Pincus, 1995; Frenz et al., 1994, Larsson & Kallenberg, 1996;Rimann & Udris, 1998; Sack et al., 1997). However, well-founded statements about thestability of this construct cannot be made without long-term studies.

Education/Socio-economic StatusNo conclusive judgement can be made with regard to the relationship between the SOCand education level and socio-economic status.A Polish study of N=523 pregnant women shortly before delivery showed no significantrelationship 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 (Hoodet al., 1996).A further representative study provided no indication of an influence of the level ofeducation on the SOC (Larsson & Kallenberg, 1996). At the same time, however, the samestudy established a significant relationship between the type of employment, income andthe SOC. Self-employed persons, white-collar salaried employees and people with higherincomes 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 theSwiss study by Rimann and Udris (1998). They found that larger professional realms ofaction 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 highestSOC values and unskilled labourers the lowest. However, Lundberg (1997) did find thatsocial class and socio-economic status during childhood did not influence the extent ofthe 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 beassumed to be confounded. Nevertheless, the studies did not demonstrate any consistentresults regarding the relationship between the three criteria and the SOC.

3.2. Sense of Coherence as Compared to Related Concepts

Parallel to Antonovsky’s SOC, influential psychological concepts have been developed inthe past few years which attempt to explain how individual characteristics affect the emer-gence and the change of health and disease. These concepts are often subsumed under thecategory “internal or personal protective factors”.

Internal protective factors are referred to as dispositional, though changeable personalcharacteristics, as well as cognitive or behavioural styles that are situational. Becausespecific health behaviours, such as taking advantage of the preventive checkups offeredby the health care system, have been assumed to help maintain health, they can also beconsidered protective factors. Commonly cited personal protective factors include the concepts of “health locus ofcontrol” (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 divergencefrom 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 men-tioned are presented in an overview and the similarities and differences are illustrated onceagain.


Health Locus of Control (HLOC)

The aspect of control is important in Antonovsky’s model of the SOC. On the one hand, itis included in the comprehensibility component. If events are predictable and can beexplained, then cognitive or other kinds of control over these events are possible. On theother hand, control is central to the component of manageability. This refers to themotivational or action-related aspect, that is, the conviction that one has possibilities orresources available. If something bad or unexpected happens, people with a strong SOChave the certainty that they can handle it. Antonovsky explicitly stressed that man-ageability included not only the individual’s abilities, but also the aid and influence ofother persons or institutions (Antonovsky, 1987a).

Within the field of social psychology, there are different approaches which consider con-trol to be the key to explaining behaviour. Common to these approaches is the assump-tion that individuals attempt to gain control over the events in their environment. In thefield of health, this is represented by the health locus of control. This concept is based onthe 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 illnesscan be influenced – independent of his or her actual objective ability to influence them(Wallston & Wallston, 1978). In contrast to Antonovsky, Wallston and Wallston regard theHLOC more as specific and situationally dependent than as stable, personally dependentfactors. They distinguish between internal, external and fatalistic loci of control. Whereas people with an internal locus of control are convinced that their state of healthcan be influenced by their own behaviour, people with an external locus of controlconsider their state of health to be dependent on other individuals or external conditions,for example, on medicinal treatment. Persons with fatalistic convictions attribute theirhealth to fate, luck or chance.

Most of the hypotheses in studies on the HLOC assume that internal loci of control arebetter. Favouring internal loci of control contradicts the neutral assessment of the differentloci of control made by Antonovsky. In his opinion, this placement might be culturallymotivated, since western industrial societies value individuality and the idea that everyoneis the master of his or her own fate.

Originally, the predictive value of the HLOC was optimistically overestimated. This mustbe qualified with regard to the latest research. The contradictory findings make it difficultto conclusively evaluate this construct (Bengel, 1993). Following Antonovsky’s line ofthinking, the results cannot be interpreted in the sense that an internal locus of controlgenerally represents a factor which protects health. According to the situational context,those behaviours associated with external loci of control which might tend to be passivecould well be adequate. They might also lead to emotional relief in the case of chronicillnesses, 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 deter-mined by expectations concerning his or her own efficacy (efficacy expectancy) and theoutcome of a behaviour (outcome expectancy). Merely the anticipation of a positive re-sult does not suffice to induce a change in behaviour. Indeed, the conviction that one canactually exercise a particular behaviour or successfully perform this behaviour is decisive.Self-efficacy is built up through the experiences an individual makes in situations thathave been successfully mastered. This, in turn, leads to the establishment of suitablecoping strategies.

Self-efficacy appears to be fundamental to the motivation of behavioural change. (For anoverview of the relationship between self-efficacy and health-related behaviour, seeSchwarzer, 1992; Strecher, McEvos Develis, Becker & Rosenstock, 1986). Self-efficacy is acomponent of the individual appraisal of one’s own coping possibilities and thus contrib-utes to coping with crises and to the construction of the individual’s personal environment(Rippetoe & Rogers, 1987). The empirically established relationship between the willing-ness 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 toimplement situationally adequate coping strategies (Rippetoe & Rogers, 1987) indicatesthat self-efficacy influences health-related behaviours and in this indirect manner repre-sents an important factor for health protection.

Bandura originally conceived self-efficacy as situational beliefs and not as a stablepersonality trait. His theory differs from Antonovsky’s approach in this point. More recentideas tend to consider self-efficacy both as a trait and as specific cognitions that are onlyvalid for clearly defined situations (Schwarzer, 1992; 1994).

Antonovsky did not distinguish between outcome and efficacy expectations. However, bothaspects are implicit in the component of manageability – the confidence that one has theresources available that one needs to cope with events. When one compares the corre-sponding questionnaires, the similarity in the composition of the component ofmanageability and the construct of self-efficacy is obvious. For example, a question in theSOC-scale asks: “Do you have the feeling that you are in an unfamiliar situation anddon’t know what to do?” In the scale for generalised self-efficacy, the question is: “Inunexpected situations, I always/never know how to act.”

Similar to the HLOC and the stress-coping theories, the self-efficacy theory is characterisedby strong action orientation. Subjective assessments influence health-related behavioursand are thus buffers or mediators of health, or rather, of disease and risk factors.


Hardiness

Kobasa (1979; Kobasa, Maddi & Kahn, 1982) presented the construct of “hardiness” at thesame time as Antonovsky coined the term “sense of coherence”. It is important to pointout that Kobasa, too, was interested in the question of invulnerability and health resour-ces, that is, she was a proponent of a salutogenic approach from the beginning, eventhough she did not use this term. In her opinion, it is the personality trait of hardinesswhich leads people to react differently to objectively identical stressors and stressfulsituations. Hardiness refers to the fact that individuals are resistant to the negative effectsof stress and as a result do not develop any negative consequences. In contrast to Anto-novsky, Kobasa does not view this trait as a static personal characteristic, whosedevelopment is completed early and is virtually fixed by adulthood. In her opinion,personality characteristics are personal styles that can develop dynamically as the indi-vidual interacts with the environment. Her standpoint allows for change and is thus notquite as pessimistic as that of Antonovsky.

Hardiness contains three components that not only overlap with each other, but also showsome very close parallels to the three components of the SOC: commitment, control andchallenge. People having pronounced hardiness are curious about and active in all areasof their lives (commitment). On the one hand, this requires the individual to be convincedof his or her own importance, actions and good judgement. On the other hand, thischaracteristic also includes social action and engagement. Antonovsky felt that whenKobasa 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 morepronounced hardiness are convinced that they can control and have influence on theirsurroundings. These persons emphasise the individual responsibility of their actions andthe possibility of reducing the negative effects of stressors through self-determinedactivities. Kobasa distinguished between external control, where the source is outside theself, 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 positsonly 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 expe-rience changes as normal and exciting, and as an opportunity for inner growth ratherthan as a threat. They actively seek new experiences and, in dealing with unexpectedsituations, 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 normativelifestyle.

Kobasa names two different mechanisms of influence on health for the personalityvariable of hardiness. First, hardiness can serve as a buffer, which makes peopleexperience stress differently and contributes to the fact that individuals employsuccessful coping strategies to solve their problems. In this case, hardiness has anindirect 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 todirectly reduce tension.

In the 1980’s, numerous studies investigated the relationship between hardiness and manydifferent kinds of health parameters, such as state of health or symptoms of disease, healthbehaviour, 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 attrib-uted 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 rela-tively stable over time and across different situations and which enables persons to per-ceive their environment in a specific way. Such individuals tend to expect positive eventsand are hopeful and confident about their outcome. The authors view this characteristicas a generalised outcome expectancy which is not limited to a specific area of behaviouror to certain situations. Their theory has a much simpler structure than that of Antonov-sky. However, the “generalised positive outcome expectancy” is identical to the SOC’s com-ponent of manageability. This concept also overlaps with the component ofcomprehensibility. However, Antonovsky did not claim that persons with a strong SOCfrequently expect positive outcomes.

The construct of “dispositional optimism” is based on a self-regulation model of be-haviour (Scheier & Carver, 1990). This model proposes that, by means of self-attentive-ness, discrepancies between momentary behaviour and behavioural goals will be perceivedand will stimulate an analysis of the reasons for these discrepancies and the related bar-riers. In this analysis process, the probability of a reduction in discrepancy is assessed. Theoutcome 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 afavourable outcome is expected, the efforts undertaken to reach the goal will be intensi-fied. In this model, confidence as a generalised outcome expectancy is the best predictorof behaviour. Dispositional optimism is not considered to be a consequence of successful


action, but in fact, the reverse is true, in the sense that it is a cause of behaviour or rele-vant for action.In contrast to this individualist perspective, Antonovsky embedded his SOC concept muchmore deeply in the social and cultural context of life circumstances and the correspond-ing developmental possibilities.

Exactly how dispositional optimism affects health has not yet been established. There isassumed to be a buffer effect or an indirect effect of disposition on health by way of copingmechanisms. Aversive events are assessed and perceived as being soluble, which leads toan active approach to problems. Optimists tend to exhibit problem-related coping and anactive search for social support (Scheier, Weintraub & Carver, 1986).

Successfully coping with stress should have a direct effect on physical complaints. Afavourable outcome expectancy can lead to increased effort which, in the sense of a self-fulfilling prophecy, can lead to successful attainment of the goal. The feeling of achieve-ment makes symptoms have less of an impact.A further explanation appears to be the quick solution of problems, that is, the problemsare not suppressed and thus do not reach the magnitude of those problems that are notpromptly confronted.

Several studies confirm the protective influence of dispositional optimism on physicalhealth, psychological well-being, life satisfaction, coping behaviour and preventive healthbehaviour (Chamberlain et al., 1992; Scheier & Carver, 1987; Wieland-Eckelmann &Carver, 1990).

The constructs discussed above are presented in the following table for comparison.

55 3

Wh

at Keep

s P

eople H

ealth

y?

Generalised Out-come Expectancy:Things will turn outpositively

Generalised Self-ef-ficacy: The convic-tion of being able tocarry out an actionindependently

Internal Locus ofControl: Convictionof having an influ-ence on events andactions

External Locus ofControl: Convictionthat others or ahigher power willtake care of things

Dealing withChange

Meaningfulness

Sense of Coherence

Conviction that thingswill turn out well

Confidence in one’sability to master life’stasks (manageability)

Resources that onehas under control(manageability)

Resources that canbe controlled bylegitimate others(manageability)

Continuity, stability asa central orientation;the world is seen asordered and predict-able (comprehensi-bility)

Life is seen as beingmeaningful, problemsare worth investingenergy in (meaning-fulness)

Loci of control (LOC)

Generalised expec-tancy as to whetherevents in an individ-ual’s realm of life canbe influenced or not

Especially internalLOC have a positiveeffect on healthparameters

External LOC usuallyhave a less positiveeffect on healthparameters

Self-efficacy

The expectancy thata specific behaviourwill lead to apredictable result

The expectancy thatone will be able toperform the appro-priate behaviour in agiven situation

Hardiness

The ability to exercisecontrol in one’ssurroundings

Self-responsibility of ac-tion and the possibility ofreducing the negative ef-fects of stressors by self-determined activities

Life changes as achallenge;normative lifestyle as anorientation towardschange and not towardsstability

Curiosity in life, commit-ment in all areas of life

DispositionalOptimism

Confidence,optimism


How people deal with stress and stressful situations has long been a subject of interest inthe health sciences. As a result of the so-called “cognitive turn” within psychology, thereis general agreement today that subjective processes of appraisal are more significant thanobjective 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 fromthe viewpoint of objective stress to the subjective coping process, that is, to those adjust-ments necessary for the individual to cope with stress (Koch & Heim, 1988). Stress is thusnot a fixed dimension, but can be changed by the individual’s information processingabilities 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 well-being. “Secondary appraisal” refers to the evaluation of personal and social resources, thatis, of one’s own possibilities to cope with a stressful situation alone or with the support ofothers. Lazarus and Folkman differentiate between five coping reactions that fulfilproblem-solving as well as emotion-regulating functions:

– The search for information serves as a basis to select coping reactions or for thereappraisal of stressful situations.

– Direct action as a coping reaction encompasses all behaviours with which a personattempts 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-see-ing, resignation, utilisation of support, active influence) (Perrez, 1988).

3.3. Stress and Resilience Research

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Within the framework of stress and coping research, successful or appropriate copingstrategies are considered to be health resources, since they lead to improved adaptation tolife’s circumstances or demand a change away from aversive situations. According toCohen and Lazarus (1979), appropriate coping strategies enable the reduction ofdestructive situational conditions, the maintenance of a positive self-image, the stabilityof emotional balance, and the establishment of satisfactory relationships. In addition, theyinfluence well-being and the state of health (Lazarus, 1981).

Active, problem-solving-oriented coping strategies tend to be considered as appropriatebehaviour for managing stressful situations (Braukmann & Filipp, 1984; Heim, 1988).Less healthy persons tend to resign in problem situations, can deal less well with stressorsthat 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 theflexible 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 conceptof the SOC (see Chapter 1). It is not always easy to understand the similarities and dif-ferences between the different approaches in stress research and the SOC. The mostimportant 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 “primaryappraisal” 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, thesalutogenic perspective has been neglected in the traditional approaches of stress research:

– Research hypotheses are formulated pathogenically and thus guide the epistemologyand insight (e.g., depression as a predictor of cancer mortality. The probability thatdepressed patients will die of cancer is twice as high as that of patients who are notdepressed. This statement ignores the fact that only very few of the depressed patientsactually ever die of cancer).

– Stressors are automatically defined as risk factors without further investigation of thisassumption. Antonovsky regarded stressors as an omnipresent component of life thatis detrimental to health only under certain circumstances.

– The dependent variables that are examined are almost exclusively measurements ofdisease 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, how-ever, refers to the individual belief system about the nature of things and not to whatone does. The strength of the SOC does not permit the prediction of concrete behaviour.


– Judgements and expectations of a person are seen as situationally dependent. In con-trast, Antonovsky sees them as a situationally-independent basic attitude (dispositionalorientation).

The interactional demands-resources model of health by Becker (1992) is anotherhealth-psychological model to explain health. It was also developed in the tradition ofLazarus’ transactional stress model, and Becker considers it to supplement the saluto-genesis model. It attempts to explain the physical and psychological state of health. Themodel postulates that, in order to cope with internal and external demands, such as roleexpectations, physical and psychological needs, internal and external resources are used.The internal resource “Seelische Gesundheit als Eigenschaft”, or “SGE” (mental healthas a characteristic), is a key factor in the behaviour and experiencing of a coping processthat is taking place. Becker regards mental health as a characteristic that remains stableover time and that enables one to meet internal and external demands. The constructconsists of the components psycho-physical well-being, self-actualisation and self- and other esteem. In keeping with Beck, these three factors constitute a type of cognitivetriad, that is, the positive view of one’s self, one’s environment and one’s future. Mentalhealth as a characteristic affects coping behaviour in progress, health behaviour and thus– indirectly – health. Since the emotions triggered by stressful events are less intense, italso 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 healthbehaviour, 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 demonstratedthat psychologically healthy persons have access to better external resources (in this casea psychologically healthy spouse) than psychologically less healthy persons (Becker,1991). Perrez (1988) found indications that psychologically healthy persons are less rest-less, depressed and anxious than psychologically less healthy patients when dealing withdaily troubles.

Common to both Becker’s and Antonovsky’s model is that, in the face of the complexinteraction between internal and external demands and resources, they attribute a key roleto stable cognitive-affective processing patterns for the emergence and maintenance of thestate of health. In addition, because of their complexity, both models are prone to meth-odological difficulties when empirically tested.

Resilience and Invulnerability Research

Like stress and coping research, resilience and invulnerability research looks for factorswhich 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 andhealthy personality and behavioural development which has emerged despite unfavour-able experiences and stress in early childhood. The findings of resilience or invul-nerability research are based on retrospective and prospective longitudinal studies thatrepresent 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 etiologicalmodel of resilience, that it lacks a conceptual framework or a theory with an explicit claimand, finally, that it examines more personal and less social risk factors. Moreover, Anto-novsky’s criticism also applies to this area of research, i.e., that statements about theinvulnerability of specific persons or groups of persons are based predominantly on riskstudies 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 contain-ing variables of pathogenic or protective influences on child development. Lösel and Ben-der (1997) regard the following social and personal resources as having confirmedprotective 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 isregarded as one of many potential resources of favourable developmental processes (seeHurrelmann, 1988; Lösel & Bender, 1997; Köferl, 1988). Antonovsky himself never madereference to the models and approaches of resilience or invulnerability research. Thisresearch tradition was established at about the same time as the salutogenic model wasdeveloped. Since it is rooted in another scientific discipline, one can assume that Anto-novsky was not very familiar with it.

The significance of invulnerability research can be attributed mainly to its methodologicalapproach of retrospective and prospective longitudinal studies. In this respect, resilienceand invulnerability research, which tends to be methodology-oriented, can complementthe model of salutogenesis. Within Antonovsky’s salutogenic model, longitudinal studiescould contribute to the question as to which circumstances lead to the development of astrong SOC. Essential for the significance of the SOC as a central protective factor wouldbe the proof that the different social and personal resources found in resilience researchare a prerequisite for the development of the SOC, but later no longer independent of the


strength of the SOC. In other words, in the case of a weak SOC, objectively available resourcesare not perceived or are not utilised. Since multifactorial processes are involved, the proofof such relationships is hindered by significant methodical problems. The registration anddescription of relationships between personal and social factors that protect health appearto be more promising in the hands of resilience or invulnerability research. Prospectivelongitudinal studies are necessary to examine causal relationships between protectivefactors and health, which is not possible in primarily correlative studies, such as thosemainly used to test the SOC concept.

4Importance and Utilisation of the Concept in DifferentAreas of Application


This chapter of the expert report describes different areas of work and research in Germanyin which salutogenic principles have been introduced and have gained scientific as wellas practical importance. This report can only address published material or that other-wise known to us. Thus, this description of the usage and the significance of salutogenicprinciples in the areas selected must remain limited and refers only to the German publichealth system.

Individual facilities devoted to prevention and health promotion, to rehabilitation andpsychosocial care, as well as out-patient and in-patient medical care, have supplementedtheir concepts with salutogenic measures or retitled the names of their former services withsalutogenic terms. Many of these approaches taken by facilities and organisations –especially in health promotion and rehabilitation – have not been documented or haveonly been registered for internal use, or are only available in the form of project reportsthat are difficult to acquire. The reports are not listed in the bibliographies of scientificliterature. Many of the facilities have neither the time, nor the capacity, nor the access tothe germane media and journals. Moreover, their work does not require documentationor legitimation by scientific publications and papers. Independent of the fact that thisoverview is incomplete, we assume that the treatment of salutogenic principles in healthcare facilities and organisations takes place in one of the following four ways:

– There is no evidence of concern with the concept of salutogenesis (most frequentcase).

– 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.), “Psycho-somatics and Psychotherapy” (Section 4.2.) as well as “Rehabilitation” (Section 4.3.) arethe only areas of application that merit thorough reviewing. In addition, ideas in a fewother 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 theInstitute for General Health in Frankfurt in July 1998),

– Salutogenic factors in patients dependent on addictive substances (Fuchtmann,1994).

4.Importance and Utilisation of the Concept in Different Areas of Application

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From a scientific perspective, the field of industrial psychology should be mentioned: themembers of the working group headed by I. Udris (Switzerland) are proponents of a sa-lutogenic approach in industrial psychological research (see, for example, Udris, Kraft &Mussmann, 1991; Udris, Kraft, Muheim, Mussmann & Rimann, 1992). In the researchproject “Personnel and Organisational Resources of Salutogenesis” (SALUTE), they ex-amined the influence that personnel and organisational factors have on the maintenanceof health in the context of employment. Their research is based on system theory and ac-tion theory models in which health or illness result from exchange and coping processesbetween internal and external resources and demands, similar to those of Antonovsky andBecker. Based on their research results, the working group formulated consequences forthe design of working structures and for industrial preventive measures. Industrial healthpromotion should not only influence individual health behaviour, but also containthorough 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-promot-ing 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 develop-ment, conception and design of preventive measures. This is based on the following ma-terial:

– Implications that can be drawn directly from Antonovsky’s theories or that heformulated himself,

– Contributions that contain the fundamental elaborations on the necessity of theintegration of salutogenic approaches in prevention, as well as those that containthe 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 forsuccessful coping with omnipresent stressors and thus for the maintenance of health(Antonovsky, 1987a). He regarded the SOC as a stable characteristic which is not onlyformed 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 tem-porarily modified by critical events. However, the stability of the SOC has not been suffi-ciently clarified. Antonovsky himself said little about ways to change the SOC throughplanned, targeted measures and interventions. He pointed out that, in many situations,


slight and temporary changes may be significant, and that it could be important to assistpeople 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 in-fluence and participate in socially recognised decision processes to be the most promisingway to positively influence the SOC. According to Antonovsky, it becomes more stable andthus more difficult to change as one gets older. The conclusion to be drawn from this isthat it is important to create a world in which children and adolescents experience con-sistency, can recover from stress, and can participate in decision-making processes.

All in all, the implications and consequences that can be drawn from Antonovsky’stheoretical elaborations on the practice of prevention tend to be rather sobering. Onceadulthood 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 “psycho-therapying” preventive measures. Measures aimed at individuals can achieve only littleif the structural and societal conditions are unfavourable. Therefore, health promotionand 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 insocially acceptable behaviour and can be developed in contexts that are destructive to ourWestern democratic ideals: “I would like to say that the rigidity of an SOC that emergesin 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 becomeimportant to the field of prevention. It serves as a meta-theory for the working field, aslegitimation for conceptual ideas and for the planning of concrete measures. It providesa framework for preventive activities that often lack a clear theoretical foundation and areundertaken in an activistic, uncoordinated manner. This theoretical framework supportsresource-oriented, competence-raising and non-specific preventive measures. The modelalso supports a critical view of the previous preventive measures taken in health educa-tion and confronts the risk factor model. In this context, the low success rate regardingthe change in risk factors should be mentioned. It is also important that the model parriesthe puritanical aspects of “warnings”, “alarms” and “austerity” belonging to the riskfactor model with a positive concept. The shift in perspective from risk factors to preven-tive factors is compatible with a modern concept of health which ranks the psychologicaland social dimensions on the same level as the physical dimension.

The inception of the salutogenesis model occurred at about the same time as the com-munity psychology movements that formulated the concept of empowerment and social-ecological approaches. All these approaches stand for or have enabled a shift in perspectivein prevention, which has had an impact on the Ottawa Charter of the WHO and theapproach of health promotion. Even though the terms “salutogenesis” or “SOC” are notmentioned 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 positiveself-perception of action competence/self-efficacy as a major element of health (Kick-busch, 1992).

Many authors seem to feel that putting the salutogenic model into practice in the field ofprevention 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 andsupport of salutogenic processes in social systems and the assistance in establishingthe structures for them”. This equates health promotion with salutogenesis. Accordingto Noack (1996a; 1996b), salutogenic resources, that is, the social, living and workingenvironment, and individual characteristics, are areas of action for health-promotingmeasures.

The meaning of the concept of health promotion and the related shift in perspective is alsounderlined by Antonovsky’s ideas. However, this also means that the sparse literature avail-able on aspects of the application of salutogenesis does not go much further beyond thediscussion on health promotion.

For example, Renner (1997) mentioned several projects by the Hessian Working Group forHealth Education, which were developed according to the WHO guidelines for health pro-motion and are aimed at strengthening salutogenic factors, such as “Healthy Cities”,“Make Children Strong”, “First Love and Sexuality” and so on. In contrast to classicalrisk-factor-oriented measures of health education, these concepts foster the activeparticipation of non-professionals or the members of self-help groups and attempt tostrengthen their resources and competence, while conveying positive forms of communi-cation 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 cam-paigns), and “health-promoting institutions”. In keeping with the Ottawa Charter,salutogenic schools do not merely provide preventive measures periodically, but involvethe entire school and all its members in a continuous health-related developmentalprocess. The measures apply to very different areas and include social, ecological andcommunal aspects of school activities (Paulus, 1995). Other authors agree that the latteris 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 avoidanceof health risk factors are claimed to be based on the salutogenesis model, or a single eventwith the theme of social support or enjoyment training is considered, as far as the initiatoris concerned, to suffice as having put Antonovsky’s model into practice.

The current situation in health promotion is characterised by the fact that the informa-tion level of the providers of health-promoting services is very different. In many cases,


they appeal for a shift to salutogenesis without having true knowledge of the model. Inother cases, previously introduced measures are continued but relabeled as “salutogenic”.

All measures on the critical discussion and reception of the model should be encouragedand supported. The scientific and health-political benefits, as well as the gain in the fieldsof 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 arefurther fields of application for the concept of salutogenesis. In the following, both areaswill be discussed together since psychotherapy is a central method in psychosomatics.

Psychosomatic medicine or psychosomatics is a specialised discipline in the canon of sub-jects in medicine. Psychosomatics is concerned with illnesses whose emergence and pro-gression are significantly affected by the psychological processes and the psychosocialsituation of the patient. However, it also encompasses physical symptoms without anorganic substrate, frequently referred to as somatisation, vegetative or functional dis-orders. Psychosomatic medicine is also very important for primary physical illnesses. Inthis case, psychological processes influence the way the patient copes with the illness, aswell as the course of the illness.

The borders between psychosomatics and clinical psychology, psychiatry, medicalpsychology, and behavioural medicine are not clear-cut. Dialogue, psychotherapeuticindividual and group treatment, and various exercises are methods used in psycho-somatics.

“Psychotherapy” is the generic term for a collection of different methods which aim toinfluence or improve behavioural or psychological disorders and other troubling con-ditions by communicative means, generally verbal. In general, the aim is to reduce thesymptoms which disturb and restrict the patient, as well as to change his or her personal-ity structure. Thus, the therapist and the patient must succeed in creating a supportiverapport, the therapist-patient relationship. Psychotherapy is predominantly conducted onan out-patient basis in private practices of psychotherapists, usually clinical psychologistsor 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 largeportion of the in-patient treatment for psychosomatic illnesses takes place in medicalrehabilitation centres.

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There are a number of psychotherapeutic schools. Most often, psychotherapy is performedon the basis of behavioural therapy, depth psychology (“Tiefenpsychologie”) or psycho-analysis and client-centred psychology (“Gesprächspsychologie”). Further psychothera-peutic schools are Gestalt therapy, systemic therapy and psychodrama. Psychotherapy isbased on a theory of mental disorders and a theory of therapeutic change.

The concept of salutogenesis rarely appears in the psychosomatic and psychotherapeuticliterature. In psychosomatic and psychotherapeutic textbooks, the terms “salutogenesis”and “sense of coherence” are seldom mentioned. To give a few examples, one textbookfrom each of the fields of psychosomatics (Ahrens, 1997), psychoanalysis (Thomä &Kächele, 1996; 1997) and behavioural therapy (Margraf, 1997) will be discussed togetherwith a so-called integrative textbook of psychotherapy (Senf & Broda, 1996).

In the “Lehrbuch der psychotherapeutischen Medizin” (Textbook of PsychotherapeuticMedicine) by Ahrens (1997), salutogenesis is merely presented as an orientation in whichthe research for health protective factors has the same rank as pathogenically-orientedresearch. In the “Lehrbuch der Verhaltenstherapie” (Textbook of Behavioural Therapy)by Margraf (1997), salutogenesis is addressed in conjunction with the euthymic basis ofbehavioural therapy (Lutz, 1997). Euthymic experience and action encompasses anythingthat does the psyche good. For this reason, psychotherapy should also concentrate onpositive feelings like fun, joy, relaxation, equilibrium and well-being – that is, they alsotake positive aspects of experience in psychotherapy into account.

Neither in the “Lehrbuch der psychoanalytischen Therapie” (Textbook of PsychoanalyticTherapy) by Thomä and Kächele (1996; 1997), nor in the textbook “Praxis der Psycho-therapie” (Practice of Psychotherapy) by Senf and Broda (1996), is the term “salutoge-nesis” listed in the index. It is remarkable that M. Broda, one of the German-speakingauthors best acquainted with Antonovsky (see Section 4.3), did not integrate the conceptof salutogenesis in his textbook. Most of the other textbooks on psychosomatics, medicalpsychology and clinical psychology do not address the subject of salutogenesis. If they domention 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 saluto-genic 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 toDepart from the Concept of Pathogenesis). Their main thesis is “that pathology-orientedthinking and action in psychosomatics cannot contribute to a reduction in the inci-dence of psychosomatic illnesses” (p. 1). This book focuses on the definition of health.In the authors’ opinion, the salutogenic perspective supports the importance of subjec-


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 con-cepts of health (Helfferich), the protective effects of coping skills (Broda), the criticism ofthe risk factor model (Reye), public health care and the political and economic effects ofthe concept of pathogenesis (Franke, Huber, Glaeske, Reiners), and the scientific eval-uation of convalescence criteria (Dahme). The conference proceedings plead against one-sided pathology-oriented thinking and action in psychosomatics and psychotherapy.However, the discussion does not go decisively beyond describing the problems of the con-cept in psychotherapy and psychosomatics. In this case, Antonovsky’s ideas could providea valuable framework for the discussion.

In 1994, the “Deutsches Kollegium für Psychosomatische Medizin” (German College ofPsychosomatic Medicine) held its 40th conference with the theme “Salutogenesis – a newconcept in psychosomatics?” The conference proceedings, edited by Lamprecht and Johnen(1994; 3rd revised edition 1997), encompassed 32 contributions on the subject. Diverseareas of work and therapeutic strategies were presented. The contributions concentratedon 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 contributionto “psychobiological aspects of protection and repair mechanisms”, addressing thequestion 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 aresick people?”) contains 24 contributions. It focuses on the debate regarding the defini-tions of health and illness. This is followed by studies and overviews or reports on differentworking areas and therapeutic approaches.

Aside from the volumes and contributions, few studies on salutogenesis and psychotherapycan be found:

– Broda et al. (1995): Therapieerfolg und Kohärenzgefühl (Therapeutic Success andthe 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 mitBelastungen (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 dis-cussed by different therapeutic schools independently of Antonovsky. The key construct –the sense of coherence – is defined by Antonovsky as one that is relatively stable anddifficult to change. Thus, it is not well-suited as a criterion for denoting the success ofpsychotherapeutic treatment. In addition, it is in competition with numerous other em-pirically well-studied dimensions, such as neuroticism and depression.

Even though, as a whole, psychotherapeutic and psychosomatic research has littlehonoured and integrated the concept of salutogenesis, we feel that the following aspectsare 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 andpsychosomatics. 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 adichotomy between disease and health might well be relevant to the theory of mentaldisorders. However, the health care system requires a clear diagnosis, that is, “ill” or“healthy” (not in need of treatment) for patients with psychological complaints andsymptoms.

The concept of salutogenesis is helpful to the extent that it requires the different schoolsof psychotherapy to re-examine their theories and concepts. It forces them to answer thequestion whether they are sufficiently taking into consideration the role of factors thatprotect and maintain health in the practice of psychotherapy and in research on aetiologyand therapy. Furthermore, it stimulates questions as to how much importance they attachto resource-activating methods and to the extent which they recognise and foster healthyaspects of the patient.

Resource activation has long been a therapeutic principle of most therapies. Examples ofresource activation are the inclusion of the patient’s partner in the therapy in a suppor-tive role or the strengthening of his or her self-help skills. Previous research on a generalmodel of psychotherapy attributes a key role to resource activation as a determinant for


the patient’s improvement. The concept is significant for the discussion regarding thera-peutic goals, since it not only implies a focus on symptom reduction, but also aims at im-proving the healthy aspects and the skills of the patient.

The discourse on the concept of salutogenesis in psychosomatics and psychotherapy iscontinued in two books:

– Schüffel et al. (Eds.): Handbuch der Salutogenese. Konzept und Praxis. Berlin/Wiesba-den: Ullstein & Mosby (Handbook of Salutogenesis. Concepts and Implementation).

– Margraf et al. (Eds.): Gesundheits- oder Krankheitstheorie? Berlin: Springer (Healthor 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 wellas drug and alcohol dependence (Bundesarbeitsgemeinschaft für Rehabilitation, 1994).

“Chronic illness” is a generic term for a number of very different illnesses of varyingaetiology, pathogenesis, symptoms and prognosis. Common to all these syndromes is thatthey 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 andits specialists for long periods of time. The aetiology is generally assumed to be multifac-torial, in which a particular disposition as well as habits or lifestyle play a role. Examplesof 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, per-sonality structure, comprehension of the illness and subjective theory of the illness),

2. Characteristics of health-related events and situations (intensity, duration, control-lability, severity),

3. Psychosocial environment (family and significant others, professional situation,leisure activities),

4. Institutional environment (extent and type of the support experienced, atmosphere onthe 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 thetherapeutic circumstances seem to provide favourable conditions for the integration ofsalutogenic principles. Nevertheless, salutogenic principles and the strategies derived fromthem 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 discussedin Section 4.2., “Psychosomatics and Psychotherapy”.

Although the topic of health promotion and prevention was treated in Section 4.1., theaspects specific to rehabilitation will also be discussed here. Measures taken concerninghealth promotion, health training and health education play an exceptional role inmedical rehabilitation. Preventive measures are recognised as an overall equivalentdimension of treatment.

Most programmes and measures aim at reducing health risk factors and behaviours andmotivating the patient to take responsibility for his or her health. The conception andstructure are mainly oriented on a medical concept of disease and rehabilitation, in whichthe reduction of risk factors is the principal goal of prevention. However, resource-orientedconcepts, the consideration of protective factors and the emphasis of social resources havebeen 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 doesnot only discuss physical skills, but also emphasises social and individual resources. Theauthors assert that in the future more attention should be paid to the question of health-maintaining factors and conditions (see also Buschmann-Steinhage & Liebing, 1996).As Doubrawa (1995) sees it, in health promotion in the field of rehabilitation, the effortsof rehabilitation are based on a holistic and positive health concept which encompassesboth physical as well as psychological well-being. Health is seen as a life-long processwhich is influenced by the individual’s biography and his or her social and ecologicalsituation. Health promotion should not only aim at the individual behaviour of thepatient, but also encourage him or her to make his or her life and environmental con-ditions healthy (see Section 4.1.).

Table 3

In health promotion, the patient is seen as a responsible partner, who is offered knowledgeon health and change, but who is left with the decision whether to put this knowledge intopractice. Doubrawa compared this concept to health education that is influenced by therisk factor model. He points out the limitations of this approach in remarking that theprinciples of health promotion in rehabilitation must have limited effects when oneconsiders the fact that a clinic stay of a few weeks is outweighed by very stable and in-fluential social, economic and political influences.

In the meantime, many conceptual descriptions of rehabilitation clinics include resource-oriented offers within the framework of health promotion, health training or healtheducation. The programme of the Verband Deutscher Rentenversicherungsträger (Associ-ation of German Pension Insurance Institutions) entitled “Gesundheit selber machen”(“Do-it-yourself health”), which had been based on the classic risk factors, not onlycontains nutrition, exercise and physical training, exercises on the use of addictivesubstances, stress and coping, but also modules pertaining to protective factors and socialsupport (Buschmann-Steinhage & Liebing, 1996).


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 – 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

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”

(Source: Doubrawa, 1995; p.20)

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Doubrawa (1995) described approaches to health promotion which are exemplary for in-patient rehabilitation (see Table 3). Many of the approaches mentioned here are aimedat 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 manyrehabilitation clinics.

The significance of salutogenesis for rehabilitation has been discussed most intensivelyin connection with oncological rehabilitation. The only review of the applications of salutogenic principles in oncological rehabilitationknown to the authors is that in the anthology by Bartsch and Bengel (1997). Of particu-lar 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 on-cological rehabilitation clinics. In addition to medical and professional rehabilitation,psychosocial rehabilitation plays an important role (psycho-oncology). Psycho-oncologyexamines the psychosocial stressors caused by cancer and its effects on the quality of lifeand family relationships, for example, the possibility of psychological-psychotherapeutictreatment of the patient and its effects on the quality of life, employment and on thecharacteristics of the illness, such as relapses, metastases and life expectancy. The questionas to whether the emergence and development of a tumour is influenced by psychologicalfactors is one of the issues concerning psycho-oncology.

Diverse psychosocial stressors are connected with falling ill with cancer: emotionalproblems, such as anxiety, depression, suicidal tendencies, hopelessness, pessimism andloss of meaningfulness, as well as ego and identity problems, partnership and familyproblems, 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 conveymethods of self-control to the patient, to strengthen and promote resources and to copewith the illness. Weis cites the following treatment goals: “strengthening the self-helppotential, encouragement to openly express feelings, the reduction of anxiety, angerand other feelings, the improvement of self-esteem and the mental attitude towardsthe cancer illness, the promotion of the remaining health and personal resources, theimprovement of communication between the patient, the partner and other relatives”.

These goals parallel in part aspects of salutogenesis or the corresponding goals put forthby Antonovsky. Weis regards cognitive restructuring and reappraisal (patients change theirassumptions about themselves, their environment and their illness) as the central issuescommon to both concepts. The types of treatment he recommends are behavioural therapy,art therapy, group therapy and imaginative exercises (procedures which work with theimages and ideas of the patient). The significance of these kinds of treatment is reinforcedby the concept of salutogenesis, yet aside from that they are relevant strategies in psycho-oncology.

Justifiably, Weis remarks that Antonovsky’s central issue revolves around preventing andmaintaining health, whereas psycho-oncology mainly deals with patients who are severelyor 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 livingwith it easier by reducing pain and maintaining the best possible quality of life. Its keycomponent is the concept of a search for meaning that is based on inner psychologicalgrowth. Weis cites a major danger that can arise when the concept is implemented in anunreflected manner. The therapist, who is confronted with his or her own helplessness andimpotence, points out positive aspects of the situation, resources and powers of self-healing to the patient. This may be of help foremost to the therapist in repressing his orher helplessness.

To date, there have been few studies or more theoretical papers on rehabilitative patientgroups not belonging to oncological and psychosomatic rehabilitation. In most cases,previous rehabilitation concepts are revised “salutogenically”, that is, supplemented withlifestyle or resource-oriented services. As a result, behavioural medicine and rehabilita-tion 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 saluto-genically-oriented treatment and care concepts cannot be assessed conclusively in thisreport. It can be presumed, however, that in the field of health promotion in rehabilita-tion, and especially in the field of oncological rehabilitation, salutogenically-orientedmeasures are being increasingly developed and introduced and traditional strategies arebeing supplemented with salutogenic ones. The only advanced ideas to date which attemptto combine the concept of salutogenesis with a general theory of coping with illness arethose formulated by Broda (1995). He calls for the development of competence-orientedrehabilitation that contrasts with the now dominant deficit-oriented rehabilitation. Com-petence-oriented rehabilitation encompasses emphasis on the responsibility of the patient,the discouraging of patient-role behaviour, as well as the strengthening of the patient’sresources.

In summary, the future development of salutogenesis within the framework of rehabili-tation is faced with the following tasks:

1. Integration of salutogenesis as a partial aspect of a theory of coping with illness anda theory of consequences of illness,

2. Analysis of the meaning of the sense of coherence in the course of the illness and itsrehabilitation (see, for example, Collins, Hanson, Mulhern & Padberg, 1992), amongother things, as a success criterion and a dimension to be influenced,

3. Development of salutogenic therapy principles for the promotion of health and copingwith illness.


Summary 5


This final chapter presents the central assumptions of the previous three chapters on thecontext, the theory formation and the current state of research of the salutogenic approachin distilled form. The concept will be evaluated from the perspective of health sciencebelow.

Historical Background

The societal and scientific background on which Aaron Antonovsky developed his theorywas influenced by growing concern about public health care and health and diseaseresearch.

As early as the 1970’s, the traditional system of public health care was criticised for beingbased on a mechanistic view of disease and overemphasising organs and symptoms. Thescientific discourse on the concepts of health and disease that followed illustrate that bothare very complex phenomena that are difficult to define. Nevertheless, definitions are im-portant, since they determine the conclusions that are drawn for the treatment of healthand disease.A consequence of the criticism of the mechanistic view of disease was the development ofa biopsychosocial model of disease. In this model, the explanation and treatment of dis-ease not only takes into account somatic, but also psychological and social factors.Parallel to the development of the biopsychosocial model, increased efforts were made toprevent disease, originally exclusively on the basis of the risk factor model. This eventu-ally led to the concept of health promotion.

The development of an extended view of health and disease also led to an expansion anddifferentiation of the scientific subjects that dealt with the topic of health, such as socialmedicine, 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 centralthesis question: what keeps people healthy – despite the many potential noxious influ-ences? The following characteristics denote the salutogenic approach.

The human organism as a system is permanently exposed to natural and man-made in-fluences and processes that upset its order, that is, its health. Health is not a state of stable

5.1. Summary and Evaluation of the Scientific Discussion

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homeostasis, but when confronted with detrimental influences must continuously be re-established. Health and disease are not mutually exclusive states, but extreme poles on acontinuum (the health ease/dis-ease continuum). In between are states of relative healthand relative disease.

The search for specific causes of disease, also referred to as the pathogenic approach, mustbe supplemented by the search for health-promoting or health-maintaining factors,known as the salutogenic approach. Antonovsky termed these factors “generalised re-sistance resources”. There are individual resistance resources, for example, physical fac-tors, intelligence or coping strategies, as well as social and cultural resistance resourceslike social support, financial power or cultural stability. Asking about resistance resourcesplaces the focus on the whole person and his or her biography and not on his or her ill-ness or symptoms only.

Antonovsky’s model proceeds in the tradition of stress and coping research. According tothis approach, health is endangered by the detrimental influence of different kinds ofstressors. In contrast to other stress researchers, Antonovsky contends that stressors areomnipresent and that their effects are not necessarily hazardous to health. Antonovskyproposes a distinction between tension and stress. In his opinion, the first reaction to stressis physiological tension. Whether or not this results in stress and is followed by processesdetrimental 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 copingreactions, as Antonovsky sees it, is the sense of coherence.

“The sense of coherence is a global orientation that expresses the extent towhich one has a pervasive, enduring though dynamic feeling of confidencethat (1) the stimuli deriving from one’s internal and external environmentsin the course of living are structured, predictable, and explicable; (2) theresources are available to one to meet the demands posed by these stimuli;and (3) these demands are challenges, worthy of investment and engage-ment” (Antonovsky, 1987a, p. 19).

The stronger one’s sense of coherence, the more success one will have staying healthy. TheSOC 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 orderedand structured and not as chaotic, arbitrary, random or inexplicable. The feeling ofmanageability concerns the conviction that problems have solutions and that one has


enough resources available to meet the demands of the situation. The feeling of mean-ingfulness describes the extent to which one experiences life as emotionally meaningfuland 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 gen-eralised resistance resources which include the different coping styles.

The SOC develops in the course of childhood and adolescence. This development is com-plete at about the age of 30 and remains relatively stable thereafter. Antonovsky thusdescribes the SOC as a dispositional orientation. However, it is not comparable to apersonality trait. In Antonovsky’s opinion, whether a weak or a strong SOC developsdepends on the social circumstances and the socialisation in the family. He feels that afundamental change in adulthood is only possible to a limited extent. Altering the SOCby means of psychotherapy can only be accomplished by long, hard work.In order to measure the SOC, Antonovsky developed a questionnaire, the “Orientation toLife Questionnaire”, also called the SOC-scale, which is available in an abbreviated andin an extensive form. The empirical evidence from the examination of the questionnaireto date shows that the three dimensions of the SOC (comprehensibility, manageability,meaningfulness) cannot be observed individually, i.e., the scale measures only the totalstrength of the SOC. The instrument proves to have high reliability; in other words, it isan accurate measure.

Current State of Research

Despite the popularity of the concept of salutogenesis, our research revealed that, in thetwenty years since Antonovsky introduced his model, no more than 200 studies have beenpublished which examine the empirical foundation of the model. This shows that themodel has attracted little attention in the scientific community. Even in the USA, whichleads 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 andphysical health and personality traits (e.g., physical complaints, anxiety, life satisfaction,stress perception, social support and health-related behaviour). These correlations do notallow conclusions to be drawn about causal relationships. If significant relationshipsbetween a high SOC and a health variable are established, it cannot be regarded as proofthat the SOC is a causal factor (that is, a prerequisite or a cause) for health and healthmaintenance.

The SOC shows a high negative correlation with measures of mental health, like anxietyand depression; e.g., people that have a high SOC value are less anxious and depressedthan those with a lower SOC value.

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The relationship between the SOC and measures of physical health is less clear. Thisfinding contradicts Antonovsky’s assumption that the SOC has a direct influence onphysical health.

The SOC seems to have an influence on the perception of stress and coping styles and canfacilitate adaptation to difficult life situations. People with a high SOC tend to perceiveevents or demands as more of a challenge and less of a strain. When they do experiencestress, they can recover from it more quickly. These premises made by Antonovsky havebeen confirmed by many empirical findings.

Few studies focus on the relationship between the SOC and the different measures of socialsupport. Individual results show a positive relationship between the SOC and the numberof friends, marital satisfaction and social support.

For the field of prevention, it is of importance whether the SOC has an effect on concretehealth behaviour, such as getting regular exercise, or risk behaviour, like smoking.Because the few studies on this subject came to contradictory results, no clear conclusionscan be drawn.

As far as gender is concerned, women appear to have lower SOC scores on average thanmen. 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 adult-hood, the studies reviewed indicate that the SOC does indeed increase with age. However,longitudinal studies must be conducted before any well-founded statements about thealterability of the construct can be made.

Because of the contradictory findings, no clear statements can be made about the rela-tionship 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 con-cepts were developed that attempt to explain how individual characteristics and cognitivestyles influence the emergence and change of health and disease, as well as coping withdisease and health behaviour. Among the most well-known personal or internal protec-tive factors are health locus of control, self-efficacy, optimism, hardiness and mentalhealth, but also depression and anxiety. The current state of research varies greatly for thedifferent constructs, that is, they differ as to the number of studies and the empiricalevidence regarding the validity of the model. There are similarities between the SOC andoptimism as well as between the SOC and hardiness. The relationship between the SOC andself-efficacy is less clear.


The constructs mentioned above and the salutogenesis model were developed within thecontext of stress research. For this reason, the fundamental theoretical ideas of morerecent approaches in stress research often show close similarities to Antonovsky’s model.

Cognitive appraisal processes are essential in evaluating and coping with stressors. Oneof the most well-known stress theories is Lazarus’ transactional stress model. He distin-guished between two appraisal processes. First, events can be judged as being a threat, achallenge or as irrelevant for one’s own well-being. Second, the resources are appraisedthat one can employ or cannot employ to cope with the stressor.

There are different coping strategies which are more or less appropriate to the adaptationto a changing life situation. Coping with stress seems to be most effective when differentcoping strategies are used flexibly. Antonovsky considers the fact that the salutogenicperspective was neglected in traditional approaches in stress research to differentiate itfundamentally.

Like stress research, resilience or invulnerability research is merely the backdrop fordiverse research directions. The concepts of “resilience” and “invulnerability” refer tostable and healthy personality and behavioural developments that have occurred despiteunfavourable experiences and stress in early childhood. The research in this field oftenlacks a fundamental theory. As a result, potentially protective factors are often presentedin the form of a catalogue of variables. In this context, the SOC is sometimes mentionedas one of the many factors, neglecting its assumed orchestrating function in the mobili-sation of resistance resources. Characteristic for resilience research are longitudinal stud-ies. They are superior to cross-sectional studies, since they are better suited to establishinga causal relationship between health and protective factors.

Evaluation

Antonovsky formulated his salutogenic model at a time when the medical care system wasbeing criticised, the research on disease and its causes was being broadened to include thepsychosocial dimension, and the significance of environmental factors was beingrecognised. At the same time, preventive efforts were being strengthened and a holistic,not exclusively symptom-oriented procedure was in demand. The basic idea of thesalutogenic approach is similar to the concept of lifestyles of the World Health Organizationand 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 recommendationsand concepts can be traced back to medicine in ancient times. Since then, predecessorsand related concepts have been developed. However, Antonovsky is the first that not onlycriticised the pathogenic model but also parried it with a salutogenic theory that hethoroughly 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 theexplanation of health (Dlugosch, 1994; Faltermeier, 1994). It takes into accountdimensions on a social, physiological, biochemical and cognitive level. Because it in-cludes many variables, it has a high integrative value (Becker, 1992). The model cor-responds to a complex, meta-theoretical and heuristic model of processing (Faltermaier,1994; Jerusalem, 1997). That means it serves as a framework for orientation that canorganise and illustrate complex relationships. Many of the assumptions that the model ofsalutogenesis makes are too complex to be easily empirically examined.

As a model of processing, it unites several time dimensions that require different method-ical approaches. It has two principle time levels:

1. The emergence of the SOC is explained by the model components of generalised resis-tance resources and their sources, life experience and the result of tension reduction.These are longitudinal processes since the development of the SOC takes place pre-dominantly 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. Theseare short or medium-term processes. The GRRs that go into effect are not identical tothose that contributed to the emergence of the SOC.

The different levels of the model illustrate that only a partial aspect of it can be exam-ined. For many of the assumptions, problems regarding their operationalisation have notbeen satisfactorily solved.

The salutogenic model assumes an information transfer between the participating levelsand subsystems. However, there is no means of explaining how this transfer takes place(Noack, 1997). Thus, Antonovsky repeatedly stresses the sociological character of hismodel, which can mainly be seen in the fact that the SOC is influenced by structuralcharacteristics. However, the theory does not offer a sufficient explanation as to howsociostructural 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 enablesa more differentiated evaluation of an individual’s state of health than would be the casewith categorisation as either healthy or ill. A disadvantage of the one-dimensional viewis that it assumes a linear relationship between the decrease in healthy and the increasein ill components. The less healthy components a person has, the more ill components heor she must have. It appears better to conceive of health and disease as two independentfactors (see Lutz & Mark, 1995).

Surprisingly, Antonovsky does not presume that there is a direct connection between thecentral variable, SOC, and the position on the health ease/dis-ease continuum.


A weakness of the model is its narrow focus on physical condition. Antonovsky’s line ofargumentation on this issue is difficult to follow. Although he assumed a relationship be-tween the SOC, physical state and psychological well-being, he refused to integrate it intohis model. Yet, separating physical and psychological well-being builds up a dichotomythat defeats the efforts to assert an holistic view of the person. The characteristics of a veryweak SOC are very similar to cognitive and emotional symptoms of depression: the in-dividual overlooks his or her resources, cannot respond flexibly and appropriately todemands, and finds life meaningless.

Antonovsky’s stress concept remains unclear on several points. For example, it does notdescribe what distinguishes a state of tension from a state of stress. The processes thatmake states of stress have a pathogenic effect also remain undefined. Although the connec-tion between noxious factors and weak areas are cited as the causes of the emergence ofhealth impairment, there is no differentiation between acute stress reactions and con-tinuous stress. Siegrist (1993) points out that Antonovsky’s theory neglects the funda-mentals 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 Anto-novsky’s model as being chiefly carried out rationally (Siegrist, 1993; 1994). A centralissue is whether the SOC actually has a superordinate, directing function as Antonovskycontends. Noack (1997), for example, does not grant the concept this function, but placesit 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 theo-retical level. This is the case although Antonovsky himself, as well as other authors, areof 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 thetradition of the stress-coping paradigm as well as taking up Antonovsky’s salutogenicperspective. Physical and mental health or disease are explained as a result of individualefforts to cope with internal and external demands with the aid of internal and externalresources.Noack (1997) calls for a further development of the salutogenic approach in order to ex-plain prerequisites for positive health developments so that health-political and practicalguidelines can be derived (see also “Theorie der Humanmedizin”, “Theory of HumanMedicine” by Uexküll & Wesiack, 1988.).

The entire model of salutogenesis is rarely, and has seldom been, the subject of empiricalexamination. This is not surprising considering the complexity of the model. On the onehand, we have a comprehensive model of health that eludes empirical testing, and on theother hand, studies on narrowly defined relationships between the central construct of themodel, 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 cur-rently be considered relatively certain, since in some cases only a few studies ever investi-gate the same relationship, or the studies contain contradictory results.

Homogeneous results have mainly been established in relation to the SOC and measuresof 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 toconstructs with a longer and more intensive research tradition, provides an additional in-formation. The direct influence of the SOC on physical health as postulated by Antonovskycannot be supported to the extent expected.Judging by the current state of research, the SOC-scale developed by Antonovsky producesonly a total value of the SOC. The values of the three dimensions “comprehensibility”,“manageability” and “meaningfulness” cannot be individually measured by the SOC-scale. Even though Antonovsky himself was not very surprised about this, it contradictsthe theoretical assumptions and the corresponding empirical results.

Antonovsky criticises the fact that the salutogenic perspective has gained little or no foot-hold in health science research. In his opinion, the research hypotheses are formulatedpathogenically from the start, resulting in a search for the causes of disease, yet withoutexplaining why people remain healthy in the face of critical life events or continuousstress. The dependent variables examined are almost exclusively parameters of disease.Positive measures of health are disregarded. In addition, without any further examina-tion, stressors are simply presumed to be detrimental to health. The studies we surveyed are salutogenically oriented in the sense that they examine theSOC. However, few fundamental differences from previous theories and research could bedetermined, since they continue to focus on the relationships between the SOC and nega-tive measures of health such as complaints, symptoms and illnesses. The assumptionregarding the stability of the SOC has not been sufficiently confirmed, and the presumedintercultural or transcultural validity has not been tested. Researching health-protectivefactors is, of course, more difficult than researching risk factors.

In summary, the SOC is one of many concepts that have been proposed and examined. Inparticular, its overlapping with other constructs and the difficulty in keeping its threecomponents separate, a problem of construct validity and dimensionality, will hinder thefurther 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-


tradiction between the model and empirical findings regarding the SOC and mentalhealth,

– 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, itstimulates research in the health sciences on protective factors and resources, and second,it broadens the view to include relationships and interactions between health risks andprotective health factors or protective health conditions. It confirms the importance of aframework theory of health or health maintenance, even though it cannot be empiricallytested 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 impor-tance in health promotion and health education or prevention. Salutogenesis provides atheoretical framework for preventive activities in these fields that often lack a theoreticalfoundation and are merely one of an eclectic many. The salutogenic model serves as ameta-theory which legitimates conceptual ideas and measures to be taken. It supports acritical view of health education and preventive efforts to date, challenges the risk factormodel, and stands for resource-oriented, competence-raising and unspecific preventivemeasures. It is also important that the model parries the puritanical aspects of “warn-ings”, “alarms” and “austerity” with a positive concept. The shift in perspective from riskfactors 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 physicaldimension.

The inception of the salutogenesis model occurred about the same time as the commu-nity psychology movements that formulated the concept of empowerment and social-ecological approaches. All these approaches stand for or have enabled a shift in perspectivein prevention, which has had an impact on the Ottawa Charter of the WHO and theapproach 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 mainconcern of health promotion on the strengthening of the SOC and Antonovsky’s positiveself-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 ofprevention is equal to implementing the WHO concept of health promotion. However, thisalso implies that the sparse literature available on the possible applications of saluto-genesis has nothing new to say or offer which goes beyond the discussion on health pro-motion. Programmes such as “Healthy Cities”, “Make Children Strong”, “First Love andSexuality”, and so on, foster the active participation of non-professionals or the membersof self-help groups and attempt to strengthen their resources and competence, whileconveying positive forms of communication and interaction independent of their riskbehaviour. These measures cover very different areas and include social, ecological andcommunal aspects in the activities.

The basic premises of Antonovsky’s model for health promotion and prevention imply theneed to create an environment which offers children and adolescents enough resources tobuild a strong sense of coherence. The SOC does dominate as a personal resource in themodel of salutogenesis; however, in order for it to develop, health-promoting andpreventive measures must aim at fostering a broad spectrum of individual, social andcultural factors, such as intelligence, education, coping strategies, social support, finan-cial 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, itis quite probable that, in the future, the informative research findings on protective fac-tors will not be presented within the context of salutogenesis, but in resilience researchand research on the epidemiology of psychological and somatic disorders in childhoodand adolescence.

As far as efforts to promote health and prevent disease in adults are concerned, Antonov-sky’s assumption of a stable SOC in adulthood paints a bleak picture. However, the sta-bility of the SOC in adulthood has not been satisfactorily confirmed by empiricalinvestigations. According to Antonovsky, the problem that arises in the face of healthpromoting interventions in adulthood is that adults would require very intensive measu-res to achieve a change.

The publications and written documents we found on salutogenesis in the field ofprevention could have been developed and introduced without Antonovsky’s theoreticalideas. However, we must qualify this remark by saying that many preventive concepts andmeasures are not available in written and evaluated form. The motivational and argu-mentational use of the salutogenic concept to plan and implement programmes, such asskill-improving programmes for pre-school children, for example, but also for the entirefield of health promotion and prevention, is a matter of conjecture.


Despite criticism of the scientific value of the concept of salutogenesis, it will continue toplay an important role, especially in prevention and health promotion. The salutogenicmodel comes closest to the intentions and goals of the actors in this field, albeit the in-formation level differs among them. In many cases, they appeal for a shift to salutogenesiswithout having true knowledge of the model. In other cases, conventional measures areretained but relabeled as “salutogenic”.

Salutogenesis in Psychosomatics and Psychotherapy

The overall low status of Antonovsky’s model in psychotherapy and psychosomatics isillustrated by the fact that, in more recent textbooks, the concept of salutogenesis ismentioned sparsely and then on a general level. Three conference proceedings discuss theimportance of the SOC and salutogenesis in psychotherapy and psychosomatics. However,the critical discussion of the pathogenic and biomedical model devoted to the disease andhealth model dominates. “Salutogenesis” is seen here as a synonym for resource activa-tion, whose importance, independent of Antonovsky, is underscored by most therapeuticschools. Yet, few studies have investigated the change in SOC as a result of psychothera-peutic treatment.

Salutogenesis in Medical Rehabilitation

In the field of medical rehabilitation, the concept of salutogenesis has gained somesignificance, but only within the framework of health promotion. The measures providedby so-called health education are usually devoted to the medical disease concept and aregeared to reducing health risk behaviour. However, resource-oriented approaches aregaining recognition, and the health promotion approach is being demanded by rehabili-tation and implemented in part. The programmes known to us are being supplementedwith modules like protective factors, social support or enjoyment training. However, thesemeasures remain centred around the individual and the way they are put into practicedeviates from the holistic concept of health promotion.

The term “salutogenesis” is often used as a new name for old services or rehabilitationgoals. However, it spurs one to rethink them. The integration of salutogenesis as a partialaspect of a theory of coping with disease and its consequences, the analysis of the signifi-cance of the SOC in the course of the disease and its rehabilitation, and the developmentof 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 con-sequences for public health and the health sciences. His concept of the health ease/dis-ease continuum animates the discussion on the concept of disease and health. He makesan appeal for interdisciplinary research on health and disease and reinforces behaviouralas well as behaviourally-oriented prevention. He thus stimulates a discussion on the im-portance of health care and the societal value of health.

The construct of the SOC as a dimension of therapeutic and preventive measures has notbeen established and researched to a sufficient extent. From a scientific view, it is doubt-ful whether this construct can or will ever assert itself. The interest in the salutogenicmodel can be explained by the criticism of current research, the criticism of the purepathological perspective, and the need for a theory of action, especially for healthpromotion and prevention.

5.3. Outlook and Recommendations

This expert report presents the current state of discussion on the concept of salutogene-sis. In this endeavour, we can only survey published material or that otherwise known tous, so that this review must remain selective and is by no means comprehensive. Theevaluation represents the opinion of the authors.

Since the reception and discussion of the concept in the health sciences began relativelylate and continued rather haltingly, we believe that a general evaluation of the conceptwould not do it justice. For this reason, we would prefer to close this report by answeringthree key questions. These questions represent possible appraisal dimensions and confirmthat the evaluation would or must reach a different conclusion according to the perspec-tive under which it is carried out.

1. Why is the concept so attractive? Is this evidence for aparadigm change in health research and health care?

The model criticises the pathogenic perspective and thus the health system exclusivelyfocused on the elimination of symptoms, suffering and disease. Salutogenesis thus in-directly demands the acceptance of health processes and, according to Franke (1997),

offers at least the possibility of integrating dying and death as unchangeable componentsof human life. Despite its political implications, the model does not provide an answer tothe question of an adequate concept for public health care.

Salutogenesis criticises the fact that health care is one-sidedly focused on disease (“Wiedas bestehende Gesundheitssystem kranke Anteile verstärkt und gesunde Anteile unter-drückt” [How the Present Health Care System Strengthens Ill Aspects and RepressesHealthy Ones], Lutz & Mark, 1994) and asks the question whether a “salutodiagnostic”approach should not complement a “pathodiagnostic” approach. It could show thepatients which healthy aspects they have apart from their symptoms and could encourageor tell them to work on strengthening them. It would also make clear to them that theseresistance factors and resources are also of high value for the therapy of their symptomsand illnesses. On the other hand, the search for resources leads to an expansion of thediagnostic evaluation, which must remain unspecified, since the resources can be foundin all areas of life and the physician or the patient might feel that their exploration isinappropriate or too invasive.

Research in the health sciences is characterised by a number of experiments and studiesthat are often unrelated to each other and are difficult to place within a unified andaction-oriented framework. Salutogenesis fulfils in part the desire and the need for acomprehensive, interdisciplinary and general theory of health and is compatible with thebiopsychosocial model of health and disease. The biopsychosocial model, in which healthand disease are viewed as dependent on biological, physical and psychological circum-stances and processes, as well as social and societal influences, still plays a more signifi-cant role, both scientifically and practically, than does the model of Antonovsky. However,the former remains predominantly pathogenically oriented, whereas the salutogenesismodel radically and more consistently takes and emphasises a health-oriented perspec-tive. Thus, selecting this model fulfils two important needs of the scientist and the prac-titioner: it offers a critical evaluation of the predominant research and health careparadigm and provides a theoretical framework for its research and practice. At the sametime, it criticises health research and health care which is one-sidedly oriented towardpathological processes.

Salutogenesis will not replace or succeed the risk factor model, but it can be seen as asignificant reminder not to concentrate exclusively on risk factors.

By emphasising a continuum, salutogenesis makes a significant contribution to thediscussion on the concepts of health and disease. Health and disease are not two mutuallyexclusive categories, but, according to Antonovsky, form the poles of a continuum. Infurther 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 eachother and interact. The ill person has healthy components and, inversely, most healthypersons 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 manythings developed before or at the same time as it did: the critical discourse on the healthcare system, the discussion of the health and disease concepts, the development of thebiopsychosocial 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 iswhether the concept can withstand a scientific analysis, or whether it is justified from ascientific point of view to plan or carry out measures based on this concept. Can thestatements be confirmed scientifically or are efforts being made to confirm them, and canrelevant 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 methodo-logically planned and conducted adequately is “scientific”. In this sense, the research andconfirmation of the central construct of the SOC has begun, but in comparison to otherconstructs, it is still minimal and by no means completed. The construct has not beencircumscribed precisely enough to set it off from other, similar constructs. The items itcontains are difficult to measure and the findings are often contradictory. The questionas to how one is to understand the conveyance or the mechanism by which the SOC influ-ences health is still unanswered. Can the SOC be altered at all in adulthood? Does theconstruct fall too short? The model as a whole has not been tested and is not testablebecause of its complexity.

The studies surveyed showed a high level of consistency between the SOC and similarconstructs. The very relationship between the SOC and behaviour or physical health hasonly been postulated – not, however, empirically confirmed. In our opinion, the currentstate of research is not sufficient to allow the evaluation of the model it merits and leavesmore 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, onemust draw the conclusion that it is at the beginning. This raises the question as towhether an intensive discussion about the model would or could yield something quali-tatively different than what was already described and appealed for in the Ottawa Char-ter of the WHO for health promotion. The ideas set down in the Ottawa Charter can betransposed without any problems or contradictions to the salutogenesis model, and viceversa.

There is a potential danger in euphorically touting salutogenic principles. The structuresof our public health care system should not be underestimated, nor should the expecta-tions and the needs of the target group. The patients have been socialised according to themedical model (that is, predominantly pathogenic); they often only want their symptomsto be alleviated and not primarily offers to increase their competency and to strengthentheir SOC. Of course, this automatically raises the question as to the quality of suchservices and their financing. Since measures aimed solely at the individual are not inkeeping with the concept, structural and societal changes are necessary.

The analysis of the fields of application shows that the concept has attained a certainamount of importance in three areas: in health promotion and prevention, in psycho-somatics and psychotherapy, and in rehabilitation. In all of these areas, salutogenesiscoincides with developments that can easily be combined with the assumptions andpremises 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 ofrehabilitation measures profit from the proposed conceptual framework of salutogenesis.Salutogenesis stresses positive aspects and positive experiences, preventing illness, andthus 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 directderivation of measures is problematic.

For practical work, one aspect is especially important: Antonovsky emphasises the rele-vance of ethical questions. On the one hand, the definition of health is always attachedto norms, and this poses the danger of discriminating against people on the basis of thesemoral or ethical principles. Since a salutogenic perspective entails the consideration of allareas of life, including very private ones, all salutogenic-oriented measures for the promotionof 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 theinstitutional organisation of a society’s health care system is the endlessexpansion 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 thequestion of who dominates the system, on the institutional as well as on theimmediate, interpersonal level of the doctor/patient relationship” (Antonovsky, 1987a, pp. 10–11).

Antonovsky sees yet another danger in unjustified association of health promotion andethical or moral behaviour. Not everything that is functional and positive for health isnecessarily morally justified, and not everything that is morally or ethically just must alsobe good for health. Even people whose behaviour is considered unethical can be in the bestof health (Antonovsky, 1995).


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The fascination of the concept also carries the danger of unreflected adoption of its prin-ciples 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, especiallyin prevention and health promotion, lack sufficient knowledge of salutogenesis or haveunrealistic expectations of the concept. Employees of health promotion and preventionfacilities, of rehabilitation clinics, of specialised psychosomatic clinics and other healthcare facilities, but also self-help groups, need information about the concept. They wouldlike 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 theconcept and an exchange about the consequences for services and measures (contributionand limits of the concept, conceptual planning of the work, possibility of a service withsalutogenic-based measures). Studying and discussing the model in the above-mentionedperspectives would be especially called for in the prevention and health promotion fields.

Presentations, conferences or seminars on the subject of salutogenesis should not only betargeted at scientists, but also at those active in the fields of health promotion and pre-vention. Such presentations should serve to exchange information and discuss the fun-damental ideas of the model. The discussion should include the possible consequencesthat can be drawn from system-induced and individual-oriented measures, and encouragethoughts on the ways in which salutogenic principles can be put into practice.

Appendix 6


The material for this expert report on salutogenesis was gathered in the course of anextensive literature research that we conducted.

Among our sources are the germane literature databases as well as the Internet:

Psyndex 1990–1998Search words: Saluto, sense of coherence, Antonovsky

Psyclit 1990–1998Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky

Medline 1990–1998Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky

Current Contents 1993–1997Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky

Dissertations Abstracts 1989–1997WISO III, PAIS, Social Sciences Index, ERICSearch 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 Psycho-therapy, Health Psychology, Personality Psychology

6.1. Documentation of the Literature Search

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Antonovsky, A. (Ed.) (1961): The early Jewish Labor Movement in the United States. New York: YIVO Instituteof Jewish Research.

Antonovsky, A. (1972): Breakdown: A needed fourth step in the conceptual armamentarium of modern medi-cine. 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 andstressful life events. In: Dohrenwend, B. S. / Dohrenwend, B. P. (Eds.): Stressful life events: theirnature and effects (pp. 245–258). New York: Wiles & Sons.

Antonovsky, A. (1979): Health, stress, and coping: New perspectives on mental and physical well-being. SanFrancisco: Jossey-Bass.

Antonovsky, A. (1983): The Sense of Coherence: Development of a Research Instrument. W. S. Schwartz Re-search 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 ofcoherence. 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. SanFrancisco: Jossey-Bass.

Antonovsky, A. (1987b): The salutogenic perspective: toward a new view of health and illness. Advances. TheJournal 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.): Learnedresourcefulness: 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 KritischeMedizin (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: JohnWiley & Sons.

Antonovsky, A. (1992a): The behavioral sciences and academic family medicine: An alternative view. FamilySystems 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.

6.2. Original Works by Antonovsky


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 Mind-Body Health, 10, 6–12.

Antonovsky, A. (1995): The moral and the healthy: Identical, overlapping or orthogonal? Israel Journal ofPsychiatry & Related Sciences, 32, 5–13.

Antonovsky, A. (1996): The sense of coherence. An historical and future perspective. Israel Journal of MedicalSciences, 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 thesequelae 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 stresssituations. Journal of Social Psychology, 126, 213–225.

Antonovsky, A. / Sourani, T. (1988): Family sense of coherence and family adaption. Journal of Marriage andthe Family, 50, 79–92.

Antonovsky, A. / Sagy, S. (1990): Confronting developmental tasks in the retirement transition. The Geronto-logist, 30, 362–368.

Antonovsky, A. / Sagy, S. / Adler, I. / Visel, R. (1990): Attitudes toward retirement in an Israeli cohort. Inter-national 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 ofcausality. Behavior, Health, and Aging, 1, 85–97.

Dahlin, L. / Cederblad, M. / Antonovsky, A. / Hagnell, O. (1990): Childhood vulnerability and adultinvincibility. Acta Psychiatrica Scandinavica, 82, 228–232.

Langius, A. / Björvell, H. / Antonovsky, A. (1992): The sense of coherence concept and its relation topersonality 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 ofMarriage and the Family, 54, 983–993.

Sagy, S. / Antonovsky, A. / Adler, I. (1990): Explaining life satisfaction in later life: The sense of coherencemodel and activity theory. Behavior, Health, and Aging, 1, 11–25.

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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: Theinterplay 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 perceptionsand their predictors. Social Science & Medicine, 36, 419–427.

Anson, O. / Rosenzweig, A. / Shwarzmann, P. (1993): The health of women married to men in regular armyservice: 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 modernmedicine. Social Science & Medicine, 6, 537–544.

Antonovsky, A. (1979): Health, stress, and coping: New perspectives on mental and physical well-being. SanFrancisco: Jossey-Bass.

Antonovsky, A. (1983): The Sense of Coherence: Development of a research instrument. W. S. SchwartzResearch 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. SanFrancisco: Jossey-Bass.

Antonovsky, A. (1987b): The salutogenic perspective: toward a new view of health and illness. Advances. TheJournal 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 ofPsychiatry & 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. TheGerontologist, 30, 362–368.

Antonovsky, A. / Sourani, T. (1988): Family sense of coherence and family adaption. Journal of Marriage andthe Family, 50, 79–92.

Antonovsky, H. / Sagy, S. (1986): The development of a sense of coherence scale and its impact on responsesto stress situations. Journal of Social Psychology, 126, 213–225.

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Artinian, B. M. (1997): The intersystem model: Integrating theory and practice. Thousand Oaks: Sage.

Bandura, A. (1977): Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84,191–215.

Bandura, A. (1982): Self-efficacy mechanism in human agency. American Psychologist, 37, 122–147.

Bandura, A. (1986): Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall.

Baro, F. / Haepers, K. / Wagenfeld, M. O. / Gallagher, T. J. (1996): Sense of coherence in caregivers todemented elderly persons in Belgium. In: Stefanis, C. / Hippius, H. / Müller-Spahn, F. (Eds.):Neuropsychiatry in old age: An update (pp. 145–156). Seattle: Hogrefe & Huber.

Bartsch, H. H. / Bengel, J. (Eds.) (1997): Salutogenese in der Onkologie. Basel: Karger.

Bartsch, H. H. / Mumm, A. (1997): Die Bedeutung salutogenetischer Prinzipien in der klinischen Onkologie.In: Bartsch, H. H. / Bengel, J. (Eds.): Salutogenese in der Onkologie (S. 117–126). Basel: Karger.

Becker, P. (1989): Der Trierer Persönlichkeitsfragebogen (TPF). Testmappe mit Handanweisung. Göttingen:Hogrefe.

Becker, P. (1991): Intrafamiliäre Ähnlichkeiten in Indikatoren der seelischen Gesundheit. Zeitschrift fürKlinische Psychologie, 20, 177–188.

Becker, P. (1992): Seelische Gesundheit als protektive Persönlichkeitseigenschaft. Zeitschrift für KlinischePsychologie, 21, 64–75.

Becker, P. / Bös, K. / Woll, A. (1994): Ein Anforderungs-Ressourcen-Modell der körperlichen Gesundheit.Zeitschrift für Gesundheitspsychologie, 2, 25–48.

Becker, P. / Bös, K. / Opper, E. / Woll, A. / Wustmann, A. (1996): Vergleich von Hochgesunden, Normal- undMindergesunden in gesundheitsrelevanten Variablen (GRV). Zeitschrift für Gesundheitspsychologie,4, 55–76.

Belz-Merk, M. / Bengel, J. / Strittmatter, R. (1992): Subjektive Gesundheitskonzepte und gesundheitlicheProtektivfaktoren. Zeitschrift für Medizinische Psychologie, 4, 153–171.

Bengel, J. (1993): Gesundheit, Risikowahrnehmung und Vorsorgeverhalten. Göttingen: Hogrefe.

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Wetzel, H. (1980): Konzepte der Normalität und Abnormität des Verhaltens. In: Wittling, W. (Ed.): Handbuchder klinischen Psychologie (pp. 14–61). Hamburg: Hoffmann und Campe.

Wieland-Eckelmann, R. / Carver, C. S. (1990): Dispositionelle Bewältigungsstile, Optimismus und Bewälti-gung: Ein interkultureller Vergleich. Zeitschrift für Differentielle und Diagnostische Psychologie, 11,167–184.

Williams, S. T. (1990): The relationship among stress, hardiness, sense of coherence and illness in criticalcare nurses. Medical Psychotherapy, 3, 171–186.

Wirsching, M. (1996): Psychosomatische Medizin. Konzepte – Krankheitsbilder – Therapien. München:Beck.

World Health Organization (1948): Präambel zur Satzung. Genf: WHO.

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Author/Year Country Sample Variables Examined Instruments

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

Israel N=238men andwomen withmild hyper-tension

SOC education employmentmarital statushappinessdistresssatisfaction with family relationssubjective evaluation ofhealth symptom perception

SOC-scaleMemorial Univer-sity of New Foundland Scaleof HappinessPsychologicalDistress ScaleMeasure FamilyFunctioningself-developedscales

Results

Gender differences were established in the sense that women have a much lower SOC scorethan men. Women have greater risks: They are more likely to lose their jobs and have lesseducation. Less women are married; women are unhappier; they experience less mental well-being, are less satisfied with the atmosphere in the family and perceive themselves as beingunhealthier.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, ofwhich N=44were mar-ried to armymembersand N=53 tocivilians

SOCavailability of social supportresidential mobilitylabour force participationhealthdistressutilisation of health services

SOC-scale, short formScale of Psycho-logical Distressself-developedscales

Results

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

6.4. Overview of the Studies on the Sense of Coherence



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

Germany N=863men andwomen ofvarying states ofhealtha non-repre-sentativesample

SOCagegendermental healthinternal health locus of controlexercise under stress conditionsdepressive coping stylehealthy nourishmentintensive exercisegood sleepsocial support(total=health-related vari-ables, “gesundheits-relevante Variablen”, “GRV”)habitual physical health level,i.e., high health, low health,normal health

Trierer Persönlich-keitsfragebogen(Trier PersonalityInventory)SOC-scaleFragebogen zursozialen Unterstützung(questionnaire ofsocial support)self-developedscales

Results

The authors differentiate between three research perspectives and thus pose three correspond-ing research questions reflecting the salutogenic, the pathogenic, and a comprehensive healthpsychological perspective. To test the first question, the high health group was compared to therest of the sample. The SOC did not distinguish this group from the other two. The low healthgroup, 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 theexception of intensive exercise.Of all GRVs, only mental health, SOC, exercise and restful sleep were predictive of the habituallevel of health. However, this variable explained only 19% of the variance.


Bös & Woll(1994)

Germany N=500 men andwomen

SOCgenderageinternal locus of controlhealth rating by physicianself-rating of healthexercise

SOC-scaleTrierer Persönlich-keitsfragebogen(Trier PersonalityInventory)I-Skala der körper-bezogenen Kon-trollüberzeugungen (I-Scale of Physi-cally-Related Locus of Control)self-developedscales

Results

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

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Bowman(1996; 1997)

USA N=186psychologystudents

SOCethnic origin: Native Ameri-can (associated with largerfamilies and lower SES) vs.Anglo-Americandepressionanxietyphysical health

SOC-scaleBeck DepressionInventoryState-Trait Perso-nality InventoryWahler PhysicalSymptom Inven-tory

Results

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


Callahan &Pincus(1995)

USA N=828 rheumatismpatients,predomi-nately white,female, andmarried

SOCpainfunctional limitationslearned helplessnessgeneral state of health

SOC-scale, long and short formMHAQ-Activity ofDaily Living Difficulty ScaleArthritis Helpless-ness-Scaleself-developedscales

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 helplessnesswith 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 theserelationships.There is a low, but significant relationship between the SOC and age.



Chamberlain,Petrie & Azariah (1992)

NewZealand

N=57 male and female,mostly olderpatients before andafter a surgicaloperation

SOCgendersurgical operationoptimism as a personalitytraitpainstate of healthlife satisfactionpositive well-beingpsychological distress

Life OrientationTestSOC-scaleMental Health Inventoryself-developedscales

Results

Optimism and the SOC correlate positively (r=.62), but they correlate to varying degrees with thedependent variables.The SOC correlates in the expected direction with life satisfaction, well-being, psychologicalsymptoms, 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 predic-tive value for positive health measures, but not for the negative ones (pain and psychologicalsymptoms); in contrast, there is no longer a predictive value for optimism.


Coe, Miller &Flaherty(1992)

USA N=148 caregivers tochronically illelderly per-sons (withAlzheimer,inconti-nence, etc.),most ofwhom white,female, andmarried tothe patients

SOCsociodemographic charac-teristicsrelationship to the patienttype of patient’s illnesscaregiving taskstime requiredemployment statusperceived burden of care-giving tasksphysical and mental healthstatusutilisation of health servicesreceived or desired help

SOC-scale, shortformGeriatric Depression Scaleno further information

Results

Caregivers with high SOC scores were compared to those with low scores. Caregivers with apronounced SOC perceived themselves as having less stress by their partners’ illness, havebetter mental health, i.e., lower depression values, etc., feel they have better support fromfriends and relatives and require less aid.Age, employment, health status, extent of the caregiving activities, and severity of the illness donot correlate significantly with the SOC. In contrast, the relationship between the SOC anddepression (r=-.49) and mental health (r=.36) is significant.The SOC values of men are higher than those of women.

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Dangoor &Florian (1994)

Israel N=88 physically disabled married younger women

SOCmedical diagnosis (neurological disease, skeletal-muscular disease,inner chronic illness)agesocio-economic statusfunctional handicapseffects of the handicapmental healthfamily adaptation to the illness

SOC-scaleMental Health Inventory Evaluating andNurturing Relationship IssuesCommunicationand HappinessScaleself-developedscales

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 forthe adaptation to the illness. Medical diagnosis and functional handicaps have no predictivevalue.The high correlation between mental health and SOC can possibly be attributed to confoundingbetween the MHI and the SOC-scale.


Dudek & Makowska(1993)

Poland N=523 pregnantwomen inhospital fordelivery

SOC ageeducationemployment

SOC-Scale

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 latterconsisted 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/educationlevel.



Flannery &Flannery(1990)

Flannery,Perry, Penk &Flannery(1994)

USA N=95 adultstudents attendingnight school, predomi-natelywomen

SOClife stress psychological distressanxiety depression

SOC-scaleHassles ScaleTaylor ManifestAnxiety Scale Beck DepressionInventory

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.


Frenz, Carey &Jorgensen(1993)

USA N=374healthy menand women,and psycho-therapy patients

SOCpatient/non-patient statusagegenderperceived stressanxietydepressionalcohol consumptionsocial desirabilityintelligence

SOC-scalePerceived StressScaleState-Trait AnxietyInventory-TraitBeck DepressionInventoryQuantity-Frequency-VariabilityQuestionnaireSocial DesirabilityScaleShipley Institute ofLiving 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 andalcohol consumption.There was a high negative relationship (r=-.73) between the SOC and perceived stress in bothgroups.There was a correlation of r=-.85 between the SOC and anxiety in the patient groups, whichraises 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; andr=-.39 between the SOC and social desirability.There was no relationship found between the SOC and intelligence.

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Gallagher,Wagenfeld,Baro & Haepers(1994)

Baro, Haepers,Wagenfeld &Gallagher(1996)

Belgium N=126caregivers(predomi-natelywomen) ofdementedand chroni-cally ill per-sons

SOCtype of illnessrole overloadcoping responses

SOC-scale Activity of DailyLivingself-developedscales

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 thesense of a coping strategy).Negative correlations also between the SOC and active coping strategies, as well as betweenthe SOC and coping strategies such as social withdrawal, smoking, and the consumption ofmedication.


Gebert, Broda& Lauterbach(1997)

Germany N=250 patients of apsychoso-matic clinic

controlgroup:N=121 clinicallyasympto-maticpersons

SOCconstructive thinking – theability to solve every dayproblems with a minimalamount of stressphysical symptomspsychological symptomsgenderpatient/non-patient statusageeducation

SOC-scaleConstructiveThinking InventoryGießener Be-schwerdebogen(Gießener Complaints Ques-tionaire)Kieler Änderungs-sensitive Sym-ptomliste (KielerSymptomlistSensitive toChange)

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 withpsychosomatic illnesses have a lower SOC value than healthy persons.



George (1996)

USA N=653 field-workers,predomi-natelyfemale, thatmake housecalls or dohome healthcare forhealth orga-nisations

SOCperception of risk to theirown health by their profes-sion (home health care)age education years of employmentgender

SOC-scaleHome HealthCare Perceptionof 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 valuesthan 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 behazardous to their health.The use of self-defence methods (an accompanying person, tear gas, etc.) is not influenced bythe strength of the SOC.The SOC correlates with cognitions, but not with behaviours: Cognitions about one’s own riskand about the possibilities of controlling them (refusing to make dangerous house calls).


Gibson &Cook (1997)

USA N=306 OpenUniversitystudents(N=67 male,N=239 fe-male)

SOCpersonality traitsgeneral state of healthgender

SOC-scaleDispositional Re-silience ScaleEysenck Perso-nality InventoryGeneral HealthQuestionnaire

Results

Significant negative correlations between general health and the SOC (r=-.26) for women; incontrast, 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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Hood,Beaudet &Catlin (1996)

Canada N=16,291Adults (NationalPopulationHealth Sur-vey)

SOCgenderage incomeeducationethnic originfamily statusemploymenttraumatic eventsrecent life eventsfunctional level of healthsubjective level of healthchronic illnesses

SOC-scale, shortformself-developedscales

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 thevariance.No gender differences.Persons with traumatic experiences have lower SOC-values than those without traumaticexperiences.


Korotkov(1993)

Canada N=712 Students

SOCdaily stressperceived physical sympto-matologyemotionality

SOC-scale, shortformHassles andUplifts Scale, revised versionSymptom Check-list, revised versionself-developedscales

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 thirdfactor 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% ofthe variance explained for physical health).No variance explained for physical health by the SOC at the second measurement (4 weeks fol-lowing the first).



Kravetz, Drory& Florian(1993)

Israel N=164 patients withcoronaryheart disease

SOChardinessLocus of Controlangerdepressionanxiety

SOC-scaleHardiness ScaleRotter’s I-E Locus of ControlScaleState-Trait An-xiety ScaleBeck DepressionInventoryAnger ArousalScale

Results

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


Langius,Björvell & Antonovsky(1992)

Sweden N=97 nurses

N=166 maleand femalepatients

N=155 menand womenof the normalpopulation

SOCself-motivationanxietyhostility

SOC-scaleSelf-MotivationInventoryKarolinskaScales ofPersonality

Results

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

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Langius &Björvell (1993)

Sweden N=145 men andwomen ofthreedifferentage groups

SOCgeneral healthphysical and psychologicalhealthage

SOC-scale, shortand long formSickness ImpactProfileself-developedscales

Results

Relationship between the SOC and the SIP-total scale r=-.29; a more exact analysis revealedhowever, that the relationship stems from significant correlations between the score on the psy-chosocial 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=-.21for the short form).Hardly any differences between the short and the long form of the SOC-scale.


Larrson & Kallenberg(1996)

Sweden N=2003 men and women of arepresenta-tive popula-tion sample

SOCagegender educationemploymentincomesize of householdnumber of friendsgeneral physical healthpsychological well-beingphysical and psychologicalsymptoms

SOC-scale, shortformStress ProfileLife Style Profileself-developedscales

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 offriends correlates significantly with the SOC.The higher the SOC the healthier the person.Relationships between the SOC and psychological well-being and psychological symptoms arelarger (r= .18 to r=.53) than between the SOC and general physical state of health and physicalsymptoms (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.



Lundberg(1997)

Lundberg &NynströmPeck (1994)

Sweden N=4390 persons of arepresenta-tive popula-tion sample(predomi-nately par-ticipants in alongitudinalstudy)

SOCagegendersocial classIndicators of childhoodconditionsIllness Indicators

SOC-scale, shortformself-developedscales

Results

Social class and socio-economic status during childhood have no influence on the SOC in adult-hood.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 thanself-employed and salaried workers.Low SOC scores correlate with poor psychological and physical health, even when controlled forage, gender, and childhood situation, i.e., the risk of psychological distress for a person with aweak 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 healthof the adult.


Margalit,Raviv & Ankonina(1992)

Israel N=161 pairs of parents ofeither han-dicapped ornon-handi-cappedchildren

SOCparent’s gender handicapped child or non-handicapped childcoping behaviourperceived family environ-mentperceived abnormalbehaviour of child

SOCCoping ScaleFamily Environ-ment ScaleChild BehaviourChecklist

Results

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

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McSherry &Holm (1994)

USA N=60 studentswith high,middle, andlow SOCscores

different strengths of theSOCanxietyangercuriositystress perceptionscoping behaviourpulse rateskin resistance

State-Trait Perso-nality InventoryStress ArousalChecklistDakota CognitiveAppraisal Inven-toryDimensional Coping Checklistphysiological datawith the aid of thenecessaryequipment

Results

The subjects were exposed to a stress situation. Time of measurement was before and after thestress stimulus. It could be demonstrated that subjects with high and average SOC scores weresignificantly 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 copingability and coping strategies, i.e., people with low SOC scores make use of less copingresources, less social, material, and psychological resources and have less confidence in theirability 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 theconfrontation 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 stressmeasurements.


Pasikowski,Sek & Scigala(1994)

Poland N=60 men andwomen

SOCgendereducationplace of residenceHealth Locus of Control(holistic-functional or bio-medical health models)

SOC-scaleHealth BeliefScale

Results

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



Petrie & Brook(1992)

NewZealand

N= 150 parasuicidalmale patients(N=39) and(N=111) fe-male patients

SOCdepressionhopelessnessself-esteemsuicidal ideation

SOC-scaleHopelessnessScaleSelf-Rating De-pression ScaleCoopersmithSelf-Esteem In-ventoryPaykel et al.Scale

Results

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


Rena, Moshe& Abraham(1996)

Israel N=80 paralysedpatients andtheir N=72spouses

SOCseverity of disabilityacceptance of disabilityanxietyhealthrelative vulnerabilitymarital satisfactionsocial activitieswork and study hours

SOC-scaleAcceptance ofDisability ScaleState-Trait Anxiety InventoryRelative Vulner-ability in CouplesRelationshipIndex of MaritalSatisfaction Questionnaireself-developedscales

Results

High, significant correlations between the SOC and anxiety, psychosomatic complaints, andacceptance 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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Rimann &Udris (1998)

Switzer-land

N=559 male and female salariedemployees

SOCstress at work and at homesocial and organisationalresourcesmental health as a personalitytrait as coined by BeckerHealth Locus of Controlvalue orientationscoping stylesagegenderprofessionposition in the company’shierarchy

SOC-scale, shortformcoping questionnaireself-developedquestionnairesno information on furtherinstruments

Results

The SOC short form is multi-dimensional, the authors did not succeed in discriminating the com-ponents 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 correla-tions are found between SOC and attempts of situational control as well as palliative copingattempts.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.


Sammallahti,Holi,Komulainen &Aalberg (1996)

Finland N=122 psychiatricpatients andN=334 persons ofthe normalpopulationas a controlgroup

SOCpsychiatric illnessmental healthdefence styles

Defence StyleQuestionnaireGeneral HealthQuestionnaireSymptom Check-list 90

Results

Two-factor-solution: 1st factor items of the SOC-scale, meaningfulness, 2nd factor, “feelings”, en-compasses the scales comprehensibility and manageability.The SOC correlates high with SCL-90 (r=-.83), GHQ (r=-.66), i.e., the severity of the psychiatricsymptoms 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.



Scherwitz &Ornish (1994)

USA N=48 older patientsscheduled forangiography;control groupdesign:LifestyleChange Inter-vention – par-ticipants andpatients onthe waitinglist

SOCpsychophysiological measurementsType A behavior patternsparticipation/non-participa-tion in the intervention

not reported

Results

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


Schmidt-Rathjens,Benz,Van Damme,Feldt & Amelang(1997)

Germany N=5133men andwomen between theages of 40and 65

SOCpersonality type(cancer personality,heart-circulatory personality as coined byGrossarth-Maticek)dispositional optimismhealth beliefstime urgency and perpetual activationanger hostilitypsychoticismpersonality traits as conceptualised by Eysenck exaggerated socialcontrolcritical life eventssocial supportphysical healthgender

SOC-scalemeasurement of thebehaviour typology(Grossarth-Maticek)Life Orientation TestFragebogen zur Er-fassung gesundheits-bezogener Kontroll-überzeugungen(Questionnaire tomeasure health be-liefs)Time Urgency andPerceptual ActivationScaleState-Trait-Anger-Ex-pression InventoryDepressivitäts Skala(Depression Scale)Eysenck Persönlich-keits Inventar (Ey-senck PersonalityInventory)Way of Life ScaleList of Critical LifeEventsQuestionnaire ofSocial 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 numeri-cally. 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 withcardiovascular disease disappear when depression and neuroticism are controlled for. Theytherefore can be explained by the last two variables.

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Antonovsky &Sagy (1990)

Sagy,Antonovsky &Adler (1990)

Israel N=805adultsshortlybeforeretirement

SOCsocio-economic statusgenderattitude towards retirement

SOC-scaleAttitude towardsRetirement-Scale

Results

The higher the SOC score, the less likely the subject was to perceive the impending retirementas 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 thusindependent of socio-economic status and gender.


Antonovsky, H.& Sagy (1986)

Israel N=418 students ofdifferentages, N=63 ofwhich be-fore and after theevacuationof the Sinai

SOCemotional closeness withparentscommunication with parentsagegenderstability of the communityanxiety

SOC-scaleState-Trait Anxiety Inventoryself-developedscales

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 theSOC 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 SOCscore.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 (oneweek before the evacuation). However, the correlation is significant six weeks after the evacua-tion, i.e., when the crisis situation got back to normal, youths with a higher SOC score showed alower anxiety score (state).

Studies Mentioned in Antonovsky’s Review Article1

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



Antonovsky &Sourani (1988)

Israel N=60 handicappedmen andtheir wives,working class

FSOC (Family Sense of Coherence)Perceived family satisfaction

Family Sense ofCoherence ScaleFamily Adaptation Scale

Results

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


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

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

Israel N=230 male andfemale members of two kibbutzim

SOCagegenderrecent life eventspsychological well-beingphysical well-beingfunctional ability

SOC-scaleThe Social Read-justment RatingScaleScale of Psycho-logical DistressQuality of Well-being Scaleself-developedscales

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 theSOC 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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Cederblad &Hansson(1996)

Cederblad,Dahlin & Hagnell (1993)

Cederblad,Dahlin,Hagnell &Hannson(1995)

Dahlin,Cederblad,Antonovsky& Hagnell (1990)

Sweden N=148personsbelonging topsychiatricrisk groups

SOCintelligenceactivity, flexibility andstability as personality traitsLocus of Controlcoping strategiesquality of lifephysical and mental health

SOC-scaleSymptom Check-list 90Quality of LifeScaleHealth SicknessRating ScaleWays of CopingChecklistLocus of ControlSjobring Model ofPersonality Dimensions

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 outcomevariables quality of life and physical and mental health.The SOC correlates significantly with SCL-90 (r=.72), QOL (r=.77), perceived health (r=.46) andHSRS (r=.51).


Hart, Hittner &Paras (1991)

USA N=59 College students

SOCanxietysocial support

SOC-scale, shortformTrait Anxiety InventoryInterpersonalSupport Evaluation List

Results

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


Source: Antonovsky, A. (1987): Unraveling the mystery of health. How people managestress and stay well.

6.5. Orientation to Life Questionnaire (SOC-Scale)

Orientation to Life Questionnaire

Here is a series of questions relating to various aspects of our lives. Each question has sevenpossible answers. Please mark the number which expresses your answer, with numbers 1 and 7being the extreme answers. If the words under 1 are right for you, circle 1; if the words under 7are right for you, circle 7. If you feel differently, circle the number which best expresses yourfeelings. 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 always have this feeling1 2 3 4 5 6 7

2. In the past, when you had to do something which depended upon cooperation withothers, did you have the feeling that it:

surely wouldn’t get done surely would get done1 2 3 4 5 6 7

5. Has it happened in the past that you were surprised by the behaviour of people whomyou thought you knew well?

never happened always happened1 2 3 4 5 6 7

6. Has it happened that people whom you counted on disappointed you?

never happened always happened1 2 3 4 5 6 7

4. Do you have the feeling that you don’t really care about what goes on around you?

very seldom or never very often1 2 3 4 5 6 7

3. Think of the people with whom you come into contact daily, aside from the ones towhom you feel closest. How well do you know most of them?

you feel that they’restrangers

you know them very well1 2 3 4 5 6 7

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10. In the past ten years your life has been:

full of changes without your knowing what will happen next

completely consistentand clear1 2 3 4 5 6 7

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

completely fascinating deadly boring1 2 3 4 5 6 7

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

very often very seldom or never1 2 3 4 5 6 7

13. What best describes how you see life:

one can always find a solution to painful thingsin life

there is no solution topainful things in life1 2 3 4 5 6 7

14. When you think about your life, you very often:

feel how good it is to be alive

ask yourself why you exist at all1 2 3 4 5 6 7

15. When you face a difficult problem, the choice of a solution is:

always confusing andhard to find

always completely clear1 2 3 4 5 6 7

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


8. Until now your life has had:

no clear goals or purposeat all

very clear goals and pur-pose1 2 3 4 5 6 7

7. Life is:

full of interest completely routine1 2 3 4 5 6 7


16. Doing the things you do every day is:

a source of deep pleasureand satisfaction

a source of pain and bore-dom1 2 3 4 5 6 7

17. Your life in the future will probably be:

full of changes withoutyour knowing what willhappen next

completely consistent andclear1 2 3 4 5 6 7

22. Do you anticipate that your personal life in the future will be:

totally without meaning or purpose

full of meaning and purpose1 2 3 4 5 6 7

18. When something unpleasant happened in the past, your tendency was:

“to eat yourself up”about it

to say “ok, that’s that, Ihave to live with it”, and goon

1 2 3 4 5 6 7

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


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


20. When you do something that gives you a good feeling:

it’s certain that you’ll goon feeling good

it’s certain that somethingwill happen to spoil thefeeling

1 2 3 4 5 6 7

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

you’re certain there will be you doubt there will be1 2 3 4 5 6 7

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


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26. When something happened, have you generally found that:

you overestimated or underestimated its importance

you saw things in the rightproportion1 2 3 4 5 6 7

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 very often1 2 3 4 5 6 7

27. When you think of difficulties you are likely to face in important aspects of your life, doyou have the feeling that:

you will always succeed in overcoming the difficulties

you won’t succeed in overcoming the difficulties

1 2 3 4 5 6 7

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


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



Item Number SOC Item Scoring Short FormSub-scale

1 C reverse scoring

2 MA positive scoring

3 C positive scoring

4 ME reverse scoring S

5 C reverse scoring S

6 MA reverse scoring S

7 ME reverse scoring

8 ME positive scoring S

9 MA positive scoring S



12 C positive scoring S

13 MA reverse scoring



16 ME reverse scoring S


18 MA positive scoring




22 ME positive scoring



25 MA reverse scoring S



28 ME positive scoring S

29 MA positive scoring S

Codification of the Items

The table on this page shows which item is attributed to which sub-scale of the SOC: C=Com-prehensibility, MA=Manageability, ME=Meaningfulness.

The score for a sub-scale and the total score for SOC as a whole can be calculated by adding thepoints marked for each item in the questionnaire. Care, however, must be taken regarding the itemscoring. If the item is positively scored, then the rating value marked is taken at face value: forexample, 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 thehighest value (i.e., 7). In keeping with this procedure, a 2 would get 6 points, a 3 would get 5 pointsand so on.

In the specialist booklet series "Research and Practice of Health Promotion"has been published previously:

Volume 1 – Gender-related Drug Prevention for YouthsPractical 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 PreventionEmpirical Research Results and Guidelines.Documentation of a FCHE status seminar held in Bad Honnef from 15 to 17 September1997.Order No. 60 801 070

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

Volume 5 – Child HealthEpidemiological Foundations.Order No. 60 805 070

To be published shortly:

Volume 6 – Evaluation as a Quality Assurance Tool in Health PromotionA project commissioned by the European Commission.Order No. 60 806 070

Volu

me

4

Publisher: Federal Centre for Health Education

VOLUME 4

RESEARCH AND PRACTICE OF HEALTH PROMOTION

ISBN 3-933191-20-3

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

BZgABundeszentralefürgesundheitlicheAufklärung

WHAT KEEPS

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THE CURRENT STATE OF DISCUSSION AND THE RELEVANCE OF ANTONOVSKY’SSALUTOGENETIC MODEL OF HEALTH

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