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This article has been cited by other articles in PMC. Abstract Study objective The aim of this paper is to synthesise empirical findings on the salutogenic concept sense of coherence SOC and examine its capacity to explain health and its dimensions. Design The study is descriptive and analytical with a systematic integration of the contemporary knowledge base on the salutogenic research published — The review includes scientific publications and 13 doctoral theses.

Setting Worldwide, based on postgraduate scientific publications in eight authorised databases, doctoral theses, and available books. Main results SOC is strongly related to perceived health, especially mental health. This relation is manifested in study populations regardless of age, sex, ethnicity, nationality, and study design.

SOC seems to have a main, moderating or mediating role in the explanation of health. Furthermore, the SOC seems to be able to predict health. Conclusion SOC seems to be a health promoting resource, which strengthens resilience and develops a positive subjective state of health. Salutogenesis is a valuable approach for health promotion and would be worth to implement in practice much more than to date.

Keywords: Antonovsky, salutogenesis, sense of coherence, health promotion This paper continues to review, analyse, and synthesise the evidence base of research on the sense of coherence SOC concept in the light of 25 years of research undertaken by the authors. This is a relevant contribution to health promotion and public health research.

It is necessary to get deeper knowledge about the interaction between SOC and socioeconomic characteristics like age, sex, social class, and how SOC might be related to physical and mental health. Are there any relations and does the SOC have an impact on health at all? How do people manage the lack of control of their life? The SOC is a resource that enables people to manage tension, to reflect about their external and internal resources, to identify and mobilise them, to promote effective coping by finding solutions, and resolve tension in a health promoting manner.

The SOC scale has proved to be psychometrically sound. This paper is part of this extensive review of the research. The aim of this paper is to synthesise findings on the relation between the SOC and health. Method This research synthesis is based on empirical studies of the SOC scale and presents the state of knowledge on the salutogenic concept — The papers are analysed according to the following dimensions: 1 the study objective, 2 the study designs and methods for analysis and, 3 the applicability and practical use of the results.

The analysis of the papers is described more in detail elsewhere. Relation implies dependency. Cross sectional studies where only bivariate analysis were used are excluded from the synthesis because of the purpose of this particular paper. Cross sectional and longitudinal studies are analysed separately, and so are quantitative and qualitative studies. Longitudinal studies are needed to confirm causality between the SOC and health.

To clarify what are the results of the examined studies and what are the interpretations and conclusions of the authors the results are presented as study generated results and synthesis generated findings.

Completing information has been acquired from the authors. Despite country of origin most studies are published in English. Search strategy The following search strategy has been used: 1 electronic search in the databases PubMed Medline , Bibsys, ISI, Libris, PsychInfo, Cinahl, Social Services Abstracts, Sociological abstracts, 2 search on the key words salutogenesis, salutogenic, sense of coherence, and the Swedish and Finnish translations, 3 reviewing reference lists in identified papers, 4 personal communication with the authors and colleagues.

After adjustment for double listing in the databases and doctoral theses hits met the inclusion criteria as of 31 December In addition some other relevant books on this topic are included. We have been aware of the potential limitation of this analysis—that is, papers in other languages than the before mentioned—but we still consider the material is adequate enough for a reasonable review.

A detailed protocol was compiled for each article or doctoral thesis. The assessment of the included papers is described in detail elsewhere. The review material includes studies of varying sizes, samples, study design, and methods of analysis.

Results Study generated results The study generated findings of how SOC might influence health are presented as a main, a moderating, and a mediating effect on health. In addition, studies where the findings failed to support an effect on health are presented.

The interpretation of causality is somewhat complicated. There are no statistical tests available that can tell us whether we have made a correct interpretation. A correct conclusion of the study results requires a careful step by step analysis in the study design. By using hierarchical regression analyses a main effect on health can be estimated. A significant increment in R2 detected in the final step of the regression model shows a direct effect of SOC on the health outcome.

A variable functions as a mediator when it accounts for the relation between the predictor and the criterion variable. Mediators specify why such effect occurs. General health was measured among others by using study specific questions of the perceived health, 25 , 26 , 28 , 30 , 33 , 45 medical examination and questions about medical history, 27 , 29 items from the stress profile and the life style profile, 28 health and life experiences questionnaire, 29 health utility index score, and items in the national population health survey, 30 , 31 , 32 and items on work stress from the Whitehall II study.

For more details on the distribution of the SOC see table 2—4 in the appendix. Here a mixed results of the relation between positive and negative outcome measures were shown. The number of childhood traumas was strongly correlated to SOC, depression and distress, and to mastery and happiness. Hood and colleagues report findings, also on a Canadian population, confirming that people with a high SOC tended to be in better health. In a Swedish longitudinal study on high risk families for mental illness, the Lundby study, 22 different coping mechanisms were discriminated.

SOC is strongly and negatively related to perceived depression. A strong SOC is associated to negative and positive affectivity. People with a strong SOC had lower diastolic blood pressure, serum triglycerides, heart rate at rest, and higher oxygen uptake capacity. A low SOC was related to mental and circulatory health problems.

Among children and young people the relations between SOC and health are the same as in the adult population. The better the health is perceived the higher the SOC and simultaneously the lower are the subjective health complains. Nordic studies on school children in different ages and their parents showed the impact of poor SOC on the subjective health. Parental complaints were associated with a 1. SOC is a mediator between stress and mental health.

An opposite finding of the mediating role of the SOC was reported by Lundberg. Key points The evidence proves the salutogenic model as a health promoting resource that improves resilience and develops a positive subjective state of both physical and mental health, quality of life and wellbeing. It is a valid, a reliable, and a cross culturally applicable instrument for measuring health.

The SOC scale consists of at least three dimensions: the comprehensibility, the manageability, and the meaningfulness components. It has been used in at least 33 languages in 32 countries with at least 15 different versions of the questionnaire on subjects from both Western cultures and countries like Thailand, China, Japan, and South Africa.

The mean SOC seems to be independent of the cultural context. The instrument has been examined on healthy populations from children to older adults, in different patients groups and professionals, within many areas of practice like health services, social work, working environment, care of relatives, and in learning situations. In stressful situations SOC seems to have a moderating effect on health. Albertsen and colleagues reported both a main, a moderating, and a mediating effect on health.

The capacity of the SOC scale to predict a future outcome—that is, health—is expressed by the predictive validity. However, there are different results reported. Predictive relations from health to SOC were not found.

The results showed no support for the status of SOC as a salutogenic resource. Smith and colleagues recommended caution of using the SOC to represent a stable global orientation within a causal context.

In two separate studies, one among American Veterans in a rehabilitation unit, the other among Swedish primary care patients, SOC did not predict a positive outcome of health. The uncertainty also means that it is never possible to rule out all the possible alternatives to a causal interpretation. We have to accept a result where the most probable alternatives are eliminated and be content with a science distinct from absolute certainty.

Correlative study design alone does not go far enough in the analysis of relation between SOC and health. It is more beneficial for the analysis to investigate the square of the correlation coefficient. SOC seems to be strongly associated to perceived good health, especially the mental dimension, at least among persons scoring high on SOC. The prediction for people scoring moderate or low on SOC is not completely clear and needs further clarification.

The relation between SOC and physical health is more complex and seems to be weaker than with mental health. Despite some uncertainty our interpretation and conclusion of the investigation of the included studies is that SOC seems to be a health resource promoting resilience and the development of a positive subjective state of health.

The very strong correlation to determinants of mental health, especially to positive emotions and opposing negative affectivity, raises the question whether SOC is a parallel expression of mental health. At least it means that a person with a strong SOC can cope with stressful situations and stay well in a better way than a person with a low SOC.

Furthermore, SOC seems to have qualities reaching beyond only the presence of positive and the absence of negative emotions. The strong relation with factors measuring positive dimensions of health like optimism and hardiness and the opposite or anxiety and depression tend to interpret the SOC as an overlapping construct of other measures of health. Our suggestion and conclusion is that SOC comes close to mental health and mental wellbeing but is not the same as mental health.

There was one finding in the review that is quite surprising. Very few investigators are aware of the potential measurement error of the SOC questionnaire regarding normal variations in the analysis of change in the SOC. A change in SOC mean has usually been interpreted as a real change. One exception is a study on Canadian labour force. The findings show that a high SOC protects health, but we have no clear indication of where the cut off point is and where SOC loses this protective effect.

Is it around the mean value, median, or somewhere else? Is it identical for all individuals, probably not. We here list some of the criticism that has been presented in earlier studies on SOC. The SOC concept has been criticised from many points of view: to be psychometrically unclear, 85 , 86 , 87 , 88 , 89 a theory confounded with emotionality, 62 other concepts available to explain health, 90 a theory full of contradictions, 91 the results to be trivial and overrated, 92 only a few have considered the concept to be worth examining, 93 and lack of evidence of the stability over time.

The psychometric properties of the SOC concept has been discussed elsewhere.


Unraveling the Mystery of Health: How People Manage Stress and Stay Well



Unraveling the Mystery of Health: How People Manage Stress and Stay Well


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