1. Antonovsky’s Sense of Coherence Dana Riley EPI 6181 November 6, 2006

2. Health, Stress & Coping Description of development of sense of coherence (SOC) Pathogenesis – focus of health care is reducing consequences of disease Morbidity hypothesis: at least 1/3 & possibly majority of population is characterized by some morbidity at any point in time Views health as a continuum ease → dis-ease

3. Salutogenesis Saluto (health) + genesis (origins) How do we stay healthy? Why? “What are the stressors in the lives of poor people that underlie the brute fact that with regard to everything related to health, illness & patienthood, the poor are screwed?”

4. Tension management 2 people confronted by same stressor, one meets challenge & other doesn’t Tension: strain incurred by exposure to stressor Stress: reserved for the strain that remains when tension is not successfully overcome Tension management: process of dealing with this tension

5. Generalized Resistance Resources GRR → {physical, biochemical, artifactual- material, cognitive, emotional, valuative- attitudinal, interpersonal-relational, macrosociocultural} → characteristic of an → {individual, group, subculture, society} → that is effective in → {avoiding, combating} → a wide variety of stressors When a person regularly experiences the availability of GRRs, a strong SOC develops

6. Sense of coherence (SOC) Global orientation that expresses the extent to which one has a pervasive, enduring & dynamic feeling of confidence that one’s internal & external environment are predictable High probability that things will work out as reasonably as can be expected Generalized, long-lasting way of seeing the world & one’s position in it

7. Sense of coherence (2) Shaped & tested, reinforced & modified Constant tendency towards consistency & generalization, stability & continuity Weak SOC: Anticipate things will go wrong, difficulty expecting needs to be fulfilled, lack hope Strong SOC: Life is complicated, but understood & in the end things will work out

8. Development of SOC Certain individuals & social groups likely to have stronger SOC than others Social-structural & cultural-historical situations provide developmental & reinforcing experiences → strong SOC Different from internal locus of control (Rotter) – “I am in control” vs. “Things are under control”

9. Operationalizing SOC Hypothesis: Strong SOC is salutogenic Operationalize: – Don’t commit to one methodology – Requires exploration before it’s a systematic tool – SOC is not dichotomous All problems have an answer, challenge/doubt intolerable, no flexibility to adapt to change, claim ultimate control/understanding, denial of sadness, incapacity to admit uncontrollable → Fake SOC

10. Relation of SOC to health High schizophrenia in lower social classes (Kohn) Giving-up process antecedent to all disease categories (Engel et al) Coping ability played an intermediary role between resources & health (Antonovsky) Social-structural evidence; Animal studies SOC: Parsimonious way of integrating a great variety of discrete variables

11. So, what has happened since 1979?

12. Unraveling the Mystery of Health (1987) Continues support of salutogenic approach over pathogenic (e.g., Dirks, Schraa & Robinson, 1982) – Who are the Type A’s that do not get CHD? – Who are the smokers that do not get lung cancer? Reject health/disease dichotomy Salutogenic approach compels us to consider the formulation of a theory of coping.

13. 3 components of SOC Comprehensibility: Extent to which one perceives stimuli as ordered, consistent, etc. Manageability: Extent to which one perceives resources available as adequate to meet demands. Meaningfulness: Extent to which one feels life makes sense, some demands worth investing in, challenges welcome.

14. SOC redefined SOC is a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that: 1. Stimuli derived from environment are structured, predictable, explicable 2. Resources are available to meet demands 3. Demand are challenges, worthy of investment & engagement

15. Stressors Stressor: characteristic that introduces entropy into the system; life experience characterized by inconsistency, under- or overload, & exclusion from decision making Chronic: Enduring, permanent, generalized phenomenon; primary determinant of SOC Major life events: Specifiable in time & space; Strength of SOC → outcome is noxious, neutral or salutary Daily hassles: No automatic adaptive response, but no impact on SOC or health status

16. Measuring the SOC concept 29-item questionnaire (11 C, 10 MA, 10 ME); 13 item short form 7-point Likert type scale Examples: When you talk to people, do you have the feeling that they don’t understand you? Has it happened that people whom you counted on disappointed you? Many people-even those with a strong character- sometimes feel like sad sacks (losers) in certain situations. How often?

17. Antonovsky, A. The structure and properties of the sense of coherence scale. Soc Sci Med. 1993;36(6):725-733. Internal consistency: Cronbach’s alpha = 0.91 in 8 published, 0.85 in 3 theses, 0.88 in 15 unpublished studies Face validity: Adequately representative. Criterion validity: Consistently high correlations with trait anxiety, hardiness & Sheridan’s Global Inventory of Stress Interesting: 2 studies present low correlations with social support Factor analysis: Principal components analysis produces one true factor

18. Eriksson, A, Lindstrom, B. Antonovsky’s the sense of coherence scale and the relation with health: A systematic review. J Epi Comm Health. 2006;60:376-381. Synthesis of findings on SOC & examination of capacity to explain health Stronger SOC → better perceived health (at least initial ↑SOC) Relation manifested regardless of age, sex, ethnicity, nationality & study design Moderating, mediating & main effects on health SOC seems to be able to predict health SOC important for health development & maintenance, but doesn’t alone explain overall health SOC health promoting resource, strengthens resilience & develops + ve subjective state of health