Antonovsky: What Keeps People Healthy

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RESEARCH AND PRACTICE OF HEALTH PROMOTION
WHAT KEEPS PEOPLE HEALTHY? ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

WHAT KEEPS
PEOPLE HEALTHY?
THE CURRENT STATE OF DISCUSSION
AND THE RELEVANCE OF ANTONOVSKY’S
SALUTOGENETIC MODEL OF HEALTH
BZgA VOLUME 4
Bundeszentrale
für
gesundheitliche
Volume 4
Aufklärung
ISBN 3-933191-20-3 Publisher: Federal Centre for Health Education
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planning – is to further extend the dialogue
between theory and practice.
Research and Practice of Health Promotion
Volume 4
What Keeps People Healthy?

The Current State of Discussion and the Relevance
of Antonovsky’s Salutogenic Model of Health
Jürgen Bengel, Regine Strittmatter and Hildegard Willmann
Expert report commissioned by the Federal Centre for Health Education
Federal Centre for Health Education (FCHE)

Cologne, 1999
Die Deutsche Bibliothek – CIP-Einheitsaufnahme
Bengel, Jürgen / Strittmatter, Regine / Willmann, Hildegard
What Keeps People Healthy? The Current State of Discussion and the Relevance of Antonovsky’s Salutogenic Model of Health / [Publ.
by the Bundeszentrale für gesundheitliche Aufklärung (BZgA) Köln.]. - Köln : BZgA, 1999
(Dt. Ausgabe u.d.T.: Was erhält Menschen gesund?)
(Research and Practice of Health Promotion ; Vol. 4)
ISBN 3-933191-20-3
This volume forms part of the specialist booklet series “Research and Practice of Health Promotion”, which is intended to be a forum for
discussion. The opinions expressed in this series are those of the respective authors, which are not necessarily shared by the publisher.
This volume is a translation of the German edition:

Bengel, Jürgen / Strittmatter, Regine / Willmann, Hildegard
Was erhält Menschen gesund? – Antonovskys Modell der Salutogenese – Diskussionsstand und Stellenwert /
Bundeszentrale für gesundheitliche Aufklärung (BZgA) Köln – Köln : BZgA, 1998
(Forschung und Praxis der Gesundheitsförderung ; Bd. 6)
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Preface
An important task of the Federal Centre for Health Education (FCHE) is to investigate the
extent to which new health concepts and models can contribute to the further 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 thus
has met with growing interest in persons active in health promotion. For this reason, the
FCHE commissioned an expert’s report with the goal of examining the utilisation of this
concept for health promotion.
In this expert’s report, Jürgen Bengel, Regine Strittmatter and Hildegard Willmann from
the University of Freiburg, Germany, present the concept of salutogenesis and compare it
to related concepts. They elucidate the current state of empirical foundation, give an over-
view of the importance and utilisation in diverse areas of application, and conclude with
their recommendations.
The FCHE presents this booklet, the fourth in the series “Research and Practice of Health
Promotion”, as an additional contribution to the discussion on suitable concepts and
strategies for the promotion of health and their continuous increase in quality.
Cologne, November 1998 Dr. Elisabeth Pott

Director of the Federal Centre
for Health Education
What Keeps People Healthy? 3

Outline of the Study
Project title: Antonovsky’s Salutogenic Model of Health.

Current State of Discussion and Relevance
Goals: • Examination of the literature

• Evaluation of the concept of salutogenesis with respect
to its application to health promotion
Material: Research monographs

Journals
Textbooks
Sources: Literature search in the databases Psyndex, Psyclit,

Medline (1990–1998), Current Contents (1993–1997),
Dissertations Abstracts (1989–1997), WISO III, PAIS,
Social Sciences Index, ERIC; Internet searches.
Implementation period: September 1997 – February 1998
Project implementation: Psychological Institute of the

University of Freiburg, Dept. of Rehabilitation Psychology
Belfortstrasse 16
D-79085 Freiburg
Tel.: +49(0)7 61/2 03 30 46
Fax: +49(0)7 61/2 03 30 40
Project management: Prof. Dr. Dr. Jürgen Bengel
Authors: Prof. Dr. Dr. Jürgen Bengel, Dipl.-Psych.

Dr. Regine Strittmatter, Dipl.-Psych.
Hildegard Willmann, Dipl.-Psych.
Sponsor: Bundeszentrale für gesundheitliche Aufklärung

(Federal Centre for Health Education – FCHE)
Ostmerheimer Str. 220
D-51109 Köln
Tel.: +49(0)221/89 92-3 28
Fax: +49(0)221/89 92-3 00
Project management: Stephan Blümel

Contents
Introduction 9
1. Historical Background 13
2. The Concept of Salutogenesis 21
2.1. The Salutogenic Problem 22
2.2. Criticism of Health Research and Health Care 24
2.3. The Salutogenic Model of Health 25

2.3.1. The Sense of Coherence 26
2.3.2. The Health Ease/Dis-ease Continuum 29
2.3.3. Stressors and Tension 29
2.3.4. Generalised Resistance Resources 31
2.3.5. An Overview of the Salutogenic Model 32
3. 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

Importance and Utilisation
4. of the Concept in Different

Areas of Application 61
4.1. Health Promotion and Prevention 63
4.2. Psychosomatics and Psychotherapy 66
4.3. Rehabilitation 70
5. Summary 75
5.1. Summary and Evaluation of the Scientific Discussion 76
5.2. Summary and Evaluation of the Importance

and the Utilisation of the Concept 84
5.3. Outlook and Recommendations 87
6. 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
8 Research and Practice of Health Promotion, Volume 4

Introduction
The subject of salutogenesis has attracted a lot of attention in the social sciences and in
medicine recently, especially in the fields of prevention and health promotion. The
American-Israeli medical sociologist, Aaron Antonovsky (1923–1994), introduced this
concept to the health sciences and public health care. He criticised an exclusively patho-
genic-curative approach and juxtaposed it against a salutogenic orientation arguing that
the question, why people stay healthy, should have priority over the question of the causes
of disease and their risk factors. The salutogenic orientation primarily explores the con-
ditions of health and the factors that protect health and contribute to invulnerability. It
focuses on the factors which maintain health. In part, one is beginning to speak of a
paradigm shift from a disease-centred model of pathogenesis to a health-centred,
resource-oriented model of salutogenesis aimed at prevention.
The concept of salutogenesis was put forth by A. Antonovsky in his two main books,
“Health, stress and coping: New perspectives on mental and physical well-being”
(1979, San Francisco, Jossey-Bass) and “Unraveling the mystery of health. How people
manage stress and stay well” (1987, San Francisco, Jossey-Bass).
In German-speaking countries, three volumes were published on the subject in 1997:

A. Antonovsky, “Salutogenese: Zur Entmystifizierung der Gesundheit” (Salutogenesis:
Unravelling the Mystery of Health), expanded edition by A. Franke (Tübingen, dgvt-Ver-
lag), H. H. Bartsch & J. Bengel (Eds.), “Salutogenese in der Onkologie” (Salutogenesis
in Oncology) (Basel, Karger), and F. Lamprecht & R. Johnen (Eds.), “Salutogenese – Ein
neues Konzept in der Psychosomatik?” (Salutogenesis – a New Concept in 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 Disease
Theory?) (Berlin, Springer).
It is remarkable that Antonovsky’s views on salutogenesis were not taken up in the health
care discussion until some time after the publication of his two main books on the 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 system
address this concept, using it as a means of embellishing their own position. In such cases,
long-established practices in health promotion are termed “salutogenic”, as are innovative
preventive measures. Other authors conduct empirical studies specifically on the sense of
coherence. They examine the extent to which the concept can be investigated 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 fields
of 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 of
salutogenesis to discuss the status of the salutogenic model and its possible consequences
for the practice of health care: “The expert report should provide an overview and an
evaluation of the writings with respect to the concept’s application to the promotion of
health.”
This report by our working group describes Antonovsky’s concept of salutogenesis and
documents its scientific treatment. We have attempted to make the basic ideas of the
concept understandable and present them within the context of the historical development
of the health sciences. The report was written to provide a clear, concise answer to the 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 check
in germane data banks as well as in the Internet: The following sources were examined
under the search words “salutogenesis, salutogenic, sense of coherence, Antonovsky”:
Psyndex (1990–1998), Psyclit (1990–1998), Medline (1990–1998), Current Contents
(1993–1997), Dissertations Abstracts (1989–1997), WISO III, PAIS, Social Sciences Index
and ERIC. In addition, we looked through health science journals and textbooks under
the entry “salutogenesis”.
The report is divided into a main text and a documentation of the sources. The first three
chapters of the text are dedicated to the formulation of the theoretical background and
the current research. Chapter 1 depicts the historical background of the salutogenic
model. Chapter 2 introduces the concept of salutogenesis and Chapter 3 describes the 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 evaluation
of the concept. It summarises the discussion introduced in the first three chapters as well
as the status and the merits of the concept and concludes with an outlook and recom-
mendations. A bibliography of the literature used for the expert report can be found in
Chapter 6 along with a bibliography of the works by Antonovsky. In addition, the empirical
studies cited in Chapter 3 on the sense of coherence are presented in a table. The ques-
tionnaire on life-orientation (SOC-scale) appears in the final section.

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

1
Historical Background
1. Historical Background
Before we illustrate the concept of salutogenesis in Chapter 2, we will first describe the
historical background and the context in which Aaron Antonovsky formulated his delib-
erations and conducted his research. The model of salutogenesis and Antonovsky’s theses
can only be understood when viewed against the background of the developments and
trends in health care and in the health sciences of the past 50 years. To this end, the
following developments, which took place concurrently, will be described:
– the criticism of the health care system,

– the examination of the concepts of health and disease,
– the development of a biopsychosocial model of disease,
– the changes in the prevention and the promotion of health.
In addition, events in Antonovsky’s life certainly had an influence on the conception of

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

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

1
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 the
capability of the organism to cope with stress and strain. These subjective notions develop
in the course of the socialisation of every individual within a specific social context and
climate. The perception of physical complaints is influenced by social and individual
judgements. This assessment is not independent of the severity of the symptoms; however,
the perception of personal and social resources has a decisive influence on the subjective
condition and the health-related behaviour of the individual.
Definitions of Health
There are a number of approaches to defining health and disease. They are oriented on
different health norms. The particular definitions of health and disease have a significant
influence on which means are considered appropriate and necessary for the restoration,
the maintenance and the promotion of health. This is essential, since these specifications
determine the amount and type of influence and responsibility for the emergence of the
disease and its cure that can or should be attributed to the patient (extent of self-
responsibility). An ideal norm of health depicts a state of perfection, whose attainment is
desirable or valuable. By defining health as a state of complete psychological and 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 the

organism: whatever holds for the majority of humanity is defined as healthy. Deviations
from these average values are considered to indicate disease. The classification of a per-
son as either ill or healthy thus requires a reference group, for factors as age and gender
as well as the predetermined value ranges. “Health” as a functional norm is based on the
person’s ability to fulfil his or her role in society. In turn, the determination of functional
norms requires the validity of superior hierarchical values (see Erben, Franzkowiak &
Wenzel, 1986; Wetzel, 1980).
In general, the definitions of health within the medical system are negative, i.e., “health”
is described as the absence of disease. Consequently, the patient is classified as ill when

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

At the outset of the 19th century, under the influence of the thoughts of the natural 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 and
structures 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 defects
make 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 of
the 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 person
could be classified as ill or not depends on whether anatomical or physiological changes
can be determined. The ill person in the form of a subject and an agent is virtually 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 treatment
aims at repairing the defect. This concept of disease led to great medical progress in many
areas, such as the treatment of metabolic disorders or the battle against infectious ill-
nesses.

Broadening the Biomedical Model
Criticism of the biomedical model of disease was raised quite early and triggered heated
debates in the 1970’s. The social medical scientist, Engel (1979), contrasted this model
with an expanded biopsychosocial model, in which both somatic as well as psychosocial
factors were used to explain the origin and the progression of disease. Research in the
social sciences, psychology and psychosomatics demonstrates that psychological and
1
social 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, the
experiencing of pain, the decision to undergo medical treatment, and to follow doctor’s
orders, to name only a few examples, are significantly influenced by psychological and
social factors.
Research on psychobiological coping and stress began to look at the protective resources,
for example within the immune system, which the organism can activate during stressful
conditions. It does not follow a pure vulnerability concept which examines how psycho-
logical stressors become detrimental under psychophysiological processes. Nowadays, in
the interdisciplinary field of the health sciences, many disciplines such as medical
psychology, the psychology of health, behavioural medicine and psychoneuroimmunology
are involved. Psychoneuroimmunology is a relatively new field of research that integrates
the knowledge and the methodology of psychology and different medical subdisciplines
to examine which interactions between different systems of the body exist, such as the 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 of
humans as well. This tendency becomes apparent in the face of the political demands
made regarding prevention concepts and the measures taken by health policies. At first
glance, this seems to be a new orientation which is moving away from a curative system.
However, a closer look reveals that the pragmatic concepts of prevention which can be sub-
sumed under the concepts of early detection and health education have been shaped by
medical thinking, even though health education in particular requires knowledge of psy-
chology (Borgers, 1981; Oyen & Feser, 1982). Despite the diverse criticism and the fact that
the importance of psychosocial and cultural factors has been established, the biomedical
model of disease still dominates institutional medicine and prevention today.
The Development of Prevention and Health Promotion
Throughout the history of medicine, efforts have been made to prevent disease. Measures
taken to improve hygienic conditions and large-scale immunisation programmes, such
as those introduced following World War II, are of great importance for the development

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

The basis for preventive measures is still the risk factor model. This model was developed
in the 1950’s in conjunction with the results of epidemiological studies and statistics from
life insurance agencies in connection with coronary heart disease. Correlations between
risk factors such as high lipid levels, tobacco consumption, obesity, psychological 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 certain
percentage 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 be
made 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 merely
indicate 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. Thus
far, the risk model contains predominantly behaviour-related risk factors (i.e., smoking,
overweight or high blood pressure), whereas context and circumstantially related factors,
such as chronic work pressure or environmental influences, are still largely neglected
(see Franzkowiak, 1996, for a summary). As a consequence, the realisation of this model
focuses mainly on individual changes in behaviour.
Health Promotion Programme

Since 1978, when the WHO Conference in Alma Alta ambitiously proclaimed “Health for
all by the year 2000”, the aim to supplement the biomedical risk factor model and all
it implies has been part of the agenda.
The WHO introduced the Health Promotion Programme in the Ottawa Charter, whose key
features can be characterised by the concept of lifestyles (Franzkowiak & Wenzel, 1982;
Federal Centre for Health Promotion, 1983).
The promotion of health as a social-ecological health and prevention model does not view
health as a goal, but rather as a means of enabling positive shaping of individual and so-
cial life. Preventive measures are thus not prescribed by the professional system. They are
targeted at active and responsible participation of the layperson in the establishment of
health-promoting conditions and at collaboration between laypersons and professionals.

With this goal, health promotion is similar to the empowerment approach which grew
out of American communal psychology (Rappaport, 1985; Stark, 1996). “Empowerment”
refers to the strengthening of competence, responsibility and resourcefulness of persons
or groups. In this way, the promotion of health is a task which changes politics and so-
ciety, which however does not make implementing the goals any easier.
1
The health promotional approach continues the above-mentioned developments in the
understanding of health and disease. It is based on a complex, multidimensional concept
of health and is founded on a biopsychosocial model of disease. In addition to individual-
related approaches, this concept of health promotion primarily stresses the necessity of
structural changes. Broadening the classic risk factor model to include psychosocial
determinants as well as surroundings and circumstances, and developing a theory of the
combined effects of risk and protective factors, fit the demands of health promotion and
the principles of the stress-coping models.
A. Antonovsky’s Biography
Aaron Antonovsky was born in the USA in Brooklyn, New York in 1923. After his military
service in World War II, he completed his doctoral thesis in sociology. At this time, he was
interested in culture and personality, social class-specific problems and ethnic relations
(Antonovsky, 1979).
In 1960, Antonovsky emigrated to Israel with his wife, Helen, and accepted a post at the
Israel Institute for Applied Social Research in Jerusalem. Rather accidentally, he became
interested in medical sociology by taking part in several different research projects in this
field, including an epidemiological study on multiple sclerosis. In the course of the years
following, he taught in the department of social medicine and worked on different
research projects on the connection between stress factors and health or disease.
In keeping with Lazarus (1966), Antonovsky began to support a stress concept in which
stressors are not automatically considered to lead to disease. In his concept, stressors are
viewed as stimuli that can trigger a state of tension which must not necessarily lead to
stress. Thus Antonovsky's social epidemiological research was a preliminary for his psy-
chological examination of individual processing patterns in the face of tension. In this
context, Antonovsky rejected the idea of a specific effect of stressors and supported the
opinion that the type of disease is determined by individual dispositional vulnerability and
not by the profile of the stressful influences.
Decisive for his further research were ideas that Antonovsky developed on the basis of a
study of adaptation to climacterium in women of different ethnic groups. One of these
groups consisted of women who had been born between 1914 and 1923 in central Europe
and some of them were interned in concentration camps. As expected, the group of con-

centration camp survivors exhibited significantly more signs of ill health than the women
in the control group. However, as many as 29%(!) of the former prisoners claimed to be
in relatively good mental health despite these traumatic experiences. Antonovsky 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 of

medicine in Beer Sheba, Israel. He returned to the USA twice as a visiting professor, from
1977 to 1978 and from 1983 to 1984. Antonovsky died at the age of 71 in 1994.

2
The Concept of Salutogenesis
2. The Concept of Salutogenesis
The goal of this chapter is to illustrate the basic ideas of salutogenesis and the salutogenic
model of health. For this purpose, we will focus on Antonovsky’s original literature. Unless
otherwise specified, the portrayal is based on Antonovsky’s book, “Unraveling the
mystery of health”, published in 1987, which has been available in German since 1997,
edited by A. Franke. First, the main questions of Antonovsky’s works will be presented.
Then, the salutogenic model of health will be introduced, which centres around the con-
struct of “the sense of coherence”.
2.1. The Salutogenic Problem
Why do people stay healthy despite so many detrimental influences? How do they manage
to recover from illnesses? What is special about people who do not get ill despite the most
extreme strain?
These are the central questions that served as the point of departure for Antonovsky's theo-
retical and empirical work. Antonovsky coined the term, “salutogenesis” (salus, Latin
for “invincibility”, “well-being”, “happiness“; genese, Greek for “genesis”, “origin”) to
emphasise its distinction from “pathogenesis” which has dominated the biomedical
approach, the current model of disease, and also the risk factor model.
Salutogenesis means not only the other side of the coin as compared to a pathogenically-
oriented perspective (Antonovsky, 1989). Thinking pathogenically means examining the
origin and the treatment of disease. Salutogenesis does not refer to the opposite in the
sense that it is devoted to the origin and maintenance of health as an absolute state.
Rather, it refers to the fact that all people are to be considered more or less healthy while
at the same time being more or less ill. Thus the question here is: How does a person
become healthier and less ill?
Antonovsky used a metaphor to compare the predominant thinking and action premises
of medicine with the salutogenic perspective. The pathogenic approach is aimed at res-
cuing people at great expense from a raging river, without taking into consideration how
they got in there and why they are not better swimmers. In contrast, seen from the per-
spective of health education, people jump into the river of their own volition, while at the

same time refusing to learn to swim. Antonovsky applied another version of this metaphor
to describe salutogenesis:
“... my fundamental philosophical assumption is that the river is the stream

of life. None walks the shore safely. Moreover, it is clear to me that much of
2
the river is polluted, literally and figuratively. There are forks in the river
that lead to gentle streams or to dangerous rapids and whirlpools. My work
has been devoted to confronting the question: ‘Wherever one is in the stream
– whose nature is determined by historical, social-cultural, and physical
environmental conditions – what shapes one’s ability to swim well?’”
(Antonovsky, 1987a, p. 90).
These images illustrate the different levels that characterise Antonovsky’s work and also
the discourse on his ideas. The metaphor of the river as a symbol for life, and the idea that
a person is always swimming in a more or less dangerous river, reflects his philosophical
views. Research questions can be posed and phrased very differently depending on whether
one intends to examine who will drown first, what is necessary to rescue someone from
drowning or whether one asks which factors facilitate swimming. Whether people are
rescued shortly before drowning or the course of the river is tamed or the people are taught
to swim all depends on the public health care policies. The individual ability to swim is
analogous to a personality disposition which Antonovsky called a “sense of coherence”
(see Section 2.3.1.). His psychological model of health is a product of linking the various
characteristics of the river and the people swimming in it.
Antonovsky’s views on the origin of health were influenced by systems theoretical consid-
erations. Health is not a normal, passive state of balance, but rather an unstable, active
and dynamic self-regulating process. The basic principle of human existence is not
balance and health but imbalance, disease and suffering. Disorganisation and the
tendency toward entropy is omnipresent. “The human organism is a system and, like
all systems, it is at the mercy of the power of entropy” (Antonovsky 1993a, p. 7). The
concept of entropy is borrowed from thermodynamics and refers to the tendency of
elementary particles to move to a state of increasing disorder. The lesser this tendency, the
more order and organisation the system possesses. This capacity of a system toward
organisation is termed negative entropy. In a figurative sense, Antonovsky employed the
concept of entropy as an expression for the ubiquitous tendency of human organisms to
lose their organised structure, but also the ability to reorder it again. Applied to one’s state
of health, this means that health must constantly be re-established and that at the same
time the loss of health is a natural and ubiquitous process. “The salutogenic approach
regards the battle towards health as permanent and never quite successful” (Anto-
novsky, 1993a, p. 10). Antonovsky admitted that his weltanschauung tends to be pessi-
mistic in this context (Antonovsky, 1987b).

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

“In science, the question is more important than the answer” (Antonovsky, 1993a, p. 18)
and “...how one poses the question is crucial to the direction one takes in looking for
the answers” (Antonovsky, 1979, p. 12). These two statements point out that his scien-
tific work distinguishes itself from others mainly by the formulation of the thesis and the
perspective taken. The concept of salutogenesis represents a criticism of a one-sided
2
orientation of the research on detrimental living conditions and pathogenic factors. He
repeatedly 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 who
do not get coronary disease? Who are the smokers who do not get lung cancer?”
(Antonovsky, 1987a, p. 10). Pathogenically-oriented research compares patients with
control groups that can be considered healthy, since they do not have a certain illness (see
Section 3.3.). However, they might suffer from other illnesses that go undetected. In
contrast, a salutogenic approach considers illnesses to be non-specific and asks why people
stay healthy and which characteristics and skills distinguish them from others. For this 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 the
origin or maintenance of health. The striking thing about his model of health is that he
did not formulate a definition of health. He claimed that he is not interested in explain-
ing health either as an absolute or an ideal concept, since this does not correspond to the
true conditions (Antonovsky, 1979). Furthermore, as he saw it, a definition of health
always requires the establishment of norms and thus risks judging others according to
values that do not apply to them (Antonovsky, 1995).
The heart of the model, the sense of coherence, will be presented first in Section 2.3.1.
Further elements are the health ease/dis-ease continuum, Section 2.3.2., stressors and
states of tension, Section 2.3.3., and the generalised resistance resources, Section 2.3.4.
Section 2.3.5. provides an overview of the model and the links between the components.

2.3.1. The Sense of Coherence
According to Antonovsky, a person’s state of health or disease is determined to a significant

extent by an individual, psychological factor: an individual’s general attitude toward the
world and his or her own life – a weltanschauung, as he once put it using the German
word (Antonovsky, 1993d, p. 972). Antonovsky realised that external factors, such as war,
starvation or poor hygienic conditions, can be detrimental to health. Yet even when 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 of
health depends on how pronounced one’s cognitive and affective-motivational outlook on
life is, which in turn influences the extent to which one is in a position to utilise the re-
sources available to maintain one’s health and well-being. Antonovsky termed this basic
outlook on life sense of coherence (SOC). “Coherence” means consistency, congruence
and harmony. The more pronounced a person’s sense of coherence, the healthier he or she
should be and the more quickly will that person regain health and remain healthy. In his
first formulation, Antonovsky defined the sense of coherence as:
“...a global orientation that expresses the extent to which one has a pervasive,
enduring though dynamic, feeling of confidence that one’s internal and
external environments are predictable and that there is a high probability
that things will work out as well as can reasonably be expected” (Antonovsky,
1979, p. 10).
The adjective “dynamic” refers to the fact that this outlook on life is constantly 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 basic
orientation to life, which thus becomes stable and enduring. The strength of the SOC is
independent of the circumstances, the social roles that one currently fulfils or is expected
to fulfil. For this reason, Antonovsky referred to this outlook on life as a dispositional
orientation (a relatively enduring characteristic). It does not, however, stand for any
particular personality trait.
According to Antonovsky, this basic attitude of experiencing the world as coherent and
meaningful is made up of three components:
1. The sense of comprehensibility

This component describes the expectation or the ability of the person to process both
familiar and unfamiliar stimuli as ordered, consistent, structured information and not
to be confronted with stimuli that are chaotic, random, accidental and inexplicable.
The term “comprehensibility” is used in the sense of a cognitive processing pattern.

2. The sense of manageability
This component describes a person’s conviction that difficulties are soluble. Antonov-
sky also called this “instrumental confidence” and defined it as “...the extent to which
one perceives that resources are at one’s disposal which are adequate to meet the
demands posed by the stimuli that bombard one” (Antonovsky, 1987a, p. 17).
2
The extent of one’s sense of manageability does not necessarily depend on one’s own
resources and competencies. It also subsumes the belief that other people or a higher
power will help one to overcome difficulties. Someone who lacks this conviction is like
a “sad sack” or “shlimazl” who invariably experiences unfortunate events without
being able to do anything about them. Antonovsky considered the sense of manage-
ability as a cognitive-emotional processing pattern.
3. The sense of meaningfulness

This 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 worth
investing energy in, are worthy of commitment and engagement, are challenges
that are ‘welcome’ rather than burdens that one would much rather do without”
(Antonovsky, 1987a, p. 18). Antonovsky considered this motivational component to be
the most important. Without the experience of meaningfulness and without positive
expectations towards life, there will not be a high SOC value despite the pronounce-
ment of the other two components. A person who does not experience meaningfulness
will perceive life as a burden and consider each new task as additional agony.
The distinction between the three components becomes clearer in the second definition of
the SOC:
“The sense of coherence is a global orientation that expresses the extent to

which one has a pervasive, enduring though dynamic feeling of confidence
that (1) the stimuli deriving from one’s internal and external environments
in the course of living are structured, predictable, and explicable; (2) the
resources are available to one to meet the demands posed by these stimuli;
and (3) these demands are challenges worthy of investment and engagement”
(Antonovsky, 1987a, p.19).
A pronounced sense of coherence enables a person to react flexibly to demands. He or she

can activate the appropriate resources for specific situations. In contrast, a person with a
weakly developed SOC would react to demands in a strong and rigid manner, since he or
she perceives himself or herself as having less coping resources.
The SOC works as a flexible directing principle, as a conductor who orchestrates the
implementation of different coping styles according to the demands to be met. “What the
person with a strong SOC does is to select the particular coping strategy that seems most
appropriate to deal with the stressors being confronted” (Antonovsky 1987a, p. 138).

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, since
the adolescent has many open choices and many areas of life have not yet been established.
In his opinion, the SOC is fully developed by the age of 30 and remains rather stable.
Without explicitly mentioning them, Antonovsky explained the formation of the SOC with
Piaget’s (1969) principles of assimilation and accommodation: external changes influ-
ence and modify internal perceptions. On the other hand, because of the pre-existing life
views, familiar realms of experiences are preferably sought, so that these tend to confirm
the pre-existing.
The comprehensibility component is formed by experiences of consistency. Since stimuli

and experiences do not occur in an arbitrary, contradictory and unpredictable manner,
they can be classified, categorised and structured. Manageability develops through
experiencing balanced strain, i.e., the person experiences neither overload nor underload.
Meaningfulness is fostered by the feeling of having influence on the shaping of situations.
According to Antonovsky, whether a strong or weak SOC develops, depends on the circum-
stances in society, that is, on the availability of generalised resistance resources (see
Section 2.3.4.) (Antonovsky, 1993a). When generalised resistance resources are present
which allow repeated, consistent experiences and permit participation in shaping outcome,
as well as a balance between overload and underload, then a strong SOC will develop over
time (Antonovsky, 1993a). Experiences that are predominantly characterised by
unpredictability, uncontrollability and uncertainty will lead to a weak SOC. This does not
mean, however, that a person must never experience uncertainty and unforeseen events
in order to acquire a strong SOC. The development of a strong SOC requires a balance 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 conditions
can lead to a significant change in the SOC. Examples of radical changes, which greatly
change the resources and opportunities available up to that point or lead to many 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 expect
that an encounter, or even a series of encounters, between client and clinician can
significantly change the SOC” (Antonovsky 1987a, p. 118).

2.3.2. The Health
Ease/Dis-ease Continuum
2
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) and
dis-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 her
must be healthy: “We are all terminal cases. But so long as there is a breath of life in
us, we are all in some measure healthy” (Antonovsky, 1987a, p. 50). The question is no
longer whether one is healthy or ill, but how far or how close one is to one of the end poles
of health ease and dis-ease.
In addition, Antonovsky assumed that there are a number of other conditions or dimen-
sions that can also be viewed as continuums and which correlate with the ease/dis-ease
continuum. For his thesis question, it is important to distinguish between physical
condition and these other dimensions of well-being/discomfort. He placed the aspect of
physical health in the centre of his model (Antonovsky, 1979).
2.3.3. Stressors and Tension
One problem germane to stress research is the definition of stressors: stressors are all
stimuli which engender stress. Whether or not a stimulus is a stressor, can only be deter-
mined by its effect and thus cannot be predicted.
To solve this problem, Antonovsky introduced a new element in the model. He postulated
that stressors start out by simply causing a physiological state of tension (psychophysical
activation), which can be traced back to the fact that individuals do not know how to react
in a given situation. Stressors are defined as “...a demand made by the internal or
external environment of an organism that upsets its homeostasis, restoration of which
depends on a non-automatic and not readily available energy-expending action”
(Antonovsky, 1979, p. 72).

For Antonovsky, the organism’s main task is coping with states of tension. Here, concepts
of coping research play a key role. When the coping strategy succeeds, it has a 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 the
person arises. Since coping strategies cannot always succeed, stress reactions and stress-
ful situations are a ubiquitous phenomenon. However, the ensuing stress reaction must
not necessarily have negative consequences for health. The strain can have a neutral or
even a health-promoting effect. It is the interaction with pathogenic agents, harmful 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 influence
through force of arms, starvation, toxic substances or pathogens can be so strong that they
have a direct effect on the state of health. In this case, the pathogenic orientation is called
for, leading to the search for a means of eliminating the stressors. Since, however, the
hazards of physical and biochemical stressors in industrialised nations have diminished,
the focus has shifted to psychosocial stressors. This is where Antonovsky employed his SOC
construct.
On the one hand, a strong SOC enables a person to judge a particular stimulus to be
neutral, which would cause tension in persons with a weak SOC. This is known as primary
appraisal I. 1 However, when a person with a high SOC judges a stimulus to be a stressor,
then he or she is in a position to determine whether the stressor is threatening, 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, people
with a high SOC will not actually feel threatened. Their fundamental confidence that the
situation will work out in the end protects them. Furthermore, Antonovsky contended that
people with a high SOC tend to react to threatening situations with appropriate and
directed feelings that can be influenced by actions, for example anger about a certain fact.
In contrast, people with a weak SOC tend to react with diffuse emotions that are difficult
to regulate, such as blind rage. They become paralysed, since they lack confidence in their
ability to cope with the problem (primary appraisal III).
1 Antonovsky refers to “primary appraisal” as an element of the transactional model of stress (see p. 56).

2.3.4. Generalised Resistance Resources
2
For a long time, Antonovsky explored different factors which facilitate successful coping
with tension and thus influence the maintenance or the improvement of health. He
gathered a broad spectrum of factors and variables in epidemiological studies that
correlate with the state of health. These variables are related to individual factors, such
as physical characteristics, intelligence and coping strategies, as well as social and
cultural factors like social support, financial power and cultural stability. Antonovsky
calls these variables “generalised resistance resources”. The term “generalised” refers
to the fact that they are effective in all kinds of situations. “Resistance” refers to the
fact that the resources increase the resistance of the person. “What is common to all
generalised resistance resources, I proposed, is that they help to make sense out of
the countless stressors with which we are constantly bombarded” (Antonovsky,
1987b, p. 48).
Resistance resources have two functions: they have a continuous impact on life experi-
ences and enable us to make meaningful and coherent life experiences which in turn form
the SOC. They function as a potential which can be activated when necessary for manag-
ing states of tension.
In his second book (1987a), Antonovsky conceptualised stressors as generalised resistance

deficits. It is thus possible to consider resistance resources and resistance deficits as
continuous dimensions. The positive pole stands for the possibility of making life ex-
periences which strengthen the SOC. The negative pole represents experiences that weaken
the SOC. For example, a large amount of financial resources or cultural stability can be
a resource, a lack thereof can be seen as a resistance deficit or as a stressor. Stressors or
resistance deficits lead to entropy 2 . In contrast, resistance resources lead to negative
entropy 3 in the human system. The SOC is the channel that “orchestrates this 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
Noack (1997) compared the basic aspects of the salutogenic model with the pathogenic
model (see Table 1).
Basic Assumptions of the Pathogenic and the Salutogenic Model
Assumption regarding Pathogenic Model Salutogenic Model
Self-regulation of the system Homeostasis Overcoming heterostasis*
Definition of health and disease Dichotomy Continuum
Scope of the concept of health Pathology of disease, Recovery resources,

reductionist sense of coherence, holistic
Causes of health and disease Risk factors, Patient’s history

negative 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.
(Source: Noack, 1997, p. 95)
Table 1
Now that the most important elements of the model of the emergence of health have been
discussed, we will go on to describe the way in which these constructs fit together and how
Antonovsky explained the improvement of the state of health within the framework of this
model. Diagram 1 provides a brief summary of the most important points.
The concept of the sense of coherence (SOC) is central to explaining health-maintaining

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

Brief Summary of the Salutogenic Model
(after Antonovsky, 1979, pp. 184–185)
Stressors
F E
2
Sources of
generalised C Generalised
G State of
resistance resistance
Tension
resources resources
D
B
Sense of
Life Coherence
Experiences A (SOC)
Tension
H Management
K
Successful Unsuccessful
I
J
Healthy Ill Stress
Health Ease/Dis-ease Continuum
Diagram 1
Life experiences form the SOC (Arrow A). A pronounced SOC requires life experiences
which are as consistent as possible, which the individual can effectively influence and
which cause neither overload nor underload.
Such experiences are made possible by so-called generalised resistance resources, such as
physical factors, intelligence, coping strategies, social support, financial power or cultural
factors (Arrow B). The emergence or the presence of resistance resources is contingent on
the social, cultural and historical context and the predominating child-raising patterns
and social roles. Finally, personal attitudes and random events can also have an influence
on resistance resources (Arrow C).
The extent to which these pre-existing generalised resistance resources can be mobilised
depends on the strength of the SOC (Arrow D). There is a recursiveness which can quickly
become a vicious circle. If there are too few resistance resources, then the emergence of
the SOC will be negatively influenced. A weak SOC, on the other hand, prevents the
optimum utilisation of the available resistance resources.
Stressors which confront the organism with stimuli for which it has no automatic
responses engender states of tension (Arrow E). The mobilised resistance resources in-

fluence stressor management (Arrow F) and the state of tension (Arrow G). This is also
recursive. The success of tension reduction acts to strengthen the SOC (Arrow H): “By
overcoming a stressor, we learn that existence is neither shattering nor meaningless”
(Antonovsky, 1979, p. 194).
As a result of the successful tension reduction, the state of health or the position on the
ease/dis-ease continuum is maintained or re-established (Arrow I). In turn, a favourable
position on the ease/dis-ease continuum facilitates the acquisition of new resistance
resources (Arrow K). Unsuccessful tension management, however, leads to a state of
tension (Arrow J). This state of tension interacts with existing pathogenic influences and
vulnerabilities and thus has a negative effect on the organism’s position on the ease/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 influences
physical health. In general, Antonovsky agreed with stress researchers that an overload of
constant or repeated experiences of stress in combination with physical weakness can be
a detriment to the organism’s state of health. In his terminology, the most important thing
is to prevent tension from becoming strain.
According to Antonovsky, the following effects of the SOC can be assumed:
1. The SOC can have a direct influence on different systems of the organism, for exam-
ple, the central nervous system, the immune system and the hormone system. It affects
thinking processes, called cognitions, which determine whether a situation is
dangerous, safe or welcome. Thus, there is a direct link between the SOC and the
engendering of complex reactions on different levels. That is to say, the strength of the
SOC influences not only the management of states of tension (buffers, see Item 2,
below), but also acts as a direct filter in information processing.
2. The SOC mobilises existing resources. Successful implementation of these resources

leads to a reduction of tension and thus indirectly affects the physiological systems
involved in the processing of stress. Antonovsky did not regard short-term physiologi-
cal stress actions (tension) to be detrimental as long as they are compensated for by
an ensuing recovery phase. Damage occurs only when these self-regulating processes
are disturbed.
3. People with a pronounced SOC are more likely to be in a position to make choices
regarding behaviour that explicitly promotes health, for example, a nutritious diet,
prompt medical attention, medical check-ups, and are able to avoid acting in ways that

endanger their health. Thus, by way of affecting health-promoting behaviour, the SOC
has an indirect influence on the state of health.
Antonovsky considered his assumptions about the interactions between the SOC and health
as confirmed by the relatively new interdisciplinary research field of psychoneuro-
2
immunology. This research field focuses on the investigation of the complex interactions
between the nervous system, the hormone system and the immune system and their effects
on the human organism, that is on physical health or illness. Within the context of
psychoneuroimmunology, Antonovsky saw his assumption confirmed that the cognitive-
motivational construct of the SOC can have a direct influence on the organism.

3
Current State of Research
3. Current State of Research
This chapter examines the importance of the concept of the sense of coherence and the
role it plays in research. First, the current state of research on the sense of coherence will
be presented and elucidated. In the second section, the extent to which the sense of 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 within
the context of various research traditions which are also concerned with the preservation
and maintenance of health.
3.1. The Sense of Coherence:

State of Empirical Foundation
The SOC-Scale
Before discussing the current state of research on the central construct, the sense of co-
herence (SOC), we will address various means of measuring or registering it. In order to
examine his theory empirically, Antonovsky developed a questionnaire, “The Orientation
to Life Questionnaire” (SOC-scale, Antonovsky, 1983). This questionnaire is based on the
data from 51 qualitative interviews in which the people questioned talked about their lives.
The interviewees were people who had been subjected to severe trauma yet seemed to come
to terms with their lives remarkably well. The statements identified as representing a
general attitude toward life or life experiences were analysed. Using Guttman’s 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 which
contains 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 eight
items. 1 The items are supposed to register a basic attitude in the sense of a dispositional
orientation. The three theoretically formulated partial constructs could not be clearly 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
1 The complete questionnaire is in the Appendix, Section 6.5.

translated into several languages. There is also a German version which, however, has not
yet been standardised and normed (Noack, Bachmann & Oliveri, 1991).
Antonovsky assumed that an extremely high score on the scale cannot be expected, or
rather must be considered pathological, since a person who consistently perceives every-
thing as being comprehensible and predictable is poorly adapted to reality. The scale is
supposed to be applicable transculturally and was conceived for the life situation of adults.
When developing an instrument of measurement, it is common practice to test it for vari-

ous validity and reliability criteria. If these criteria are satisfied, the instrument can be
3
considered to measure what it is supposed to measure both accurately and reliably. The
SOC-scale is presumed to meet the demands of test theory. 2
Whether or not the instrument measures what it claims to measure is a matter of construct
validity. There are different ways to establish this. In order to test the concept of the sense
of coherence, it was mainly compared with similar constructs. High correlations are
considered to confirm the similarity and thus the validity of the construct, whereas
correlations which are too high may indicate that the construct lacks independence. As
expected, the sense of coherence correlates highly with related concepts (see Section 3.2).
Very high correlations with anxiety and depression raise the question as to whether the
SOC-scale might simply represent the reverse of these two constructs. However, doubt has
been cast on the procedure of correlative comparison itself as a means of testing construct
validity (e.g. Siegrist, 1994). Few attempts have been made to validate the construct with
non-correlative methods.
Empirical Studies on the Sense of Coherence
The following discussion on the current state of research is based on approximately 50 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 been
published up to 1990 and critically examined their results (Antonovsky 1993c). The pub-
lications mentioned here consist of the literature on salutogenesis obtained with the help
of CD-ROM literature databases in addition to other literature that was available to us
(see the Introduction and Section 6.1. of the Appendix). We have not only reviewed the
English and the German literature, but also that appearing in other European countries.
The studies mentioned here are presented in an overview in Section 6.4 of the Appendix.
To begin with, we can say that twenty years have gone by since Antonovsky presented his
concept of the SOC in his book “Health, stress and coping” (1979). To date, not much
2 Internal consistency: Cronbach alpha .82 and higher; Test-retest-reliability at time intervals from 7–30 days, product-moment-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 spectrum
of the areas in which salutogenesis had been researched was impressive. Our evaluation
is less euphoric.
The majority of these studies were conducted by a few working groups in Israel and 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 en
vogue. 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, the
actual value of the construct as a means of explaining health, as Antonovsky intended,
has not been acknowledged to any considerable extent, not even after twenty years and
especially not by the scientific “opinion-makers” in the USA.
Despite the fact that a change in perspective is often propagated (some even speak of a
paradigm shift), one can also observe that studies on health psychology that examine the
prognostic value of other constructs continue to prefer a study design which is oriented
on the deficit or risk model.
Independent of the empirical evidence on the SOC, it can be established that, despite the
international publications by the scientific community in the last twenty years, only a few
have considered the SOC to be worth examining and those were mostly members of Anto-
novsky’s own research groups.
Subject and Aims of the Studies Reviewed

None of the studies available to us aimed at testing Antonovsky’s salutogenic model of
health in its entirety (see Chapter 2). Such an attempt would have to fail because of the
complexity of the model. The studies are mainly cross-sectional and measure the relationship
between the SOC (rated according to the abbreviated and the complete versions of the 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. For
example, 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

Stress Perception and Coping:
– Stress perception
– Coping
Social Environment:
– Social support
– Social activities
– Family and marital satisfaction/communication
Health Behaviour:
3
– 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 personality
traits, suicidal ideation, learned helplessness, defence mechanisms, Type-A behaviour
pattern, physiological data, social desirability, intelligence, attitudes toward retirement,
health beliefs, risk perception.
SOC and Health
Antonovsky considered the strength of the SOC to be directly connected to health. 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, examining
hypotheses regarding a direct relationship between the central construct of the model –
the SOC – and health parameters conforms to the model.
Surprisingly, in Antonovsky’s model, health is reduced to a physical or seemingly 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 of
mental health, such as well-being and life satisfaction: “I would, of course, be flattered
should other investigators report data linking the SOC to other aspects of well-being,
but will not be too disappointed by limited results” (Antonovsky, 1987a, p. 182). The
results discussed below indicate that relationships between the SOC and various aspects
of mental health are closer than those between the SOC and physical health. In some cases,
no direct influence of the SOC on physical health could be found, contradicting the
hypotheses formulated in the examination.

SOC and Mental Health
The studies we examined showed correlations between the SOC and measurements of
mental health that were more or less high, yet nevertheless significant. Among other
aspects, the relationships were confirmed on representative population samples.
Thus, for a Swedish population sample (N=4390), Lundberg (1997) was able to establish
that the risk of psychological problems in persons with a high SOC was 3.5 times lower
than in persons with a low SOC. This relationship is independent of the variables of age
and gender.
Another representative study on a Swedish population sample with N=2003 subjects
yielded similar results. Larsson and Kallenberg (1996) found significant correlations
between the SOC and measurements of mental health, such as moodiness, restlessness,
fatigue, concentration problems and so forth (between r=.18 and r=.53).
The relationship between the SOC and psychological symptoms was confirmed in other
studies 3 . Significant correlations could be found between positive aspects of mental
health, such as well-being, life satisfaction, and the SOC (Anson et al., 1993a; 1993b;
Chamberlain et al., 1992; Larsson & Kallenberg, 1996).
The high correlations between the SOC and anxiety, as well as the SOC and depression, are
striking. Various studies 4 show correlation coefficients as high as r=-.85. This legitimately
raises the question as to whether the SOC can be characterised as a new dimension of
mental health, or whether the known constructs as well as tried and true instruments can
be maintained. However, this question cannot be answered completely on the basis of the
current state of research.
SOC and Physical Health

As mentioned above, in contradiction to Antonovsky’s assumption, the relationship
between the SOC and physical health is not very clear.
Hood, Beaudet and Catlin (1996) examined the influence of the SOC on three different
measures of health in a representative Canadian population sample (N=16291; adult men
and women). In addition to a subjective assessment of general health, they presented a
scale for the measurement of functional aspects of health, which not only questions
physical functions, such as hearing and eyesight, mobility, pain, ability to concentrate and
so on, but also emotional well-being. A third scale contains the number of chronic
physical illnesses, such as cancer, high blood pressure, migraines and so forth. Weak
correlations between the SOC and all three measures of health could be found (between
r=-.10 and r=.31). The coefficients are significant, which is to be expected in view of the
3 See Anson, Paran, Neumann & Chernichovsky, 1993a; 1993b; Callahan & Pincus, 1995; Chamberlain, Petrie & Azariah, 1992; Dangoor
& Florian, 1994; Gebert, Broda & Lauterbach, 1997; Korotkov, 1993; Sack, Künsebeck & Lamprecht, 1997; Sammallahti, Holi,
Komulainen & Aalberg, 1996.
4 See Bowman, 1996; 1997; Coe, Miller & Flaherty, 1992; Collins, Hanson, Mulhern & Padberg, 1992; Flannery, Perry, Penk & Flannery,
1994; Frenz et al., 1993; Kravetz, Drory & Florian, 1993; Langius, Björvell & Antonovsky, 1992; McSherry & Holm, 1994; Petrie & Brook,
1992; Rena, Moshe & Abraham, 1996; Sack et al., 1997; Schmidt-Rathjens, Benz, Van Damme, Feldt & Amelang, 1997.

size of the sample. The SOC can explain 10% of the variance of the functional state of
health, but only 4% of the subjective appraisal of one’s own state of health. Used as a
predictor of chronic illness, the SOC can only explain 1% of the variance and is thus
extremely low.
Bös and Woll (1994) found no relationship between the physician’s assessment of health
and the SOC in a study of N=500 men and women.
Dangoor and Florian (1994) also came to the conclusion that the medical diagnosis and
functional limitations do not contribute to the prediction of the SOC.
Langius and Björvell (1993) used the Sickness Impact Profile (SIP) to study a Swedish
random sample of N=145 men and women. They found a significant correlation with the
3
SOC of r=-.29. A more exact analysis, however, showed that this was only to be traced back
to the “psychosocial complaints” sub-scale and otherwise no statistically significant
relationship to physical complaints could be established.
Nor could any relationship be found between pain and the SOC in a sample of N=57
patients before surgery. A second study after the operation showed, however, that patients
with a higher SOC reported significantly less pain six weeks after the operation (Chamber-
lain et al., 1992).
Becker, Bös and Woll (1994) found statistically significant correlations between the SOC
and measures of physical health. However, in contradiction to Antonovsky’s hypotheses,
there was no direct relationship in a path-analytical model between the SOC and physi-
cal health.
This finding was also confirmed in another study with a path-analytical design by
Williams (1990). It is clear in this case that the inferential or predictive value of 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 of
whom were white and married. They found significant correlations between the SOC
(assessed using both the complete and the abbreviated form) and Activities of Daily Living
(ADL-scale), pain and general state of health. As in other studies, this finding is not es-
pecially meaningful, since the correlation coefficients between the SOC and measurements
of physical health are relatively low. They are between r=-.10 and r=-.37 (Anson et al.,
1993a; 1993b; Hood et al., 1996; Larsson & Kallenberg, 1996).
For two patient samples, scales were used to measure physical health that also inquire
about psychosomatic symptoms, such as loss of appetite, sleeping disorders, headaches,
etc. In this case, statistically significant correlations around r=-.50 were found (Gebert
et al., 1997; Rena et al., 1996).
In the study mentioned above, Lundberg (1997) came to the conclusion that the relation-
ship between the SOC and physical illness could be understood in terms of the complaints
made by the patient. People with low SOC values might tend to complain more than those
with higher SOC values.

SOC and Subjective Judgement of the General State of Health
In some studies, the subjective judgement of the general state of health was assessed and
related to the SOC. Exactly which subjective health definitions the subjects based their
judgement of their health on, and whether the results can be classified as a physical,
psychological or holistic conception of health, remains unclear. Because of the relatively
low correlation coefficients between r=.21 and r=.37, it can be assumed that the subjects
most likely rated their physical health rather than well-being or mental health. 5
Summary
In summary, the state of research to date shows that SOC and mental health are closely
related. The correlation between SOC and anxiety or depression is even so high that the
question is raised whether the SOC-scale measures something else or something more than
the germane instruments for assessing the above-mentioned dimensions of mental health
or illness. The relationship between the SOC and measures of physical health or the
subjective general state of health proved to be less clear. To be sure, further studies with a
suitable research design are necessary to clarify this question.
SOC, Stress Management and Coping
Some studies address the question whether the amount of SOC can influence the percep-
tion and evaluation of a stimulus as a stressor. In stress research, three types of stress
stimuli are distinguished: chronic stress, daily hassles and critical live events. Antonov-
sky considered chronic stressors which characterise the life situation of a person to be the
primary determinants of the SOC level. He assumes that they have a negative effect on the
SOC. In contrast to Lazarus and Folkman (1984), Antonovsky doubted whether daily
hassles can be considered to have a similar effect on the SOC (Antonovsky, 1987a). A
conclusive evaluation regarding the accuracy of these theoretical assumptions is not
possible based on the research findings currently available. On the one hand, correlation
studies do not permit testing of causal relationships and, on the other hand, relatively low
but nevertheless significant correlations between the SOC and daily hassles were found in
the studies by Bishop (1993), Flannery et al. (1994) and Korotkov (1993).
There is also evidence for a relationship between the amount of perceived stress and the
SOC. McSherry and Holm (1994) were able to demonstrate on the basis of a sample of
N=60 students that the subjects with high and medium SOC values felt significantly less
“stressed” than those with low SOC values. Interestingly, the results can even be confirmed
on a physiological level. High SOC values lower the physiological parameter towards the
end of the confrontation with the stress stimulus, that is, although all three groups react
to the stress stimulus, people with low SOC values begin and end the stress situation with
higher stress values. Further studies also confirm that the SOC and the appraisal of a
situation as stressful are related.
5 See Anson et al., 1993a, 1993b; Becker, Bös, Opper, Woll & Wustmann, 1996; Bös & Woll, 1994; Callahan & Pincus, 1995; Chamberlain
et al., 1992; Hood et al., 1996; Langius et al., 1992; Larsson & Kallenberg, 1996.

With regard to the relationship between the SOC and coping strategies, Antonovsky wrote:
“Knowing what the SOC level of a person is, we cannot predict whether, in a given
stressor situation, he or she will fight, freeze or flee, be quiet or speak up, seek to
dominate or melt into the shadows, or whatever other categories of overt behaviour
we may construct” (Antonovsky, 1987a, p. 187). However, he assumed that people with
a high SOC value, in contrast to those with low values, perceive problems as being more
comprehensible and manageable and more likely to be a challenge than to be a burden.
The results of the above-mentioned study by McSherry and Holm confirmed this last
assumption that persons with lower SOC values perceive themselves as having relatively
less coping resources and less social, material and psychological resources. They have less
3
confidence that they will be able to master situations than the students with a high SOC
in the study.
According to the studies to date, the SOC appears to facilitate adaptation to difficult life
situations, such as taking care of an ill relative (Dangoor & Florian, 1994; Rena et al.,
1996).
Baro, Haepers, Wagenfeld and Gallagher (1996) examined N=126 relatives, mostly wives,
who took care of demented and chronically physically ill people. A low SOC value was
found to be related to a perceived overload due to the care-taking tasks and to 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 allows
them to attribute meaningfulness to their task. Antonovsky believed that the search for a
“coping strategy that is universally effective in successful dealing with stressors” is
useless (Antonovsky, 1987a, p. 144.). However, he felt that people with a high SOC have
the required flexibility to select the appropriate coping strategy to meet situational
demands, which need not necessarily be active and solution-oriented. At the same time,
he mentioned that a person with a strong SOC is motivated to analyse a problem and to
activate the most suitable resource he or she has available. This statement was confirmed
by the studies we examined. Low SOC values correlated with depressive coping behaviour
(Becker et al., 1996), defence mechanisms (Sammallahti et al., 1996), helplessness
(Callahan & Pincus, 1995), and with palliative coping attempts and with resignation
(Rimann & Udris, 1998) and active coping strategies. In contrast, high SOC values show
a positive relation to situational control attempts (Rimann & Udris, 1998) and active
coping strategies (Gallagher, Wagenfeld, Baro & Haepers, 1994; Margalit, Raviv & 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 absence
of social support – do not have the same opportunity to develop their sense of coherence
as do people who grow up in a social environment which is supportive from a develop-

mental psychological point of view. Antonovsky, however, did not regard the importance
of social support as being very high. He considered it to be merely one of many general
resistance resources. A few of the studies we reviewed dealt with the relationship between
the SOC and different measures of social support. In their representative population
sample, Larsson and Kallenberg (1996) found a relationship between the SOC and the
number of friends – the higher a person’s SOC value, the more friends he or she had. In
a sample of N=80 paralysed patients and their spouses, Rena et al. (1996) found that the
SOC value corresponds to the amount of marital satisfaction. Becker et al. (1996) reported
a correlation coefficient of r=.46 between social support and the SOC for N=863 women
and men.
SOC and Health Behaviour
Antonovsky did not regard the influence of the SOC on health-related behaviour or the
avoidance of behaviour that is hazardous to health, such as cigarette smoking or poor
eating habits, as being central to the problem of salutogenesis:
“I make no claim that persons with a strong SOC are more likely to engage
in those behaviours that evidence indicates are good for the health – not
eating between meals, not smoking, regular physical activity, and so on.
These behaviours are far more determined by social-structural and cultural
factors than by the way one sees the world, and I do not wish to confuse the
two” (Antonovsky, 1987a, p. 152–153).
He qualified this statement, however, by stressing that people with a high SOC value have
a lesser tendency to turn to inappropriate coping strategies, such as addictive drugs or non-
compliance 6 , than people with low SOC values, since the former have diverse alternatives
and thus can select coping behaviour which is more appropriate for the problem. “From
this point of view, there is indeed a basis for anticipating a causal sequence between
the SOC, health behaviours, and health” (Antonovsky, 1987a, p. 153). At the same time,
he hypothesised that the strength of the SOC has direct physiological consequences and
affects health status through the central pathways of the neuroimmunological and
endocrine systems (Antonovsky, 1987a, p. 154).
The few studies which have addressed the relationship between the SOC and behaviour
relevant to health could not provide clear indications for such a relationship.
Bös and Woll (1994) examined, among other things, the amount of exercise done by
N=500 men and women. They found that older persons with a high SOC get more exercise
that those with low SOC values. This finding could not be established for younger persons.
6 “Non-compliance” refers to the disregarding of therapeutic measures and agreements.

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 normal
women are significantly higher than those who have drug problems. In contrast to their
hypothesis, Frenz et al. (1993) found no significant relationship between the SOC and
alcohol consumption.
Behaviour detrimental to health employed as a coping strategy in the face of a stressful
home situation was demonstrated in the study by Gallagher et al. (1994) mentioned above
in those caregivers that showed low SOC values.
In an elaborate study, Becker et al. (1996) investigated the influence of numerous vari-
ables, including SOC, healthy eating habits, intensive exercise and restful sleep, on the
3
habitual physical level of health of N=863 men and women. The SOC did not correlate
with intensive exercise. Significant, yet not very pronounced correlation coefficients of
r=.17, r=.13 and r=.23 were determined for the relationship between the SOC and
healthy eating habits and between the SOC and exercise in stressful situations as well as
restful sleep.
Seen as a whole, the research findings are contradictory. Up to this point, the SOC cannot
be considered to be a good predictor of health behaviour.
SOC and Personal Characteristics
Antonovsky assumes that the strength of the SOC is independent of sociocultural and
sociodemographic influences. However, he qualifies this statement by considering the
criterion of participation in decision-making processes to be decisive for the development
and maintenance of the SOC, while at the same time emphasising that the decision-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. At
this point, it is not yet possible to make a conclusive statement about the above-mentioned
remarks.
Cultural Group
The transcultural validity of the construct of the SOC has been the subject of several studies
in different countries, which do not indicate any major deviation from the SOC values
measured. Similar values have been obtained for populations of different ethnic groups.
Bowman (1996), for example, was able to demonstrate that the pronouncement of the SOC
in a group of Anglo-Americans was similar to that of a group of Native Americans, despite
great differences in the socio-economic conditions between the two groups.
Hood et. al (1996) also could not establish any differences between Canadians of Euro-
pean origin and immigrants from Asia.
Seen as a whole, the cultural differences between countries like Sweden, the USA and
Germany are not succinct enough to be able to speak of the transcultural validity of the
construct.

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

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

as Compared to Related Concepts
3
Parallel to Antonovsky’s SOC, influential psychological concepts have been developed in
the past few years which attempt to explain how individual characteristics affect the emer-
gence and the change of health and disease. These concepts are often subsumed under the
category “internal or personal protective factors”.
Internal protective factors are referred to as dispositional, though changeable personal

characteristics, as well as cognitive or behavioural styles that are situational. Because
specific health behaviours, such as taking advantage of the preventive checkups offered
by the health care system, have been assumed to help maintain health, they can also be
considered protective factors.
Commonly cited personal protective factors include the concepts of “health locus of
control” (Wallston & Wallston, 1978), “self-efficacy” (Bandura, 1977; 1982), “hardiness”
(Kobasa, 1979; Kobasa, Maddi & Kahn, 1982), “optimism” (Scheier & Carver, 1985; 1987),
“mental health as an attribute” (Becker, 1992) and perceived or expected “social support”
(Cohen & Syme, 1985; Schwarzer & Leppin, 1989).
The following constructs were examined regarding their correspondence to and divergence
from the SOC:
– Health locus of control,

– Self-efficacy,
– Hardiness,
– Optimism.
In Table 2 at the end of this section, the contextual components of the constructs men-
tioned are presented in an overview and the similarities and differences are illustrated once
again.

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

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 the
outcome 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 can
actually exercise a particular behaviour or successfully perform this behaviour is decisive.
Self-efficacy is built up through the experiences an individual makes in situations that
3
have been successfully mastered. This, in turn, leads to the establishment of suitable
coping strategies.
Self-efficacy appears to be fundamental to the motivation of behavioural change. (For an

overview of the relationship between self-efficacy and health-related behaviour, see
Schwarzer, 1992; Strecher, McEvos Develis, Becker & Rosenstock, 1986). Self-efficacy is a
component of the individual appraisal of one’s own coping possibilities and thus 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 to
implement situationally adequate coping strategies (Rippetoe & Rogers, 1987) indicates
that 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 stable

personality trait. His theory differs from Antonovsky’s approach in this point. More recent
ideas tend to consider self-efficacy both as a trait and as specific cognitions that are only
valid for clearly defined situations (Schwarzer, 1992; 1994).
Antonovsky did not distinguish between outcome and efficacy expectations. However, both
aspects are implicit in the component of manageability – the confidence that one has the
resources available that one needs to cope with events. When one compares the corre-
sponding questionnaires, the similarity in the composition of the component of
manageability and the construct of self-efficacy is obvious. For example, a question in the
SOC-scale asks: “Do you have the feeling that you are in an unfamiliar situation and
don’t know what to do?” In the scale for generalised self-efficacy, the question is: “In
unexpected situations, I always/never know how to act.”
Similar to the HLOC and the stress-coping theories, the self-efficacy theory is characterised
by strong action orientation. Subjective assessments influence health-related behaviours
and are thus buffers or mediators of health, or rather, of disease and risk factors.

Hardiness
Kobasa (1979; Kobasa, Maddi & Kahn, 1982) presented the construct of “hardiness” at the
same time as Antonovsky coined the term “sense of coherence”. It is important to point
out that Kobasa, too, was interested in the question of invulnerability and health resour-
ces, that is, she was a proponent of a salutogenic approach from the beginning, even
though she did not use this term. In her opinion, it is the personality trait of hardiness
which leads people to react differently to objectively identical stressors and stressful
situations. Hardiness refers to the fact that individuals are resistant to the negative effects
of stress and as a result do not develop any negative consequences. In contrast to Anto-
novsky, Kobasa does not view this trait as a static personal characteristic, whose
development is completed early and is virtually fixed by adulthood. In her opinion,
personality characteristics are personal styles that can develop dynamically as the indi-
vidual interacts with the environment. Her standpoint allows for change and is thus not
quite as pessimistic as that of Antonovsky.
Hardiness contains three components that not only overlap with each other, but also show
some very close parallels to the three components of the SOC: commitment, control and
challenge. People having pronounced hardiness are curious about and active in all areas
of their lives (commitment). On the one hand, this requires the individual to be convinced
of his or her own importance, actions and good judgement. On the other hand, this
characteristic also includes social action and engagement. Antonovsky felt that when
Kobasa uses the term “commitment”, she means “exactly the same thing” as his term
“meaningfulness” (Antonovsky, 1987a, p. 49).
”Control” is meant to be the opposite of “helplessness”. In other words, people with more
pronounced hardiness are convinced that they can control and have influence on their
surroundings. These persons emphasise the individual responsibility of their actions and
the possibility of reducing the negative effects of stressors through self-determined
activities. Kobasa distinguished between external control, where the source is outside the
self, and internal, self-determined control.
Internal control is meant to be synonymous with self-responsibility and active behaviour.

As Antonovsky wrote: “Kobasa’s use of Rotter’s Internal-External Locus of Control Scale
(...) is explicitly at variance with my approach. This culturally narrow scale posits
only two alternatives: either I control matters or someone or something ‘out there’
does. It posits a fundamental mistrust in power being in the hands of anyone else”
(Antonovsky, 1987a, p. 52).
Furthermore, persons with high hardiness feel challenged by changes in life. They expe-
rience changes as normal and exciting, and as an opportunity for inner growth rather
than as a threat. They actively seek new experiences and, in dealing with unexpected
situations, show openness and cognitive flexibility. The last component bears a basic dif-

ference to the SOC, since change rather than stability is considered to be the normative
lifestyle.
Kobasa names two different mechanisms of influence on health for the personality
variable of hardiness. First, hardiness can serve as a buffer, which makes people
experience stress differently and contributes to the fact that individuals employ
successful coping strategies to solve their problems. In this case, hardiness has an
indirect effect on health. It influences the perception and appraisal of a stressful event,
and leads to successful, active coping with situations characterised by aversive stimuli
(Ouellette-Kobasa & Puccetti, 1983). Second, like the SOC, hardiness is also thought to
3
directly reduce tension.
In the 1980’s, numerous studies investigated the relationship between hardiness and many
different kinds of health parameters, such as state of health or symptoms of disease, health
behaviour, coping with illness, social support, job satisfaction and personal well-being
(see Maddi, 1990, for an overview). The inconsistency in the results can certainly be 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 events
and are hopeful and confident about their outcome. The authors view this characteristic
as a generalised outcome expectancy which is not limited to a specific area of behaviour
or to certain situations. Their theory has a much simpler structure than that of 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 of
comprehensibility. However, Antonovsky did not claim that persons with a strong SOC
frequently expect positive outcomes.
The construct of “dispositional optimism” is based on a self-regulation model of be-

haviour (Scheier & Carver, 1990). This model proposes that, by means of self-attentive-
ness, discrepancies between momentary behaviour and behavioural goals will be perceived
and 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. The
outcome expectancy influences subsequent behaviour. In the case of negative outcome,
the behaviour will be discontinued or the amount of energy invested will be reduced. If a
favourable outcome is expected, the efforts undertaken to reach the goal will be intensi-
fied. In this model, confidence as a generalised outcome expectancy is the best predictor
of behaviour. Dispositional optimism is not considered to be a consequence of successful

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 much
more 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 is
assumed to be a buffer effect or an indirect effect of disposition on health by way of coping
mechanisms. Aversive events are assessed and perceived as being soluble, which leads to
an active approach to problems. Optimists tend to exhibit problem-related coping and an
active search for social support (Scheier, Weintraub & Carver, 1986).
Successfully coping with stress should have a direct effect on physical complaints. A
favourable outcome expectancy can lead to increased effort which, in the sense of a 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 problems
are not suppressed and thus do not reach the magnitude of those problems that are not
promptly confronted.
Several studies confirm the protective influence of dispositional optimism on physical

health, psychological well-being, life satisfaction, coping behaviour and preventive health
behaviour (Chamberlain et al., 1992; Scheier & Carver, 1987; Wieland-Eckelmann &
Carver, 1990).
The constructs discussed above are presented in the following table for comparison.

What Keeps People Healthy?
Sense of Coherence Loci of control (LOC) Self-efficacy Hardiness Dispositional

Optimism
Generalised Out- Conviction that things Generalised expec- The expectancy that Confidence,
come Expectancy: will turn out well tancy as to whether a specific behaviour optimism
Things will turn out events in an individ- will lead to a
positively ual’s realm of life can predictable result
be influenced or not
Generalised Self-ef- Confidence in one’s The expectancy that The ability to exercise
ficacy: The convic- ability to master life’s one will be able to control in one’s
tion of being able to tasks (manageability) perform the appro- surroundings
carry out an action priate behaviour in a
independently given situation
Internal Locus of Resources that one Especially internal Self-responsibility of ac-

Control: Conviction has under control LOC have a positive tion and the possibility of
of having an influ- (manageability) effect on health reducing the negative ef-
ence on events and parameters fects of stressors by self-
actions determined activities
External Locus of Resources that can External LOC usually

Control: Conviction be controlled by have a less positive
that others or a legitimate others effect on health
higher power will (manageability) parameters
take care of things
Dealing with Continuity, stability as Life changes as a

Change a central orientation; challenge;
the world is seen as normative lifestyle as an
ordered and predict- orientation towards
able (comprehensi- change and not towards
bility) stability
Meaningfulness Life is seen as being Curiosity in life, commit-

meaningful, problems ment in all areas of life
are worth investing
energy in (meaning-
fulness)
55
3
3.3. Stress and Resilience Research
How people deal with stress and stressful situations has long been a subject of interest in
the health sciences. As a result of the so-called “cognitive turn” within psychology, there
is general agreement today that subjective processes of appraisal are more significant than
objective factors (Beutel, 1989).
Transactional Model of Stress
Probably the most influential stress coping theory is the transactional model of stress
(Lazarus, 1966; 1981; Lazarus & Folkman, 1987). It permits a change in perspective from
the viewpoint of objective stress to the subjective coping process, that is, to those adjust-
ments necessary for the individual to cope with stress (Koch & Heim, 1988). Stress is thus
not a fixed dimension, but can be changed by the individual’s information processing
abilities and by situational variables (Lazarus & Folkman, 1987).
The transactional stress model distinguishes between two different appraisal processes.
“Primary appraisal” refers to the appraisal of characteristics of a situation. In other words,
stressful events can be judged as a threat, as a challenge or as irrelevant to one’s well-
being. “Secondary appraisal” refers to the evaluation of personal and social resources, that
is, of one’s own possibilities to cope with a stressful situation alone or with the support of
others. Lazarus and Folkman differentiate between five coping reactions that fulfil
problem-solving as well as emotion-regulating functions:
– The search for information serves as a basis to select coping reactions or for the
reappraisal of stressful situations.
– Direct action as a coping reaction encompasses all behaviours with which a person
attempts to gain control of stressful events.
– The omission of action can also serve as a coping strategy.
– Intrapsychic forms of coping include all cognitive processes that enable the
regulation of emotions, such as defence mechanisms, avoidance, self-deception, etc.
– The search for social support as a further coping behaviour refers to the active
search for and the utilisation of help from others.
Coping behaviour has also been categorised in other ways, for example, active-cognitions,
active-behaviour, or avoidance behaviour (Billings & Moos, 1981), person-related coping
(information search and avoidance, re-appraisal, reproaches towards self and others,
palliation) and environmentally-related coping (withdrawal, avoidance, waiting-and-see-
ing, resignation, utilisation of support, active influence) (Perrez, 1988).

Within the framework of stress and coping research, successful or appropriate coping
strategies are considered to be health resources, since they lead to improved adaptation to
life’s circumstances or demand a change away from aversive situations. According to
Cohen and Lazarus (1979), appropriate coping strategies enable the reduction of
destructive situational conditions, the maintenance of a positive self-image, the stability
of emotional balance, and the establishment of satisfactory relationships. In addition, they
influence well-being and the state of health (Lazarus, 1981).
Active, problem-solving-oriented coping strategies tend to be considered as appropriate

behaviour for managing stressful situations (Braukmann & Filipp, 1984; Heim, 1988).
3
Less healthy persons tend to resign in problem situations, can deal less well with stressors
that cannot be influenced and exhibit a higher tendency to take refuge in flight (Perrez,
1988). The most important requirement for effective coping, however, seems to be the
flexible implementation of different behaviour patterns (Lazarus & Folkman, 1987).
Stress Research and the Sense of Coherence
Stress research provided the framework within which Antonovsky developed his concept
of the SOC (see Chapter 1). It is not always easy to understand the similarities and dif-
ferences between the different approaches in stress research and the SOC. The most
important approaches are those from Selye and Cannon, Holmes and Rahe, and Lazarus.
Some of the fundamental theoretical ideas are very similar. Thus the concept of “primary
appraisal” in Lazarus’ model is comparable to the SOC component of “meaningfulness”,
whereas the concept of “secondary appraisal” has similarities with the component of
“manageability”. Divergences have emerged mainly because, according to Antonovsky, the
salutogenic perspective has been neglected in the traditional approaches of stress research:
– Research hypotheses are formulated pathogenically and thus guide the epistemology
and insight (e.g., depression as a predictor of cancer mortality. The probability that
depressed patients will die of cancer is twice as high as that of patients who are not
depressed. This statement ignores the fact that only very few of the depressed patients
actually ever die of cancer).
– Stressors are automatically defined as risk factors without further investigation of this
assumption. Antonovsky regarded stressors as an omnipresent component of life that
is detrimental to health only under certain circumstances.
– The dependent variables that are examined are almost exclusively measurements of
disease or risk factors, positive measures of health are not investigated.
– Coping strategies are considered to be buffers, as mediators between disease and health.
Factors that might directly contribute to health are not investigated.
– The focus is usually on specific behaviour that acts as coping strategies. The SOC, how-
ever, refers to the individual belief system about the nature of things and not to what
one does. The strength of the SOC does not permit the prediction of concrete behaviour.

– Judgements and expectations of a person are seen as situationally dependent. In con-
trast, Antonovsky sees them as a situationally-independent basic attitude (dispositional
orientation).
The interactional demands-resources model of health by Becker (1992) is another

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

and invulnerability originated in developmental psychology. They denote a stable and
healthy 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 that
represent an extremely elaborate form of psychological research (Köferl, 1988).
Characteristic of the research in this area is that it is often not based on an etiological
model of resilience, that it lacks a conceptual framework or a theory with an explicit claim
and, finally, that it examines more personal and less social risk factors. Moreover, Anto-
novsky’s criticism also applies to this area of research, i.e., that statements about the
3
invulnerability of specific persons or groups of persons are based predominantly on risk
studies that in turn stem from a deficit model of developmental processes.
The results of resilience research are usually presented in the form of a catalogue 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 confirmed
protective effects:
– Temperamental characteristics (e.g., a predominantly positive mood)

– Cognitive and social competence (e.g., effective problem-solving abilities)
– Self-reflective cognitions and emotions (e.g., positive self-esteem)
– An emotionally secure bond to one special other
– Characteristics of the child-raising environment (e.g., stimulating, emotionally
warm)
– Social support within and outside the family
– The experience of meaning and structure in life (e.g., ethical value system)
Within the framework of resilience or invulnerability research, the sense of coherence is

regarded as one of many potential resources of favourable developmental processes (see
Hurrelmann, 1988; Lösel & Bender, 1997; Köferl, 1988). Antonovsky himself never made
reference to the models and approaches of resilience or invulnerability research. This
research tradition was established at about the same time as the salutogenic model was
developed. Since it is rooted in another scientific discipline, one can assume that Anto-
novsky was not very familiar with it.
The significance of invulnerability research can be attributed mainly to its methodological

approach of retrospective and prospective longitudinal studies. In this respect, resilience
and invulnerability research, which tends to be methodology-oriented, can complement
the model of salutogenesis. Within Antonovsky’s salutogenic model, longitudinal studies
could contribute to the question as to which circumstances lead to the development of a
strong SOC. Essential for the significance of the SOC as a central protective factor would
be the proof that the different social and personal resources found in resilience research
are a prerequisite for the development of the SOC, but later no longer independent of the

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

4
of the Concept in Different
Areas of Application
4. of the Concept in Different Areas

of Application
This chapter of the expert report describes different areas of work and research in Germany
in which salutogenic principles have been introduced and have gained scientific as well
as practical importance. This report can only address published material or that other-
wise known to us. Thus, this description of the usage and the significance of salutogenic
principles in the areas selected must remain limited and refers only to the German public
health system.
Individual facilities devoted to prevention and health promotion, to rehabilitation and

psychosocial care, as well as out-patient and in-patient medical care, have supplemented
their concepts with salutogenic measures or retitled the names of their former services with
salutogenic terms. Many of these approaches taken by facilities and organisations –
especially in health promotion and rehabilitation – have not been documented or have
only been registered for internal use, or are only available in the form of project reports
that are difficult to acquire. The reports are not listed in the bibliographies of scientific
literature. Many of the facilities have neither the time, nor the capacity, nor the access to
the germane media and journals. Moreover, their work does not require documentation
or legitimation by scientific publications and papers. Independent of the fact that this
overview is incomplete, we assume that the treatment of salutogenic principles in health
care facilities and organisations takes place in one of the following four ways:
– There is no evidence of concern with the concept of salutogenesis (most frequent

case).
– The service is supplemented with salutogenically-oriented elements.
– The previous services are relabeled “salutogenic”.
– The philosophy and conception adhere to salutogenic principles.
In our opinion, the areas of “Health Promotion and Prevention” (Section 4.1.), “Psycho-
somatics and Psychotherapy” (Section 4.2.) as well as “Rehabilitation” (Section 4.3.) are
the only areas of application that merit thorough reviewing. In addition, ideas in a few
other fields are discussed, for example:
– Resource orientation in nursing (Artinian, 1991; 1997; Schachtner, 1996),

– Physicians’ attention to patients’ health resources (Hollnagel & Malterud, 1995; a
conference on the subject of “Salutogenesis in General Medicine” took place at the
Institute for General Health in Frankfurt in July 1998),
– Salutogenic factors in patients dependent on addictive substances (Fuchtmann,
1994).

From a scientific perspective, the field of industrial psychology should be mentioned: the
members of the working group headed by I. Udris (Switzerland) are proponents of a sa-
lutogenic approach in industrial psychological research (see, for example, Udris, Kraft &
Mussmann, 1991; Udris, Kraft, Muheim, Mussmann & Rimann, 1992). In the research
project “Personnel and Organisational Resources of Salutogenesis” (SALUTE), they ex-
amined the influence that personnel and organisational factors have on the maintenance
of health in the context of employment. Their research is based on system theory and ac-
tion theory models in which health or illness result from exchange and coping processes
between internal and external resources and demands, similar to those of Antonovsky and
Becker. Based on their research results, the working group formulated consequences for
the design of working structures and for industrial preventive measures. Industrial health
promotion should not only influence individual health behaviour, but also contain
thorough and holistic measures for the design of work and organisational structures
(Udris et al., 1992).
Concrete applications of the salutogenic approach in the form of specific health-promot-
4
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 he

formulated himself,
– Contributions that contain the fundamental elaborations on the necessity of the
integration of salutogenic approaches in prevention, as well as those that contain
the key word “salutogenesis“,
– Literature on health promotion as conceived by the WHO.
Antonovsky’s principal thesis is that a strong sense of coherence is the decisive factor for
successful coping with omnipresent stressors and thus for the maintenance of health
(Antonovsky, 1987a). He regarded the SOC as a stable characteristic which is not only
formed by individual factors, but also by historical, social and cultural conditions.
The development of the SOC is completed by adulthood and can only be slightly or 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 through
planned, 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 assist
people in critical life situations so that their SOC does not start to decline temporarily.
Antonovsky considered structural and social measures that enable the individual to in-
fluence and participate in socially recognised decision processes to be the most promising
way to positively influence the SOC. According to Antonovsky, it becomes more stable and
thus more difficult to change as one gets older. The conclusion to be drawn from this is
that it is important to create a world in which children and adolescents experience 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’s
theoretical elaborations on the practice of prevention tend to be rather sobering. Once
adulthood is reached, the SOC can be changed only slightly or temporarily. If at all,
changes can only be made by long-term assistance or intervention which results in “psycho-
therapying” preventive measures. Measures aimed at individuals can achieve only little
if the structural and societal conditions are unfavourable. Therefore, health promotion
and preventive measures must be geared to changing a broad spectrum of individual,
social and cultural factors.
Antonovsky himself stressed again and again that a strong SOC does not always result in
socially acceptable behaviour and can be developed in contexts that are destructive to our
Western democratic ideals: “I would like to say that the rigidity of an SOC that emerges
in such a context inevitably makes it fragile, inauthentic, and doomed to shattering.
But we must grant that the evidence is not at all clear” (Antonovsky, 1987a, p. 106).
Despite Antonovsky’s pessimistic elaborations, the salutogenesis model has become

important to the field of prevention. It serves as a meta-theory for the working field, as
legitimation for conceptual ideas and for the planning of concrete measures. It provides
a framework for preventive activities that often lack a clear theoretical foundation and are
undertaken in an activistic, uncoordinated manner. This theoretical framework supports
resource-oriented, competence-raising and non-specific preventive measures. The model
also supports a critical view of the previous preventive measures taken in health educa-
tion and confronts the risk factor model. In this context, the low success rate regarding
the change in risk factors should be mentioned. It is also important that the model parries
the puritanical aspects of “warnings”, “alarms” and “austerity” belonging to the risk
factor model with a positive concept. The shift in perspective from risk factors to preven-
tive factors is compatible with a modern concept of health which ranks the psychological
and social dimensions on the same level as the physical dimension.
The inception of the salutogenesis model occurred at about the same time as the 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 perspective
in prevention, which has had an impact on the Ottawa Charter of the WHO and the
approach of health promotion. Even though the terms “salutogenesis” or “SOC” are not
mentioned in the Ottawa Charter of the WHO of 1986, it subsequently placed the main

concern of health promotion on the strengthening of the SOC and Antonovsky’s positive
self-perception of action competence/self-efficacy as a major element of health (Kick-
busch, 1992).
Many authors seem to feel that putting the salutogenic model into practice in the field of
prevention is equal to implementing the WHO concept of health promotion. For example,
Freidl, Rásky and Noack (1995, p. 16) defined health promotion as “the initiation and
support of salutogenic processes in social systems and the assistance in establishing
the structures for them”. This equates health promotion with salutogenesis. According
to Noack (1996a; 1996b), salutogenic resources, that is, the social, living and working
environment, and individual characteristics, are areas of action for health-promoting
measures.
The meaning of the concept of health promotion and the related shift in perspective is also
underlined by Antonovsky’s ideas. However, this also means that the sparse literature avail-
4
able on aspects of the application of salutogenesis does not go much further beyond the
discussion on health promotion.
For example, Renner (1997) mentioned several projects by the Hessian Working Group for
Health Education, which were developed according to the WHO guidelines for health 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 classical
risk-factor-oriented measures of health education, these concepts foster the active
participation of non-professionals or the members of self-help groups and attempt to
strengthen their resources and competence, while conveying positive forms of 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 involve
the entire school and all its members in a continuous health-related developmental
process. The measures apply to very different areas and include social, ecological and
communal aspects of school activities (Paulus, 1995). Other authors agree that the latter
is essential in putting the WHO guidelines into practice adequately.
Not everything we found that bore the name “salutogenesis” and “health promotion”
actually put these concepts into use. For example, classical programmes on the avoidance
of health risk factors are claimed to be based on the salutogenesis model, or a single event
with the theme of social support or enjoyment training is considered, as far as the initiator
is concerned, to suffice as having put Antonovsky’s model into practice.
The current situation in health promotion is characterised by the fact that the 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. In
other cases, previously introduced measures are continued but relabeled as “salutogenic”.
All measures on the critical discussion and reception of the model should be encouraged
and supported. The scientific and health-political benefits, as well as the gain in the fields
of health promotion and prevention, are far from being conclusively determined.
4.2. Psychosomatics and Psychotherapy
In addition to health promotion and prevention, psychosomatics and psychotherapy are

further fields of application for the concept of salutogenesis. In the following, both areas
will be discussed together since psychotherapy is a central method in psychosomatics.
Psychosomatic medicine or psychosomatics is a specialised discipline in the canon of sub-

jects in medicine. Psychosomatics is concerned with illnesses whose emergence and pro-
gression are significantly affected by the psychological processes and the psychosocial
situation of the patient. However, it also encompasses physical symptoms without an
organic substrate, frequently referred to as somatisation, vegetative or functional dis-
orders. Psychosomatic medicine is also very important for primary physical illnesses. In
this case, psychological processes influence the way the patient copes with the illness, as
well as the course of the illness.
The borders between psychosomatics and clinical psychology, psychiatry, medical

psychology, and behavioural medicine are not clear-cut. Dialogue, psychotherapeutic
individual and group treatment, and various exercises are methods used in psycho-
somatics.
“Psychotherapy” is the generic term for a collection of different methods which aim to
influence or improve behavioural or psychological disorders and other troubling con-
ditions by communicative means, generally verbal. In general, the aim is to reduce the
symptoms which disturb and restrict the patient, as well as to change his or her personal-
ity structure. Thus, the therapist and the patient must succeed in creating a supportive
rapport, the therapist-patient relationship. Psychotherapy is predominantly conducted on
an out-patient basis in private practices of psychotherapists, usually clinical psychologists
or physicians, but also on an in-patient basis in psychiatric and psychosomatic clinics.
There is some overlapping with the field of rehabilitation (Section 4.3), since a large
portion of the in-patient treatment for psychosomatic illnesses takes place in medical
rehabilitation centres.

There are a number of psychotherapeutic schools. Most often, psychotherapy is performed
on 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 is
based on a theory of mental disorders and a theory of therapeutic change.
The concept of salutogenesis rarely appears in the psychosomatic and psychotherapeutic

literature. In psychosomatic and psychotherapeutic textbooks, the terms “salutogenesis”
and “sense of coherence” are seldom mentioned. To give a few examples, one textbook
from each of the fields of psychosomatics (Ahrens, 1997), psychoanalysis (Thomä &
Kächele, 1996; 1997) and behavioural therapy (Margraf, 1997) will be discussed together
with a so-called integrative textbook of psychotherapy (Senf & Broda, 1996).
In the “Lehrbuch der psychotherapeutischen Medizin” (Textbook of Psychotherapeutic

Medicine) by Ahrens (1997), salutogenesis is merely presented as an orientation in which
4
the research for health protective factors has the same rank as pathogenically-oriented
research. In the “Lehrbuch der Verhaltenstherapie” (Textbook of Behavioural Therapy)
by Margraf (1997), salutogenesis is addressed in conjunction with the euthymic basis of
behavioural therapy (Lutz, 1997). Euthymic experience and action encompasses anything
that does the psyche good. For this reason, psychotherapy should also concentrate on
positive feelings like fun, joy, relaxation, equilibrium and well-being – that is, they also
take positive aspects of experience in psychotherapy into account.
Neither in the “Lehrbuch der psychoanalytischen Therapie” (Textbook of Psychoanalytic

Therapy) by Thomä and Kächele (1996; 1997), nor in the textbook “Praxis der 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-speaking
authors best acquainted with Antonovsky (see Section 4.3), did not integrate the concept
of salutogenesis in his textbook. Most of the other textbooks on psychosomatics, medical
psychology and clinical psychology do not address the subject of salutogenesis. If they do
mention it, they only devote a few sentences or pages to it. (See, for example, Ahrens, 1997;
Gerber, Basler & Tewes, 1994; Rösler, Szewczyk & Wildgrube, 1996; Siegrist, 1995; Tress,
1997; Wirsching, 1996.)
In German-speaking countries, three conference proceedings have focused on the 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 to
Depart from the Concept of Pathogenesis). Their main thesis is “that pathology-oriented
thinking and action in psychosomatics cannot contribute to a reduction in the 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 of
the risk factor model (Reye), public health care and the political and economic effects of
the concept of pathogenesis (Franke, Huber, Glaeske, Reiners), and the scientific 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 provide
a valuable framework for the discussion.
In 1994, the “Deutsches Kollegium für Psychosomatische Medizin” (German College of

Psychosomatic Medicine) held its 40th conference with the theme “Salutogenesis – a new
concept in psychosomatics?” The conference proceedings, edited by Lamprecht and Johnen
(1994; 3rd revised edition 1997), encompassed 32 contributions on the subject. Diverse
areas of work and therapeutic strategies were presented. The contributions concentrated
on the following questions:
– How can salutogenic principles be integrated in psychosomatic-psychotherapeutic work?

– Where are salutogenic principles already being implemented?
– Is the sense of coherence suitable as a criterion for therapeutic success or should the
sense of coherence be a psychotherapeutic goal?
In this volume, Hellhammer and Buske-Kirschbaum made a fundamental contribution

to “psychobiological aspects of protection and repair mechanisms”, addressing the
question as to how the organism can mobilise additional strength when under stress.
The book by Lutz and Mark (1995) entitled “Wie gesund sind Kranke?” (“How healthy are
sick people?”) contains 24 contributions. It focuses on the debate regarding the defini-
tions of health and illness. This is followed by studies and overviews or reports on different
working areas and therapeutic approaches.
Aside from the volumes and contributions, few studies on salutogenesis and psychotherapy
can be found:
– Broda et al. (1995): Therapieerfolg und Kohärenzgefühl (Therapeutic Success and

the Sense of Coherence).
– Broda et al. (1996): Selbstmanagement – Therapie und Gesundheitsressourcen
(Self-management – Therapy and Health Resources).
– Haltenhofer & Vossler (1997): Coping der Depression (Coping with Depression).
– Plassmann & Färber (1997): Salutogenetische Therapieorganisation in der
Psychosomatischen Klinik (Salutogenic Therapy Organisation in the
Psychosomatic Clinic).

– Sack et al. (1997): Kohärenzgefühl und psychosomatischer Behandlungserfolg
(The Sense of Coherence and the Outcome of Psychosomatic Treatment).
– Schulte-Cloos & Baisch (1996): Lebenskraft – Ressourcen im Umgang mit
Belastungen (Life Strength – Resources in Coping with Stress).
The concept of salutogenesis has had little impact on psychosomatics and psychotherapy.
On the one hand, this is because the aspects of resource activation had already been 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 and
difficult to change. Thus, it is not well-suited as a criterion for denoting the success of
psychotherapeutic treatment. In addition, it is in competition with numerous other em-
pirically well-studied dimensions, such as neuroticism and depression.
Even though, as a whole, psychotherapeutic and psychosomatic research has little

honoured and integrated the concept of salutogenesis, we feel that the following aspects
4
are relevant to the discourse:
– The concept of health and illness,

– The goals of psychotherapy and treatment strategies,
– Preventive orientation and resource activation,
– Life situation and social environment.
The concept of health and disease is especially problematic in psychotherapy and

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

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 is

continued 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 (Health
or Illness Theory?).
4.3. Rehabilitation
The illnesses most frequently diagnosed for rehabilitation are chronic physical illnesses,
physical and sensory organ handicaps, mental disorders and mental retardation, as well
as drug and alcohol dependence (Bundesarbeitsgemeinschaft für Rehabilitation, 1994).
“Chronic illness” is a generic term for a number of very different illnesses of varying
aetiology, pathogenesis, symptoms and prognosis. Common to all these syndromes is that
they worsen continuously or in phases which can occur without warning. Frequently,
causal therapy is not possible. The patients are dependent on the health care system and
its specialists for long periods of time. The aetiology is generally assumed to be multifac-
torial, in which a particular disposition as well as habits or lifestyle play a role. Examples
of chronic physical illnesses are: cardiovascular disease, cancer, chronic kidney disease,
orthopaedic illnesses, illnesses of the digestive system or metabolism, HIV infection/AIDS,
illnesses of the nervous system and of the skin.
Coping with illness and the rehabilitation process are influenced by a number of factors:
1. Characteristics of the persons affected (e.g., sociodemographic characteristics, 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 on
the ward, self-help).

The strength of the German rehabilitation system lies in the coordination of somatic,
functional, professional and psychosocial measures.
On the basis of the characteristics of chronic illnesses, the aims of rehabilitation and the
therapeutic circumstances seem to provide favourable conditions for the integration of
salutogenic principles. Nevertheless, salutogenic principles and the strategies derived from
them have little impact on medical rehabilitation and the treatment of chronic illnesses.
Exceptions are:
– Psychosomatic rehabilitation,
– Health education and health promotion in rehabilitation,
– The rehabilitation of cancer patients.
Psychosomatic care in Germany takes place to a great extent in rehabilitation facilities.
4
Since, in this case, the focus is on psychotherapeutic measures, this aspect was discussed
in Section 4.2., “Psychosomatics and Psychotherapy”.
Although the topic of health promotion and prevention was treated in Section 4.1., the
aspects specific to rehabilitation will also be discussed here. Measures taken concerning
health promotion, health training and health education play an exceptional role in
medical rehabilitation. Preventive measures are recognised as an overall equivalent
dimension of treatment.
Most programmes and measures aim at reducing health risk factors and behaviours and
motivating the patient to take responsibility for his or her health. The conception and
structure are mainly oriented on a medical concept of disease and rehabilitation, in which
the reduction of risk factors is the principal goal of prevention. However, resource-oriented
concepts, the consideration of protective factors and the emphasis of social resources have
been receiving more and more attention (Liebing & Vogel, 1995; Broda & Dusi, 1996;
Doubrawa, 1995).
The review by Liebing and Vogel (1995) is based on a positive concept of health and does
not only discuss physical skills, but also emphasises social and individual resources. The
authors assert that in the future more attention should be paid to the question of 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 efforts
of rehabilitation are based on a holistic and positive health concept which encompasses
both physical as well as psychological well-being. Health is seen as a life-long process
which is influenced by the individual’s biography and his or her social and ecological
situation. Health promotion should not only aim at the individual behaviour of the
patient, but also encourage him or her to make his or her life and environmental con-
ditions healthy (see Section 4.1.).

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)
Table 3
In health promotion, the patient is seen as a responsible partner, who is offered knowledge
on health and change, but who is left with the decision whether to put this knowledge into
practice. Doubrawa compared this concept to health education that is influenced by the
risk factor model. He points out the limitations of this approach in remarking that the
principles of health promotion in rehabilitation must have limited effects when one
considers the fact that a clinic stay of a few weeks is outweighed by very stable and 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 health
education. 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 only
contains nutrition, exercise and physical training, exercises on the use of addictive
substances, stress and coping, but also modules pertaining to protective factors and social
support (Buschmann-Steinhage & Liebing, 1996).

Doubrawa (1995) described approaches to health promotion which are exemplary for in-
patient rehabilitation (see Table 3). Many of the approaches mentioned here are aimed
at protective factors and the improvement of skills. They intend to improve well-being,
problem-solving skills, the sense of enjoyment and the expression of emotions. However,
the ideas and principles mentioned here have only just begun to be introduced in many
rehabilitation clinics.
The significance of salutogenesis for rehabilitation has been discussed most intensively
in connection with oncological rehabilitation.
The only review of the applications of salutogenic principles in oncological rehabilitation
known to the authors is that in the anthology by Bartsch and Bengel (1997). Of 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-oncology
4
examines the psychosocial stressors caused by cancer and its effects on the quality of life
and family relationships, for example, the possibility of psychological-psychotherapeutic
treatment of the patient and its effects on the quality of life, employment and on the
characteristics of the illness, such as relapses, metastases and life expectancy. The question
as to whether the emergence and development of a tumour is influenced by psychological
factors is one of the issues concerning psycho-oncology.
Diverse psychosocial stressors are connected with falling ill with cancer: emotional
problems, such as anxiety, depression, suicidal tendencies, hopelessness, pessimism and
loss of meaningfulness, as well as ego and identity problems, partnership and family
problems, for example, communication and relationship problems, changes in roles,
sexual problems and employment problems (Weis, 1997).
Weis contends that the goal of psychosocial rehabilitation in oncology is to convey
methods of self-control to the patient, to strengthen and promote resources and to cope
with the illness. Weis cites the following treatment goals: “strengthening the self-help
potential, encouragement to openly express feelings, the reduction of anxiety, anger
and other feelings, the improvement of self-esteem and the mental attitude towards
the cancer illness, the promotion of the remaining health and personal resources, the
improvement of communication between the patient, the partner and other relatives”.
These goals parallel in part aspects of salutogenesis or the corresponding goals put forth
by Antonovsky. Weis regards cognitive restructuring and reappraisal (patients change their
assumptions about themselves, their environment and their illness) as the central issues
common to both concepts. The types of treatment he recommends are behavioural therapy,
art therapy, group therapy and imaginative exercises (procedures which work with the
images and ideas of the patient). The significance of these kinds of treatment is reinforced
by the concept of salutogenesis, yet aside from that they are relevant strategies in psycho-
oncology.

Justifiably, Weis remarks that Antonovsky’s central issue revolves around preventing and
maintaining health, whereas psycho-oncology mainly deals with patients who are severely
or incurably ill. However, palliative treatment also has a use for salutogenic procedures.
Palliative treatment is not designed to put an end to an illness, but rather to make living
with it easier by reducing pain and maintaining the best possible quality of life. Its key
component is the concept of a search for meaning that is based on inner psychological
growth. Weis cites a major danger that can arise when the concept is implemented in an
unreflected manner. The therapist, who is confronted with his or her own helplessness and
impotence, points out positive aspects of the situation, resources and powers of self-
healing to the patient. This may be of help foremost to the therapist in repressing his or
her helplessness.
To date, there have been few studies or more theoretical papers on rehabilitative patient
groups not belonging to oncological and psychosomatic rehabilitation. In most cases,
previous rehabilitation concepts are revised “salutogenically”, that is, supplemented with
lifestyle or resource-oriented services. As a result, behavioural medicine and 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 this
report. It can be presumed, however, that in the field of health promotion in rehabilita-
tion, and especially in the field of oncological rehabilitation, salutogenically-oriented
measures are being increasingly developed and introduced and traditional strategies are
being supplemented with salutogenic ones. The only advanced ideas to date which attempt
to combine the concept of salutogenesis with a general theory of coping with illness are
those formulated by Broda (1995). He calls for the development of competence-oriented
rehabilitation that contrasts with the now dominant deficit-oriented rehabilitation. 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’s
resources.
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 and

a theory of consequences of illness,
2. Analysis of the meaning of the sense of coherence in the course of the illness and its
rehabilitation (see, for example, Collins, Hanson, Mulhern & Padberg, 1992), among
other things, as a success criterion and a dimension to be influenced,
3. Development of salutogenic therapy principles for the promotion of health and coping
with illness.

Summary 5
5.1. Summary and Evaluation
of the Scientific Discussion
This final chapter presents the central assumptions of the previous three chapters on the
context, the theory formation and the current state of research of the salutogenic approach
in distilled form. The concept will be evaluated from the perspective of health science
below.
Historical Background
The societal and scientific background on which Aaron Antonovsky developed his theory
was influenced by growing concern about public health care and health and disease
research.
As early as the 1970’s, the traditional system of public health care was criticised for being
based on a mechanistic view of disease and overemphasising organs and symptoms. The
scientific discourse on the concepts of health and disease that followed illustrate that both
are very complex phenomena that are difficult to define. Nevertheless, definitions are im-
portant, since they determine the conclusions that are drawn for the treatment of health
and disease.
A consequence of the criticism of the mechanistic view of disease was the development of
a biopsychosocial model of disease. In this model, the explanation and treatment of 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 to
prevent 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 and
differentiation of the scientific subjects that dealt with the topic of health, such as social
medicine, environmental medicine, medical psychology, psychosomatic medicine,
psychoneuroimmunology, health psychology, behavioural medicine or public health.
The Concept of Salutogenesis
Using the model of salutogenesis, Antonovsky intended to find an answer to his central
thesis question: what keeps people healthy – despite the many potential noxious 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

homeostasis, but when confronted with detrimental influences must continuously be re-
established. Health and disease are not mutually exclusive states, but extreme poles on a
continuum (the health ease/dis-ease continuum). In between are states of relative health
and relative disease.
The search for specific causes of disease, also referred to as the pathogenic approach, must
be supplemented by the search for health-promoting or health-maintaining factors,
known as the salutogenic approach. Antonovsky termed these factors “generalised re-
sistance resources”. There are individual resistance resources, for example, physical fac-
tors, intelligence or coping strategies, as well as social and cultural resistance resources
like social support, financial power or cultural stability. Asking about resistance resources
places the focus on the whole person and his or her biography and not on his or her ill-
ness or symptoms only.
Antonovsky’s model proceeds in the tradition of stress and coping research. According to
this approach, health is endangered by the detrimental influence of different kinds of
stressors. In contrast to other stress researchers, Antonovsky contends that stressors are
omnipresent and that their effects are not necessarily hazardous to health. Antonovsky
proposes a distinction between tension and stress. In his opinion, the first reaction to stress
is physiological tension. Whether or not this results in stress and is followed by processes
5
detrimental to health depends on the appraisal and the coping reactions of the individual.
The most important dimension that determines the outcome of these appraisal and coping
reactions, as Antonovsky sees it, is the sense of coherence.
“The sense of coherence is a global orientation that expresses the extent to

which one has a pervasive, enduring though dynamic feeling of confidence
that (1) the stimuli deriving from one’s internal and external environments
in the course of living are structured, predictable, and explicable; (2) the
resources are available to one to meet the demands posed by these stimuli;
and (3) these demands are challenges, worthy of investment and engage-
ment” (Antonovsky, 1987a, p. 19).
The stronger one’s sense of coherence, the more success one will have staying healthy. The
SOC is made up of three components:
– The feeling of comprehensibility,

– The feeling of manageability, and
– The feeling of meaningfulness.
The feeling of comprehensibility refers to the ability to perceive the world as being ordered
and structured and not as chaotic, arbitrary, random or inexplicable. The feeling of
manageability concerns the conviction that problems have solutions and that one has

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 meaningful
and that problems and challenges are worth investing energy in.
The special thing about the SOC is its orchestrating function. According to Antonovsky,
the strength of the SOC determines the flexible and appropriate implementation of 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 thus
describes the SOC as a dispositional orientation. However, it is not comparable to a
personality trait. In Antonovsky’s opinion, whether a weak or a strong SOC develops
depends on the social circumstances and the socialisation in the family. He feels that a
fundamental change in adulthood is only possible to a limited extent. Altering the SOC
by means of psychotherapy can only be accomplished by long, hard work.
In order to measure the SOC, Antonovsky developed a questionnaire, the “Orientation to
Life Questionnaire”, also called the SOC-scale, which is available in an abbreviated and
in an extensive form. The empirical evidence from the examination of the questionnaire
to date shows that the three dimensions of the SOC (comprehensibility, manageability,
meaningfulness) cannot be observed individually, i.e., the scale measures only the total
strength of the SOC. The instrument proves to have high reliability; in other words, it is
an accurate measure.
Current State of Research
Despite the popularity of the concept of salutogenesis, our research revealed that, in the
twenty years since Antonovsky introduced his model, no more than 200 studies have been
published which examine the empirical foundation of the model. This shows that the
model has attracted little attention in the scientific community. Even in the USA, which
leads research in the health sciences, only few studies have been conducted.
The empirical foundation of the salutogenic model is limited to cross-sectional studies,

which measure the relation between the SOC and diverse parameters of psychological and
physical health and personality traits (e.g., physical complaints, anxiety, life satisfaction,
stress perception, social support and health-related behaviour). These correlations do not
allow conclusions to be drawn about causal relationships. If significant relationships
between a high SOC and a health variable are established, it cannot be regarded as proof
that the SOC is a causal factor (that is, a prerequisite or a cause) for health and health
maintenance.
The SOC shows a high negative correlation with measures of mental health, like anxiety
and depression; e.g., people that have a high SOC value are less anxious and depressed
than those with a lower SOC value.

The relationship between the SOC and measures of physical health is less clear. This
finding contradicts Antonovsky’s assumption that the SOC has a direct influence on
physical health.
The SOC seems to have an influence on the perception of stress and coping styles and can
facilitate adaptation to difficult life situations. People with a high SOC tend to perceive
events or demands as more of a challenge and less of a strain. When they do experience
stress, they can recover from it more quickly. These premises made by Antonovsky have
been confirmed by many empirical findings.
Few studies focus on the relationship between the SOC and the different measures of social
support. Individual results show a positive relationship between the SOC and the number
of friends, marital satisfaction and social support.
For the field of prevention, it is of importance whether the SOC has an effect on concrete
health behaviour, such as getting regular exercise, or risk behaviour, like smoking.
Because the few studies on this subject came to contradictory results, no clear conclusions
can be drawn.
As far as gender is concerned, women appear to have lower SOC scores on average than
5
men. Female socialisation might be a barrier for the development of a strong SOC.
In contrast to Antonovsky’s assumption that the SOC remains stable throughout 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 the
alterability 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 cognitive
styles influence the emergence and change of health and disease, as well as coping with
disease and health behaviour. Among the most well-known personal or internal protec-
tive factors are health locus of control, self-efficacy, optimism, hardiness and mental
health, but also depression and anxiety. The current state of research varies greatly for the
different constructs, that is, they differ as to the number of studies and the empirical
evidence regarding the validity of the model. There are similarities between the SOC and
optimism as well as between the SOC and hardiness. The relationship between the SOC and
self-efficacy is less clear.

The constructs mentioned above and the salutogenesis model were developed within the
context of stress research. For this reason, the fundamental theoretical ideas of more
recent approaches in stress research often show close similarities to Antonovsky’s model.
Cognitive appraisal processes are essential in evaluating and coping with stressors. One
of the most well-known stress theories is Lazarus’ transactional stress model. He distin-
guished between two appraisal processes. First, events can be judged as being a threat, a
challenge or as irrelevant for one’s own well-being. Second, the resources are appraised
that one can employ or cannot employ to cope with the stressor.
There are different coping strategies which are more or less appropriate to the adaptation
to a changing life situation. Coping with stress seems to be most effective when different
coping strategies are used flexibly. Antonovsky considers the fact that the salutogenic
perspective was neglected in traditional approaches in stress research to differentiate it
fundamentally.
Like stress research, resilience or invulnerability research is merely the backdrop for
diverse research directions. The concepts of “resilience” and “invulnerability” refer to
stable and healthy personality and behavioural developments that have occurred despite
unfavourable experiences and stress in early childhood. The research in this field often
lacks a fundamental theory. As a result, potentially protective factors are often presented
in the form of a catalogue of variables. In this context, the SOC is sometimes mentioned
as one of the many factors, neglecting its assumed orchestrating function in the 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 establishing
a causal relationship between health and protective factors.
Evaluation
Antonovsky formulated his salutogenic model at a time when the medical care system was
being criticised, the research on disease and its causes was being broadened to include the
psychosocial dimension, and the significance of environmental factors was being
recognised. At the same time, preventive efforts were being strengthened and a holistic,
not exclusively symptom-oriented procedure was in demand. The basic idea of the
salutogenic approach is similar to the concept of lifestyles of the World Health Organization
and the concept of health promotion as it was laid down in the 1986 Ottawa Charter.
The basic ideas of the salutogenic approach are not new. Salutogenic recommendations
and concepts can be traced back to medicine in ancient times. Since then, predecessors
and related concepts have been developed. However, Antonovsky is the first that not only
criticised the pathogenic model but also parried it with a salutogenic theory that he
thoroughly described and tried to confirm with empirical evidence.

The salutogenic model can be considered the first and the most advanced model on the
explanation of health (Dlugosch, 1994; Faltermeier, 1994). It takes into account
dimensions on a social, physiological, biochemical and cognitive level. Because it 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 can
organise and illustrate complex relationships. Many of the assumptions that the model of
salutogenesis makes are too complex to be easily empirically examined.
As a model of processing, it unites several time dimensions that require different 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. These
are short or medium-term processes. The GRRs that go into effect are not identical to
those that contributed to the emergence of the SOC.
The different levels of the model illustrate that only a partial aspect of it can be exam-
ined. For many of the assumptions, problems regarding their operationalisation have not
been satisfactorily solved.
The salutogenic model assumes an information transfer between the participating levels
5
and subsystems. However, there is no means of explaining how this transfer takes place
(Noack, 1997). Thus, Antonovsky repeatedly stresses the sociological character of his
model, which can mainly be seen in the fact that the SOC is influenced by structural
characteristics. However, the theory does not offer a sufficient explanation as to how
sociostructural factors influence the strength of the SOC (Siegrist, 1993). In the same vein,
genetic factors, among others, are not included.
The idea that health and disease are to be conceived as two poles on a continuum enables
a more differentiated evaluation of an individual’s state of health than would be the case
with categorisation as either healthy or ill. A disadvantage of the one-dimensional view
is that it assumes a linear relationship between the decrease in healthy and the increase
in ill components. The less healthy components a person has, the more ill components he
or she must have. It appears better to conceive of health and disease as two independent
factors (see Lutz & Mark, 1995).
Surprisingly, Antonovsky does not presume that there is a direct connection between the
central variable, SOC, and the position on the health ease/dis-ease continuum.

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

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 measures
of mental health, which Antonovsky did not take into consideration or expect. Here,
especially high correlations between the SOC, anxiety and depression were found. Thus,
the question is still open as to whether the measurement of the SOC, as opposed to
constructs with a longer and more intensive research tradition, provides an additional in-
formation. The direct influence of the SOC on physical health as postulated by Antonovsky
cannot be supported to the extent expected.
Judging by the current state of research, the SOC-scale developed by Antonovsky produces
only a total value of the SOC. The values of the three dimensions “comprehensibility”,
“manageability” and “meaningfulness” cannot be individually measured by the SOC-
scale. Even though Antonovsky himself was not very surprised about this, it contradicts
the theoretical assumptions and the corresponding empirical results.
Antonovsky criticises the fact that the salutogenic perspective has gained little or no foot-
hold in health science research. In his opinion, the research hypotheses are formulated
pathogenically from the start, resulting in a search for the causes of disease, yet without
5
explaining why people remain healthy in the face of critical life events or continuous
stress. The dependent variables examined are almost exclusively parameters of disease.
Positive measures of health are disregarded. In addition, without any further examina-
tion, stressors are simply presumed to be detrimental to health.
The studies we surveyed are salutogenically oriented in the sense that they examine the
SOC. However, few fundamental differences from previous theories and research could be
determined, since they continue to focus on the relationships between the SOC and nega-
tive measures of health such as complaints, symptoms and illnesses. The assumption
regarding the stability of the SOC has not been sufficiently confirmed, and the presumed
intercultural or transcultural validity has not been tested. Researching health-protective
factors is, of course, more difficult than researching risk factors.
In summary, the SOC is one of many concepts that have been proposed and examined. In
particular, its overlapping with other constructs and the difficulty in keeping its three
components separate, a problem of construct validity and dimensionality, will hinder the
further development of its empirical foundation.
Aside from the integrative power of the salutogenic model, the main issues of criticism are:
– The focus on cognitive and subjective dimensions (SOC) as decisive,

– The low status of mental health,
– The limited analysis of the interaction between physical and mental health,
– The unexplained interaction between the SOC and health or disease, that is, the con-

tradiction between the model and empirical findings regarding the SOC and mental
health,
– The methodological problems posed by empirical testing of the model.
We consider the significance of the concept for the health sciences to be twofold. First, it
stimulates research in the health sciences on protective factors and resources, and second,
it broadens the view to include relationships and interactions between health risks and
protective health factors or protective health conditions. It confirms the importance of a
framework theory of health or health maintenance, even though it cannot be empirically
tested by today’s methods.
Summary and Evaluation
5.2. 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 a
theoretical framework for preventive activities in these fields that often lack a theoretical
foundation and are merely one of an eclectic many. The salutogenic model serves as a
meta-theory which legitimates conceptual ideas and measures to be taken. It supports a
critical view of health education and preventive efforts to date, challenges the risk factor
model, and stands for resource-oriented, competence-raising and unspecific preventive
measures. It is also important that the model parries the puritanical aspects of “warn-
ings”, “alarms” and “austerity” with a positive concept. The shift in perspective from risk
factors to preventive factors is compatible with a modern, interactive concept of health,
which ranks the psychological and social dimensions on the same level as the physical
dimension.
The inception of the salutogenesis model occurred about the same time as the 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 perspective
in prevention, which has had an impact on the Ottawa Charter of the WHO and the
approach of health promotion. Even though the terms “salutogenesis” or “SOC” are not

mentioned in the Ottawa Charter of the WHO of 1986, it subsequently placed the main
concern of health promotion on the strengthening of the SOC and Antonovsky’s positive
self-perception of self-efficacy as a major element of health.
Many authors seem to feel that putting the salutogenic model into practice in the field of
prevention is equal to implementing the WHO concept of health promotion. However, this
also implies that the sparse literature available on the possible applications of 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 and
Sexuality”, and so on, foster the active participation of non-professionals or the members
of self-help groups and attempt to strengthen their resources and competence, while
conveying positive forms of communication and interaction independent of their risk
behaviour. These measures cover very different areas and include social, ecological and
communal aspects in the activities.
The basic premises of Antonovsky’s model for health promotion and prevention imply the
need to create an environment which offers children and adolescents enough resources to
build a strong sense of coherence. The SOC does dominate as a personal resource in the
model of salutogenesis; however, in order for it to develop, health-promoting and
preventive measures must aim at fostering a broad spectrum of individual, social and
5
cultural 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, it
is 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 research
and research on the epidemiology of psychological and somatic disorders in childhood
and adolescence.
As far as efforts to promote health and prevent disease in adults are concerned, 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 empirical
investigations. According to Antonovsky, the problem that arises in the face of health
promoting interventions in adulthood is that adults would require very intensive measu-
res to achieve a change.
The publications and written documents we found on salutogenesis in the field of

prevention could have been developed and introduced without Antonovsky’s theoretical
ideas. However, we must qualify this remark by saying that many preventive concepts and
measures are not available in written and evaluated form. The motivational and argu-
mentational use of the salutogenic concept to plan and implement programmes, such as
skill-improving programmes for pre-school children, for example, but also for the entire
field of health promotion and prevention, is a matter of conjecture.

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

illustrated by the fact that, in more recent textbooks, the concept of salutogenesis is
mentioned sparsely and then on a general level. Three conference proceedings discuss the
importance of the SOC and salutogenesis in psychotherapy and psychosomatics. However,
the critical discussion of the pathogenic and biomedical model devoted to the disease and
health model dominates. “Salutogenesis” is seen here as a synonym for resource activa-
tion, whose importance, independent of Antonovsky, is underscored by most therapeutic
schools. 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 some
significance, but only within the framework of health promotion. The measures provided
by so-called health education are usually devoted to the medical disease concept and are
geared to reducing health risk behaviour. However, resource-oriented approaches are
gaining recognition, and the health promotion approach is being demanded by rehabili-
tation and implemented in part. The programmes known to us are being supplemented
with modules like protective factors, social support or enjoyment training. However, these
measures remain centred around the individual and the way they are put into practice
deviates from the holistic concept of health promotion.
The term “salutogenesis” is often used as a new name for old services or rehabilitation
goals. However, it spurs one to rethink them. The integration of salutogenesis as a partial
aspect of a theory of coping with disease and its consequences, the analysis of the signifi-
cance of the SOC in the course of the disease and its rehabilitation, and the development
of salutogenic therapy goals, are important tasks for rehabilitation.

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 makes
an appeal for interdisciplinary research on health and disease and reinforces behavioural
as well as behaviourally-oriented prevention. He thus stimulates a discussion on the 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 not
been 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 salutogenic
model can be explained by the criticism of current research, the criticism of the pure
pathological perspective, and the need for a theory of action, especially for health
promotion and prevention.
5.3. Outlook and Recommendations
This expert report presents the current state of discussion on the concept of salutogene-
sis. In this endeavour, we can only survey published material or that otherwise known to
5
us, so that this review must remain selective and is by no means comprehensive. The
evaluation represents the opinion of the authors.
Since the reception and discussion of the concept in the health sciences began relatively
late and continued rather haltingly, we believe that a general evaluation of the concept
would not do it justice. For this reason, we would prefer to close this report by answering
three key questions. These questions represent possible appraisal dimensions and confirm
that the evaluation would or must reach a different conclusion according to the perspec-
tive under which it is carried out.
1. Why is the concept so attractive? Is this evidence for a

paradigm change in health research and health care?
The model criticises the pathogenic perspective and thus the health system exclusively
focused on the elimination of symptoms, suffering and disease. Salutogenesis thus 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 components
of human life. Despite its political implications, the model does not provide an answer to
the question of an adequate concept for public health care.
Salutogenesis criticises the fact that health care is one-sidedly focused on disease (“Wie
das bestehende Gesundheitssystem kranke Anteile verstärkt und gesunde Anteile unter-
drückt” [How the Present Health Care System Strengthens Ill Aspects and Represses
Healthy Ones], Lutz & Mark, 1994) and asks the question whether a “salutodiagnostic”
approach should not complement a “pathodiagnostic” approach. It could show the
patients which healthy aspects they have apart from their symptoms and could encourage
or tell them to work on strengthening them. It would also make clear to them that these
resistance factors and resources are also of high value for the therapy of their symptoms
and illnesses. On the other hand, the search for resources leads to an expansion of the
diagnostic evaluation, which must remain unspecified, since the resources can be found
in all areas of life and the physician or the patient might feel that their exploration is
inappropriate or too invasive.
Research in the health sciences is characterised by a number of experiments and studies

that are often unrelated to each other and are difficult to place within a unified and
action-oriented framework. Salutogenesis fulfils in part the desire and the need for a
comprehensive, interdisciplinary and general theory of health and is compatible with the
biopsychosocial model of health and disease. The biopsychosocial model, in which health
and disease are viewed as dependent on biological, physical and psychological 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 salutogenesis
model 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 care
paradigm and provides a theoretical framework for its research and practice. At the same
time, it criticises health research and health care which is one-sidedly oriented toward
pathological processes.
Salutogenesis will not replace or succeed the risk factor model, but it can be seen as a
significant reminder not to concentrate exclusively on risk factors.
By emphasising a continuum, salutogenesis makes a significant contribution to the

discussion on the concepts of health and disease. Health and disease are not two mutually
exclusive categories, but, according to Antonovsky, form the poles of a continuum. In
further development, they can be considered to be parallel, measured next to each other,
describable and subjectively experienceable units that, of course, are in relation to each
other and interact. The ill person has healthy components and, inversely, most healthy
persons have ill or less well-functioning components. Health and disease are not static

dimensions, but are constantly undergoing change both in the individual and in society.
One cannot say that Antonovsky’s model has launched a paradigm change. Too many
things developed before or at the same time as it did: the critical discourse on the health
care system, the discussion of the health and disease concepts, the development of the
biopsychosocial models and the principles of health promotion.
2. Is the salutogenesis model scientific?
This question is often posed by representatives of institutions involved in prevention,

health care, rehabilitation, and by high-ranking politicians. What it really means is
whether the concept can withstand a scientific analysis, or whether it is justified from a
scientific point of view to plan or carry out measures based on this concept. Can the
statements be confirmed scientifically or are efforts being made to confirm them, and can
relevant and well-founded guidelines for fields of application be derived from them?
Any study on the subject of salutogenesis and the SOC that is contextually and methodo-
logically planned and conducted adequately is “scientific”. In this sense, the research and
confirmation of the central construct of the SOC has begun, but in comparison to other
constructs, it is still minimal and by no means completed. The construct has not been
5
circumscribed precisely enough to set it off from other, similar constructs. The items it
contains are difficult to measure and the findings are often contradictory. The question
as to how one is to understand the conveyance or the mechanism by which the SOC influ-
ences health is still unanswered. Can the SOC be altered at all in adulthood? Does the
construct fall too short? The model as a whole has not been tested and is not testable
because of its complexity.
The studies surveyed showed a high level of consistency between the SOC and similar
constructs. The very relationship between the SOC and behaviour or physical health has
only been postulated – not, however, empirically confirmed. In our opinion, the current
state of research is not sufficient to allow the evaluation of the model it merits and leaves
more questions open than it answers.
3. Which consequences result for practical work?
Looking at the number of attempts made to put salutogenic principles into practice, one
must draw the conclusion that it is at the beginning. This raises the question as to
whether an intensive discussion about the model would or could yield something 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 be
transposed without any problems or contradictions to the salutogenesis model, and vice
versa.

There is a potential danger in euphorically touting salutogenic principles. The structures
of our public health care system should not be underestimated, nor should the expecta-
tions and the needs of the target group. The patients have been socialised according to the
medical model (that is, predominantly pathogenic); they often only want their symptoms
to be alleviated and not primarily offers to increase their competency and to strengthen
their SOC. Of course, this automatically raises the question as to the quality of such
services and their financing. Since measures aimed solely at the individual are not in
keeping with the concept, structural and societal changes are necessary.
The analysis of the fields of application shows that the concept has attained a certain
amount of importance in three areas: in health promotion and prevention, in psycho-
somatics and psychotherapy, and in rehabilitation. In all of these areas, salutogenesis
coincides with developments that can easily be combined with the assumptions and
premises of salutogenesis: resource orientation, focus on health-maintaining factors,
holism, concentration on the acquisition of skills, emphasis on environmental aspects,
positive definition of health, and the criticism of the concept of pathology. In these cases,
too, the providers of health-promoting services, psychotherapists and the providers of
rehabilitation measures profit from the proposed conceptual framework of salutogenesis.
Salutogenesis stresses positive aspects and positive experiences, preventing illness, and
thus is quite compatible with many of the self-set goals in these fields of application. Here,
too, it serves as a meta-theory. However, if one takes a closer look, one sees that the direct
derivation of measures is problematic.
For practical work, one aspect is especially important: Antonovsky emphasises the rele-
vance of ethical questions. On the one hand, the definition of health is always attached
to norms, and this poses the danger of discriminating against people on the basis of these
moral or ethical principles. Since a salutogenic perspective entails the consideration of all
areas of life, including very private ones, all salutogenic-oriented measures for the promotion
of health also carry the danger of a totalitarian influence by the empowered institutions:
“I am fully aware that one implication of the salutogenic approach or the

institutional organisation of a society’s health care system is the endless
expansion of social control in the hands of those who dominate this system.
The direction of the answer, to the extent that there is one, lies precisely in the
question of who dominates the system, on the institutional as well as on the
immediate, interpersonal level of the doctor/patient relationship”
(Antonovsky, 1987a, pp. 10–11).
Antonovsky sees yet another danger in unjustified association of health promotion and
ethical or moral behaviour. Not everything that is functional and positive for health is
necessarily morally justified, and not everything that is morally or ethically just must also
be good for health. Even people whose behaviour is considered unethical can be in the best
of health (Antonovsky, 1995).

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, especially
in prevention and health promotion, lack sufficient knowledge of salutogenesis or have
unrealistic expectations of the concept. Employees of health promotion and prevention
facilities, of rehabilitation clinics, of specialised psychosomatic clinics and other health
care facilities, but also self-help groups, need information about the concept. They would
like to discuss the current status and possible consequences for their field of work.
Thus, the authors strongly urge the communication of the central assumptions of the
concept and an exchange about the consequences for services and measures (contribution
and limits of the concept, conceptual planning of the work, possibility of a service with
salutogenic-based measures). Studying and discussing the model in the above-mentioned
perspectives would be especially called for in the prevention and health promotion fields.
Presentations, conferences or seminars on the subject of salutogenesis should not only be

targeted at scientists, but also at those active in the fields of health promotion and pre-
vention. Such presentations should serve to exchange information and discuss the fun-
damental ideas of the model. The discussion should include the possible consequences
that can be drawn from system-induced and individual-oriented measures, and encourage
5
thoughts on the ways in which salutogenic principles can be put into practice.

Appendix
6
6.1. Documentation of the Literature Search
The material for this expert report on salutogenesis was gathered in the course of an
extensive literature research that we conducted.
Among our sources are the germane literature databases as well as the Internet:
Psyndex 1990–1998
Search words: Saluto, sense of coherence, Antonovsky
Psyclit 1990–1998
Search words: salutogenesis, salutogenic, sense of coherence, Antonovsky
Medline 1990–1998
Current Contents 1993–1997

Dissertations Abstracts 1989–1997

WISO III, PAIS, Social Sciences Index, ERIC
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

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

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 of
Psychiatry & Related Sciences, 32, 5–13.
Antonovsky, A. (1996): The sense of coherence. An historical and future perspective. Israel Journal of Medical
Sciences, 32, 170–178.
Antonovsky, A. (1997): Salutogenese. Zur Entmystifizierung der Gesundheit. Expanded German edition by
A. Franke. Tübingen: dgvt.
Antonovsky, A. / Maoz, B. / Dowty, N. / Wijsenbeek, H. (1971): Twenty-five years later. A limited study of the
sequelae of the Concentration Camp experience. Social Psychiatry, 6, 186–193.
Antonovsky, A. / Sagy, S. (1986): The development of a sense of coherence and its impact on responses to stress
situations. Journal of Social Psychology, 126, 213–225.
Antonovsky, A. / Sourani, T. (1988): Family sense of coherence and family adaption. Journal of Marriage and
the Family, 50, 79–92.
Antonovsky, A. / Sagy, S. (1990): Confronting developmental tasks in the retirement transition. The 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 of
causality. Behavior, Health, and Aging, 1, 85–97.
Dahlin, L. / Cederblad, M. / Antonovsky, A. / Hagnell, O. (1990): Childhood vulnerability and adult
invincibility. Acta Psychiatrica Scandinavica, 82, 228–232.
Langius, A. / Björvell, H. / Antonovsky, A. (1992): The sense of coherence concept and its relation to
personality traits in Swedish samples. Scandinavian Journal of Caring Sciences, 6, 165–171.
Sagy, S. / Antonovsky, A. (1992): The family sense of coherence and the retirement transition. Journal of
Marriage and the Family, 54, 983–993.
Sagy, S. / Antonovsky, A. / Adler, I. (1990): Explaining life satisfaction in later life: The sense of coherence
model and activity theory. Behavior, Health, and Aging, 1, 11–25.

6.3. References
Ahrens, S. (Ed.) (1997): Lehrbuch der Psychotherapeutischen Medizin. Stuttgart: Schattauer.

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

Artinian, B. M. (1991): The development of the intersystem model. Journal of Advanced Nursing, 16,
194–205.
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 to
demented 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 für
Klinische Psychologie, 20, 177–188.
Becker, P. (1992): Seelische Gesundheit als protektive Persönlichkeitseigenschaft. Zeitschrift für Klinische
Psychologie, 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- und
Mindergesunden in gesundheitsrelevanten Variablen (GRV). Zeitschrift für Gesundheitspsychologie,
4, 55–76.
Belz-Merk, M. / Bengel, J. / Strittmatter, R. (1992): Subjektive Gesundheitskonzepte und gesundheitliche
Protektivfaktoren. Zeitschrift für Medizinische Psychologie, 4, 153–171.
Bengel, J. (1993): Gesundheit, Risikowahrnehmung und Vorsorgeverhalten. Göttingen: Hogrefe.
Beutel, M. (1989): Was schützt Gesundheit? Zum Forschungsstand und der Bedeutung von personalen
Ressourcen in der Bewältigung von Alltagsbelastungen und Lebensereignissen. Psychotherapie,
Psychosomatik, Medizinische Psychologie, 39, 452–462.
Billings, A. G. / Moos, R. H. (1981): The role of coping responses and social resources in attenuating the stress
of life events. Journal of Behavioral Medicine, 4, 139–157.
Bishop, G. D. (1993): The sense of coherence as a resource in dealing with stress. Psychologia, 36, 259–263.
Blättner, B. (1997): Paradigmenwechsel: von der Gesundheitsaufklärung und -erziehung zur Gesundheits-
bildung und -förderung. In: Weikunat, R. / Haisch, J. / Kessler, M. (Eds.): Public Health und Gesund-
heitsförderung (pp. 119– 125). Bern: Huber.
Borg, I. (1993): Grundlagen und Ergebnisse der Facettentheorie. Bern: Huber.
Borgers, D. (1981): Primärprävention von Volkskrankheiten. Biotechnischer Eingriff und soziale Prävention.
Prävention: Gesundheit und Politik. Argument Sonderband 64 (pp. 27–51). Berlin: Argument.
Bös, K. / Woll, A. (1994): Das Saluto-Genese-Modell. Theoretische Überlegungen und erste empirische
Ergebnisse. In: Alfermann, D. / Scheid, V. (Eds.): Psychologische Aspekte von Sport und Bewegung in
Prävention und Rehabilitation (pp. 29–38). Köln: bps.
Bowman, B. (1996): Cross-cultural validation of Antonovsky’s Sense of Coherence Scale. Journal of Clinical
Psychology, 52, 547–549.
Bowman, B. (1997): Cultural pathway towards Antonovsky’s Sense of Coherence. Journal of Clinical
Psychology, 53, 139–142.
Braukmann, W. / Filipp, S.-H. (1984): Strategien und Techniken der Lebensbewältigung. In: Baumann, U. /
Berbalk, H. / Seidensticker, G. (Eds.): Klinische Psychologie. Trends in Forschung und Praxis, Bd. 6
(pp. 52–87). München: Urban & Schwarzenberg.

Broda, M. / Bürger, W. / Dinger-Broda, A. (1995): Therapieerfolg und Kohärenzgefühl – Zusammenhänge
zwei bis fünf Jahre nach stationärer verhaltensmedizinischer Behandlung. In: Lutz R. / Mark, N.
(Eds.): Wie gesund sind Kranke? (pp. 113–122). Göttingen: VAP.
Broda, M. / Dinger-Broda, A. / Bürger, W. (1996): Selbstmanagement-Therapie und Gesundheitsressourcen –
katamnestische Untersuchung zum Kohärenzgefühl bei verhaltensmedizinisch behandelten
Patienten. In: Reinecker, H. S. / Schmelzer, D. (Eds.): Verhaltenstherapie – Selbstregulation –
Selbstmanagement (pp. 257–272). Göttingen: Hogrefe.
Broda, M. / Dusi, D. (1996): Ressourcenorientiertes Vorgehen in der stationären Verhaltensmedizin. In: Ver-
band Deutscher Rentenversicherungsträger (Ed.): 6. Rehabilitationswissenschaftliches Kolloquium.
Tagungsband (pp. 396–397). Frankfurt: VDR.
Broda, M. (1995): Chronisches Krankheitsverhalten – ein hilfreiches Paradigma für die psychosoziale
Rehabilitation. Praxis der Klinischen Verhaltensmedizin und Rehabilitation, 8, 180–186.
Bundesarbeitsgemeinschaft für Rehabilitation (Ed.) (1994): Rehabilitation Behinderter. Köln: Deutscher
Ärzte-Verlag.
Bundeszentrale für gesundheitliche Aufklärung (Ed.) (1983): Europäische Monographien zur Forschung in
Gesundheitserziehung, Bd 5. Köln: Bundeszentrale für gesundheitliche Aufklärung.
Buschmann-Steinhage, R. / Liebing, D. (1996): Gesundheitsbildung in der medizinischen Rehabilitation.
In: Verband Deutscher Rentenversicherungsträger (Ed.): 6. Rehabilitationswissenschaftliches Kol-
loquium. Tagungsband (S. 397–398). Frankfurt: VDR.
Callahan, L. F. / Pincus, T. (1995): The Sense of Coherence Scale in patients with rheumatoid arthritis.
Arthritis Care and Research, 8, 28–35.
Carmel, S. / Anson, O. / Levenson, A. / Bonneh, D. / Maoz, B. (1991): Life events, sense of coherence and
health: Gender differences on the Kibbutz. Social Science & Medicine, 32, 1089–1096.
Cederblad, M., / Hansson, K. (1996): Sense of coherence – a concept influencing health and quality of life in
a swedish psychiatric at-risk group. Israel Journal of Medical Sciences, 32, 194–199.
Cederblad, M. / Dahlin, L. / Hagnell, O. / Hansson, K. (1995): Coping with life span crises in a group at risk
of mental and behavioral disorders: from the Lundby study. Acta Psychiatrica Scandinavica, 91,
322–330.
Chamberlain, K. / Petrie, K. / Azariah, R. (1992): The role of optimism and sense of coherence in predicting
6
recovery following surgery. Psychology & Health, 7, 301–310.
Coe, R. M. / Miller, D. K. / Flaherty, J. (1992): Sense of Coherence and perception of caregiving burden.
Behavior, Health, and Aging, 2, 93–99.
Cohen, F. / Lazarus, R. S. (1979): Coping with the stress of illness. In: Stone, G. C. / Cohen, F. / Adler, N. E.
(Eds.): Health Psychology: A handbook (pp. 217–254). San Francisco: Jossey-Bass.
Cohen, S. / Syme, S. L. (Eds.) (1985): Social support and health. New York: Academic Press.
Collins, J. F. / Hanson, K. / Mulhern, M. / Padberg, R. M. (1992): Sense of coherence over time in cancer
patients. A preliminary report. Medical Psychotherapy, 5, 73–82.
Dahlin, L. / Cederblad, M. / Antonovsky, A. / Hagnell, O. (1990): Childhood vulnerability and adult invinci-
bility. Acta Psychiatrica Scandinavica, 82, 228–232.
Dangoor, N. / Florian, V. (1994): Women with chronic physical disabilities: Correlates of their long-term
psychosocial adaptation. International Journal of Rehabilitation, 17, 159–168.
DiClemente, C. C. (1981): Self-efficacy and smoking cessation maintenance: A preliminary report. Cognitive
Therapy and Research, 5, 175–187.
Dlugosch, G. E. (1994): Modelle in der Gesundheitspsychologie. In: Schwenkmezger, P. / Schmidt, L. (Eds.):
Lehrbuch der Gesundheitspsychologie (pp. 101–117). Stuttgart: Enke.
Doubrawa, R. (1995): Gesundheitsförderung im sozialen Kontext. Report Psychologie, 20, 14–23.
Dudek, B. / Makowska, Z. (1993): Psychometric characteristics of the Orientation to Life Questionnaire for
measuring the sense of coherence. Polish Psychological Bulletin, 24, 309–318.

Engel, G. L. (1979): Die Notwendigkeit eines neuen medizinischen Modells: Eine Herausforderung der
Biomedizin. In: Keupp, H. (Ed.): Normalität und Abweichung. Fortsetzung einer notwendigen
Kontroverse (pp. 63–86). München: Urban & Schwarzenberg.
Erben, R. / Franzkowiak, P. / Wenzel, E. (1986): Die Ökologie des Körpers. Konzeptuelle Überlegungen zur
Gesundheitsförderung. In: Wenzel, E. (Ed.): Die Ökologie des Körpers (pp. 13–120). Frankfurt:
Suhrkamp.
Faltermaier, T. (1994): Gesundheitsbewußtsein und Gesundheitshandeln. Weinheim: Beltz.
Flannery, R. B. / Perry, C. / Penk, W. E. / Flannery, G. J. (1994): Validating Antonovsky’s Sense of Coherence
Scale. Journal of Clinical Psychology, 50, 575–577.
Franke, A. (1997): Zum Stand der konzeptionellen und empirischen Entwicklung des Salutogenesekonzepts.
In: Antonovsky, A.: Salutogenese. Zur Entmystifizierung der Gesundheit. (Expanded German edition
by A. Franke), Tübingen: dgvt.
Franke, A. / Broda, M. (Eds.) (1993): Psychosomatische Gesundheit. Versuch einer Abkehr vom Pathogenese-
Konzept. Tübingen: dgvt.
Franke, A. / Elsesser, K. / Algermissen, G. / Sitzler, F. (1997): Gesundheit und Abhängigkeit bei Frauen. Eine
salutogenetische Verlaufsstudie. Bonn: Bundesministerium für Gesundheit.
Franzkowiak, P. / Sabo, P. (1993): Die Entwicklung der Gesundheitsförderung in internationalen und natio-
nalen Dokumenten. In: Franzkowiak, P. / Sabo, P. (Eds.): Dokumente der Gesundheitsförderung
(pp. 11–61). Mainz: Peter Sabo.
Franzkowiak, P. (1996): Risikofaktoren. In: Bundeszentrale für gesundheitliche Aufklärung (Ed.):
Leitbegriffe der Gesundheitsförderung (pp. 94–96). Schwabenheim: Peter Sabo.
Franzkowiak, P. / Wenzel, E. (1982): Risikoverhalten und Gesundheitsförderung. Hygie, Internationales
Journal für Gesundheitserziehung, 1, 33–40.
Freidl, W. / Rásky, E. / Noack, R. H. (1995): Gesundheitsförderung – aus einer systemtheoretisch-gesundheits-
wissenschaftlichen Perspektive. Praxis der Klinischen Verhaltenstherapie und Rehabilitation, 8, 13–17.
Frenz, A. W. / Carey, M. P. / Jorgensen, R. S. (1993): Psychometric evaluation of Antonovsky’s Sense of
Coherence Scale. Psychological Assessment, 5, 145–153.
Fuchtmann, E. (1994): Pathogene und salutogene Faktoren – Persönlichkeitsentwicklung und Sucht-
karrieren. Gesundheitswesen, 56, 92–94.
Gallagher, T. J. / Wagenfeld, M. O. / Baro, F. / Haepers, K. (1994): Sense of Coherence, coping and caregiver
role overload. Social Science & Medicine, 39, 1615–2622.
Gebert, N. / Broda, M. / Lauterbach, W. (1997): Kohärenzgefühl und Konstruktives Denken als Prädiktoren psy-
chosomatischer Belastung. Praxis der Klinischen Verhaltensmedizin und Rehabilitation, 40, 70–75.
George, V. D. (1996): Field-workers’ sense of coherence and perception of risk when making home visits.
Public Health Nursing, 13, 144–152.
Gerber, W.-D. / Basler, H.-D. / Tewes, U. (Eds.) (1994): Medizinische Psychologie. München: Urban &
Schwarzenberg.
Gibson, L. M. / Cook, M. J. (1997): Do health questionnaires which do not consider sex differences miss
important information? Psychological Reports, 81, 163–171.
Haltenhofer, H. / Vossler, A. (1997): Coping der Depression: Wie begegnen depressive Patienten ihrer
Erkrankung? Eine Literaturübersicht. Zeitschrift für Klinische Psychologie, Psychopathologie &
Psychotherapie, 42, 201–229.
Hart, K. E. / Hittner, J. B., / Paras, K. C. (1991): Sense of coherence, trait anxiety, and the perceived availability
of social support. Journal of Research in Personality, 25, 137–145.
Heim, E. (1988): Coping und Adaptivität: Gibt es geeignetes oder ungeeignetes Coping? Psychotherapie,
Psychosomatik, Medizinische Psychologie, 38, 8–18.
Helfferich, C. (1993): Das unterschiedliche “Schweigen der Organe” bei Frauen und Männern – subjektive
Gesundheitskonzepte und “objektive” Gesundheitsdefinitionen. In: Franke, A. / Broda, M. (Eds.):
Psychosomatische Gesundheit (pp. 35–66). Tübingen: dgvt.

Hellhammer, D. H. / Buske-Kirschbaum, A. (1994): Psychobiologische Aspekte von Schutz- und Reparatur-
mechanismen. In: Lamprecht, F. / Johnen, R. (Eds.): Salutogenese. Ein neues Konzept für die
Psychosomatik? (pp. 95–105). Frankfurt: VAS.
Hollnagel, H. / Malterud, K. (1995): Shifting attention from objective risk factors to patients’ self-assessed
health resources: A clinical model for general practice. Family Practice, 12, 423–429.
Hood, S. C. / Beaudet, M. P. / Catlin, G. (1996): A healthy outlook. Health Reports, 7, 25–32.
Hurrelmann, K. (1988): Sozialisation und Gesundheit. Somatische, psychische und soziale Risikofaktoren
im Lebenslauf. Weinheim: Juventa.
Jerusalem, M. (1997): Gesundheitspsychologie: Zur Mehrdimensionalität der Salutogenese. In: Seelbach, H. /
Kugler, J. / Neumann, W. (Eds.): Von der Krankheit zur Gesundheit (pp. 389–401). Bern: Huber.
Kickbusch, I. (1992): Plädoyer für ein neues Denken: Muster – Chaos – Kontext. Neue Handlungsansätze in
der Gesundheitsförderung. In: Paulus, P. (Ed.): Prävention und Gesundheitsförderung – Perspek-
tiven für die psychosoziale Praxis (pp. 23–33). Köln: GwG.
Kobasa, S. C. (1979): Stressful life events, personality and health: An inquiry in hardiness. Journal of
Personality and Social Psychology, 34, 839–850.
Kobasa, S. C. / Maddi, S. R. / Kahn, S. (1982): Hardiness and health: A prospective study. Journal of
Koch, U. / Heim, E. (1988): Editorial “Schwerpunktheft”: Bewältigungsprozesse bei chronischen Erkran-
kungen. Psychotherapie, Psychosomatik, Medizinische Psychologie, 38, 1–2.
Köferl, P. (1988): Invulnerabilität und Streßresistenz: Theoretische und empirische Befunde zur effektiven
Bewältigung von psychosozialen Stressoren. Psychologische Dissertation, Universität Bielefeld.
Korotkov, D. L. (1993): An assessment of the (short-term) sense of coherence personality measure: issues of
validity and well-being. Personality & Individual Differences, 14, 575–538.
Kravetz, S. / Drory, Y. / Florian, V. (1993): Hardiness and sense of coherence and their relation to negative
affect. European Journal of Personality, 7, 233–244.
Lamprecht, F. / Johnen, R. (Eds.) (1994): Salutogenese. Ein neues Konzept in der Psychosomatik? Frankfurt:
VAS.
Lamprecht, F. / Johnen, R. (Eds.) (1997): Salutogenese. Ein neues Konzept in der Psychosomatik? 3rd. revised
edition. Frankfurt: VAS.
6
Langius, A. / Björvell, H. (1993): Coping ability and functional status in a Swedish population sample.
Scandinavian Journal of Caring Sciences, 7, 3–10.
Langius, A. / Björvell, H. / Antonovsky, A. (1992): The sense of coherence concept and its relation to
personality traits in Swedish samples. Scandinavian Journal of Caring Sciences, 6, 165–171.
Larsson, G. / Kallenberg, K. O. (1996): Sense of coherence, socioeconomic conditions and health. European
Journal of Public Health, 6, 175–180.
Lazarus, R. S. (1966): Psychological stress and the coping process. New York: McGraw.
Lazarus, R. S. (1981): Streß und Streßbewältigung – Ein Paradigma. In: Filipp, S.-H. (Ed.): Kritische
Lebensereignisse, Bd. 1 (pp. 198–232). München: Urban & Schwarzenberg.
Lazarus, R. S. / Folkman, S. (1987): Transactional theory and research of emotions and coping. In: Laux, L. /
Vossel, G. (Eds.): Special Issue. European Journal of Personality, 1, 141–170.
Liebing, D. / Vogel, H. (1995): Zur Weiterentwicklung der Gesundheitsbildung im Rahmen medizinischer
Rehabilitation der Rentenversicherung. Praxis der Klinischen Verhaltensmedizin und Rehabili-
tation, 8, 18–25.
Lösel, F. / Bender, D. (1997): Antisoziales Verhalten von Kindern und Jugendlichen. Psycho, 5, 321–329.
Lundberg, O. (1997): Childhood conditions, Sense of Coherence, social class and adult ill health: Exploring
their theoretical and empirical relations. Social Science & Medicine, 44, 821–831.
Lundberg, O. / Nynström Peck, M. (1994): Sense of coherence, social structure and health. European Journal
of Public Health, 4, 252–257.
Lutz, R. / Mark, M. (Eds.) (1995): Wie gesund sind Kranke? Göttingen: VAP.

Lutz, R. (1997): Gesundheit und Genuß: Euthyme Grundlagen der Verhaltenstherapie. In: Margraf, J. (Ed.):
Lehrbuch der Verhaltenstherapie (pp. 113–128). Berlin: Springer.
Maddi, S. R. (1990): Issues and interventions in stress mastery. In: Friedman, H. S. (Ed.): Personality and
disease (pp.121–154). New York: Wiley.
Margalit, M. / Raviv, A. / Ankonina, D. B. (1992): Coping and coherence among parents with disabled
children. Journal of Clinical Child Psychology, 21, 202–209.
Margraf, J. (Ed.) (1997): Lehrbuch der Verhaltenstherapie. Berlin: Springer.
Margraf, J. / Siegrist, J. / Neumer, S. (Eds.) (1998): Gesundheits- oder Krankheitstheorie? Berlin: Springer.
McSherry, W. C. / Holm, J. E. (1994): Sense of coherence: Its effects on psychological and physiological pro-
cesses prior to, during, and after a stressful situation. Journal of Clinical Psychology, 50, 476–487.
Noack, R. H. / Bachmann, N. / Oliveri, M. (1991): Fragebogen zum Kohärenzgefühl (SOC-Fragebogen)
Autorisierte Übersetzung des Sense of Coherence Questionnaire.
Noack, R. H. (1996a): Public Health, Salutogenese und Gesundheitsförderung. In: Lobnig, H. / Pelikan, J. M.
(Eds.): Gesundheitsförderung in Settings: Gemeinde, Betrieb, Schule und Krankenhaus (pp. 26–38).
Wien: Facultas Universitätsverlag.
Noack, R. H. (1996b): Salutogenese und Systemintervention als Schlüsselkonzepte von Gesundheitsförderung
und Public Health. Prävention, 19, 37–39.
Noack, R. H. (1997): Salutogenese: Ein neues Paradigma in der Medizin? In: Bartsch, H. H. / Bengel, J. (Eds.):
Salutogenese in der Onkologie (pp. 88–105). Basel: Karger.
O’Leary, A. (1985): Self-efficacy and health. Behavior Research and Therapy, 23, 437–451.
Ouellette-Kobasa, S. C. / Puccetti, M. (1983): Personality and social resources in stress resistance. Journal of
Oyen, R. / Feser, H. (1982): Entwicklung eines modernen Gesundheitsbegriffes als Grundlage konzeptueller
Überlegungen zur Gesundheitserziehung. Prävention, 5, 99–103.
Pasikowski, T. / Sek, H. / Scigala, I. (1994): “Sense of coherence” and subjective health concepts. Polish
Psychological Bulletin, 25, 15–23.
Paulus, P. (1995): Die Gesundheitsfördernde Schule. Der innovativste Ansatz gesundheitsbezogener
Interventionen bei Schulen. Die Deutsche Schule, 87, 262–281.
Perrez, M. (1988): Bewältigung von Alltagsbelastungen und seelische Gesundheit. Zusammenhänge auf der
Grundlage computer-unterstützter Selbstbeobachtungs- und Fragebogendaten. Zeitschrift für
Klinische Psychologie, 17, 292–306.
Petrie, K. / Brook, R. (1992): Sense of coherence, self-esteem, depression and hopelessness as correlates of
reattempting suicide. British Journal of Clinical Psychology, 31, 293–300.
Piaget, J. (1969): Nachahmung, Spiel und Traum. Die Entwicklung der Symbolfunktion beim Kinde.
Stuttgart: Klett.
Plassmann, R. / Färber, K. (1997): Salutogenetische Therapieorganisation in der Psychosomatischen Klinik.
Praxis der Klinischen Verhaltensmedizin und Rehabilitation, 10, 66–70.
Rappaport, J. (1985): Ein Plädoyer für die Widersprüchlichkeit: ein sozialpolitisches Konzept des “empower-
ment” anstelle präventiver Ansätze. Verhaltenstherapie und psychosoziale Praxis, 17, 257–278.
Rena, F. / Moshe, S. / Abraham, O. (1996): Couples’ adjustment to one partner’s disability: the relationship
between sense of coherence and adjustment. Social Science & Medicine, 43, 163–167.
Renner, H. (1997): Gesundheitsförderung im salutogenen Kontext – vom Entwurf zur Praxis. Prävention, 20,
57–59.
Rimann, M. / Udris, I. (1998): “Kohärenzerleben” (Sense of Coherence): Zentraler Bestandteil von
Gesundheit oder Gesundheitsressource? In: Schüffel, W. et al. (Eds.): Handbuch der Salutogenese.
Konzept und Praxis. Wiesbaden: Ullstein & Mosby.
Rippetoe, P. A. / Rogers, R. W. (1987): Effects of components of Protection Motivation Theory on adaptive and
maladaptive coping with a health threat. Journal of Personality and Social Psychology, 52, 596–604.
Rösler, H.-D. / Szewczyk, H. / Wildgrube, K. (1996): Medizinische Psychologie. Heidelberg: Spektrum.

Rotter, J. B. (1966): Generalized expectancies for internal versus external control of reinforcement. Psycho-
logical Monographs, 80, No. 609.
Rotter, J. B. (1975): Some problems and misconceptions related to the construct of internal versus external
control of reinforcement. Journal of Consulting and Clinical Psychology, 43, 56–67.
Sack, M. / Künsebeck, H.-W. / Lamprecht, F. (1997): Kohärenzgefühl und psychosomatischer Behandlungs-
erfolg. Psychotherapie, Psychosomatik und Medizinische Psychologie, 47, 149–155.
Sagy, S. / Antonovsky, A. / Adler, I. (1990): Explaining life satisfaction in later life: The sense of coherence
model and activity theory. Behavior, Health, and Aging, 1, 11–25.
Sammallahti, P. R. / Holi, M. J. / Komulainen, E. J. / Aalberg, V. A. (1996): Comparing two self-report meas-
ures of coping – the Sense of Coherence Scale and the Defense Style Questionnaire. Journal of
Clinical Psychology, 52, 517–524.
Schachtner, C. (1996): Die Ressourcen-Orientierung in der Pflege. Pflege, 9, 198–206.
Scheier, M. F. / Carver, C. S. (1985): Optimism, coping, and health: Assessment and implications of
generalized outcome expectancies. Health Psychology, 4, 219–247.
Scheier, M. F. / Carver, C. S. (1987): Dispositional optimism and physical well-being: The influence of
generalized outcome expectancies on health. Journal of Personality, 55, 169–210.
Scheier, M. F. / Carver, C. S. (1990): Origins and functions of positive and negative affect: A control-process
view. Psychological Review, 97, 19–35.
Scheier, M. F. / Weintraub, J. K. / Carver, C. S. (1986): Coping with stress: Divergent strategies of optimists and
pessimists. Journal of Personality and Social Psychology, 51, 1257–1264.
Scherwitz, L. / Ornish, D. (1994): The impact of major lifestyle changes on coronary stenosis, CHD risk factors
and psychosocial status: results from the San Francisco Lifestyle Trial. Homeostasis in Health and
Disease, 35, 190–197.
Schmidt-Rathjens, C. / Benz, D. / Van Damme, D. / Feldt, K. / Amelang, M. (1997): Über zwiespältige
Erfahrungen mit Fragebögen zum Kohärenzsinn sensu Antonovsky. Diagnostica, 43, 327–346.
Schüffel, W. / Brucks, U. / Johnen, R. / Köllner, V. / Lamprecht, F. / Schnyder, U. (Eds.) (1998): Handbuch der
Salutogenese. Konzept und Praxis. Wiesbaden: Ullstein & Mosby.
Schulte-Cloos, C. / Baisch, A. (1996): Lebenskraft – Ressourcen im Umgang mit Belastungen. Verhaltens-
therapie und psychosoziale Praxis, 28, 421–440.
6
Schulz, K.-H. (1994): Psychoneuroimmunologie. In: Gerber, W.-D. / Basler, H.-D. / Tewes, U. (Eds.): Medizi-
nische Psychologie (pp. 129–138). München: Urban & Schwarzenberg.
Schwarzer, R. / Leppin, A. (1989): Social support and health. A meta-analysis. Psychology and Health, 3, 1–15.
Schwarzer, R. (1992): Psychologie des Gesundheitsverhaltens. Göttingen: Hogrefe.
Schwarzer, R. (1994): Optimistische Kompetenzerwartung: Zur Erfassung einer personellen Bewältigungs-
ressource. Diagnostica, 40, 105–123.
Schwenkmezger, P. (1994): Gesundheitspsychologie: Die persönlichkeitspsychologische Perspektive. In:
Schwenkmezger, P. / Schmidt, L. (Eds.): Lehrbuch der Gesundheitspsychologie (pp. 46–64).
Stuttgart: Enke.
Senf, W. / Broda, M. (Eds.) (1996): Praxis der Psychotherapie: Theoretische Grundlagen von Psychoanalyse
und Verhaltenstherapie. Stuttgart: Thieme.
Shye, S. (Ed.) (1978): Theory Construction and Data Analysis in the Behavioral Sciences. San Francisco:
Jossey-Bass.
Siegrist, J. (1993): Sense of coherence and sociology of emotions. Social Science & Medicine, 37, 968–979.
Siegrist, J. (1994): Selbstregulation, Emotion und Gesundheit – Versuch einer sozialwissenschaftlichen
Grundlegung. In: Lamprecht, F. / Johnen, R. (Eds.): Salutogenese. Ein neues Konzept für die
Psychosomatik? (pp. 85–94). Frankfurt/Main: VAS.
Siegrist, J. (1995): Medizinische Soziologie. München: Urban & Schwarzenberg.
Stark, W. (1996): Empowerment. In: Bundeszentrale für gesundheitliche Aufklärung (Ed.): Leitbegriffe der
Gesundheitsförderung (pp. 17–18). Schwabenheim: Peter Sabo.

Strecher, V. J. / McEvoy Devellis, B. / Becker, M. H. / Rosenstock, I. M. (1986): The role of self-efficacy in
achieving health behavior change. Health Education Quarterly, 13, 73–91.
Strittmatter, R. (1994): Alltagswissen über Gesundheit und gesundheitliche Protektivfaktoren. Frankfurt:
Peter Lang.
Thomä, H. / Kächele, H. (1996): Lehrbuch der psychoanalytischen Therapie. Band 1 – Grundlagen. Berlin:
Springer.
Thomä, H. / Kächele, H. (1997): Lehrbuch der psychoanalytischen Therapie. Band 2 – Praxis. Berlin:
Springer.
Tress, W. (Ed.) (1997): Psychosomatische Grundversorgung. Kompendium der interpersonellen Medizin.
Stuttgart: Schattauer.
Udris, I. / Kraft, U. / Mussmann, C. (1991): Warum sind “gesunde” Personen “gesund”? Untersuchungen zu
Ressourcen von Gesundheit (Forschungsprojekt “Personale und organisationale Ressourcen der
Salutogenese”, Bericht Nr. 1). Zürich: Eidgenössische Technische Hochschule, Institut für
Arbeitspsychologie.
Udris, I. / Kraft, U. / Muheim, M. / Mussmann, C. / Rimann, M. (1992): Ressourcen der Salutogenese. In:
Schröder, H. / Reschke, K. (Eds.): Psychosoziale Prävention und Gesundheitsförderung (pp. 85–103).
Regensburg: Roderer.
Uexküll, T. v. / Wesiack, W. (1988): Theorie der Humanmedizin. München: Urban & Schwarzenberg.
Wallston, B. S. / Wallston, K. A. (1978): Locus of control and health: A review of the literature. Health
Education Monographs, 6, 107–117.
Weis, J. (1997): Das Konzept der Salutogenese in der Psychoonkologie. In: Bartsch, H. H. / Bengel, J. (Eds.):
Salutogenese in der Onkologie (pp.106–116). Basel: Karger.
Wetzel, H. (1980): Konzepte der Normalität und Abnormität des Verhaltens. In: Wittling, W. (Ed.): Handbuch
der 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 critical
care 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.

6.4. Overview of the Studies on the
Sense of Coherence
Author/Year Country Sample Variables Examined Instruments

Anson, Israel N=238 SOC SOC-scale
Paran, men and education Memorial Univer-
Neumann & women with employment sity of New
Chernichovsky mild hyper- marital status Foundland Scale
(1993a; 1993b) tension happiness of Happiness
distress Psychological
satisfaction with family Distress Scale
relations Measure Family
subjective evaluation of Functioning
health self-developed
symptom perception scales
Results
Gender differences were established in the sense that women have a much lower SOC score
than men. Women have greater risks: They are more likely to lose their jobs and have less
education. Less women are married; women are unhappier; they experience less mental well-
being, are less satisfied with the atmosphere in the family and perceive themselves as being
unhealthier.
The higher the SOC score, the better the questionee estimated his or her own health to be
(r=-.23) and the less symptoms of illness were reported (r=-.24).
Author/Year
Anson,
Rosenzweig &
Shwarzmann,
(1993)
Country
Israel
Sample
N=97
women, of
which N=44
were mar-
ried to army
members
Variables Examined
SOC
availability of social support
residential mobility
labour force participation
health
distress
Instrumentes
SOC-scale,
short form
Scale of Psycho-
logical Distress
self-developed
scales
6
and N=53 to utilisation of health services
civilians
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. The
SOC 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 psychological
well-being was determined in both samples.

Becker, Bös, Germany N=863 SOC Trierer Persönlich-
Opper, Woll & men and age keitsfragebogen
Wustmann women of gender (Trier Personality
(1996) varying mental health Inventory)
states of internal health locus of SOC-scale
health control Fragebogen zur
a non-repre- exercise under stress sozialen
sentative conditions Unterstützung
sample depressive coping style (questionnaire of
healthy nourishment social support)
intensive exercise self-developed
good sleep scales
social support
(total=health-related vari-
ables, “gesundheits-
relevante Variablen”, “GRV”)
habitual physical health level,
i.e., high health, low health,
normal health
Results
The authors differentiate between three research perspectives and thus pose three correspond-
ing research questions reflecting the salutogenic, the pathogenic, and a comprehensive health
psychological perspective. To test the first question, the high health group was compared to the
rest of the sample. The SOC did not distinguish this group from the other two. The low health
group, however, had significantly lower SOC scores than the rest of the sample.
The SOC correlated with all GRVs (health-related variables) in the expected direction with the
exception of intensive exercise.
Of all GRVs, only mental health, SOC, exercise and restful sleep were predictive of the habitual
level of health. However, this variable explained only 19% of the variance.

Bös & Woll Germany N=500 SOC SOC-scale
(1994) men and gender Trierer Persönlich-
women age keitsfragebogen
internal locus of control (Trier Personality
health rating by physician Inventory)
self-rating of health I-Skala der körper-
exercise bezogenen Kon-
trollüberzeugunge
n (I-Scale of Physi-
cally-Related
Locus of Control)
self-developed
scales
Results
The SOC correlates in the expected direction with mental health, internal locus of control, and
self-evaluation of health. No relationship could be established, however, between the SOC and
the rating of the state of health by physician.
Older persons with a high SOC score get more exercise. This relationship is not significant for
younger persons.

Bowman USA N=186 SOC SOC-scale
(1996; 1997) psychology ethnic origin: Native Ameri- Beck Depression
students can (associated with larger Inventory
families and lower SES) vs. State-Trait Perso-
Anglo-American nality Inventory
depression Wahler Physical
anxiety Symptom Inven-
physical health 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 Native
Americans, r=-.66 in Anglo-Americans), anxiety (r=-.43 and r=-.64, respectively), and physical
health (r=-.29 and r=-.41, respectively).

Callahan & USA N=828 SOC SOC-scale,
6
Pincus rheumatism pain long and
(1995) patients, functional limitations short form
predomi- learned helplessness MHAQ-Activity of
nately white, general state of health Daily Living
female, and Difficulty Scale
married Arthritis Helpless-
ness-Scale
self-developed
scales
Results
In contrast to Antonovsky, the authors did not find a three-factor solution but only one factor.
The short form is as reliable as the long form.
Patients with lower ADL status, more pain, worse state of general health, and more helplessness
with respect to their illness have lower SOC scores.
The correlation coefficients, r=-.25 and r=-.42, are however relatively low.
The duration of the illness, sex, ethnic origin, and education level had no influence on these
relationships.
There is a low, but significant relationship between the SOC and age.

Chamberlain, New N=57 SOC Life Orientation
Petrie & Zealand male and gender Test
Azariah (1992) female, surgical operation SOC-scale
mostly older optimism as a personality Mental Health
patients trait Inventory
before and pain self-developed
after a state of health scales
surgical life satisfaction
operation positive well-being
psychological distress
Results
Optimism and the SOC correlate positively (r=.62), but they correlate to varying degrees with the
dependent variables.
The SOC correlates in the expected direction with life satisfaction, well-being, psychological
symptoms, and state of health, but not, however, with pain before the operation.
When the preoperative values of the dependent variables are controlled, the SOC has a predic-
tive value for positive health measures, but not for the negative ones (pain and psychological
symptoms); in contrast, there is no longer a predictive value for optimism.

Coe, Miller & USA N=148 SOC SOC-scale, short
Flaherty caregivers to sociodemographic charac- form
(1992) chronically ill teristics Geriatric
elderly per- relationship to the patient Depression Scale
sons (with type of patient’s illness no further
Alzheimer, caregiving tasks information
inconti- time required
nence, etc.), employment status
most of perceived burden of care-
whom white, giving tasks
female, and physical and mental health
married to status
the patients utilisation of health services
received or desired help
Results
Caregivers with high SOC scores were compared to those with low scores. Caregivers with a
pronounced SOC perceived themselves as having less stress by their partners’ illness, have
better mental health, i.e., lower depression values, etc., feel they have better support from
friends and relatives and require less aid.
Age, employment, health status, extent of the caregiving activities, and severity of the illness do
not correlate significantly with the SOC. In contrast, the relationship between the SOC and
depression (r=-.49) and mental health (r=.36) is significant.
The SOC values of men are higher than those of women.

Dangoor & Israel N=88 SOC SOC-scale
Florian physically medical diagnosis Mental Health
(1994) disabled (neurological disease, Inventory
married skeletal-muscular disease, Evaluating and
younger inner chronic illness) Nurturing
women age Relationship
socio-economic status Issues
functional handicaps Communication
effects of the handicap and Happiness
mental health Scale
family adaptation to the self-developed
illness scales
Results
The SOC correlates high with mental health (r=.80) and family adaptation to the illness (r=.53)
and correlates negatively (r=-.23) with the effects of the handicap.
Not the objective aspects of the handicap but the extent of the SOC appears to be decisive for
the adaptation to the illness. Medical diagnosis and functional handicaps have no predictive
value.
The high correlation between mental health and SOC can possibly be attributed to confounding
between the MHI and the SOC-scale.
Author/Year
Dudek &
Makowska
(1993)
Country
Poland
Sample
N=523
pregnant
women in
hospital for
delivery
Variables Examined
SOC
age
education
employment
Instruments
SOC-Scale
6
Results
The authors found high item intercorrelations and high correlations between the sub-scales.
Manageability explains 80% of the variance of the complete SOC-scale.
The scale has high reliability (split-half method r=.91).
The authors found a five-factor-solution: Meaningfulness and Comprehensibility – the latter
consisted of 3 sub-scales.
No relationship could be established between age and education level and the SOC.
Low correlations (r=.11 and .14, respectively) between comprehensibility and age/education
level.

Flannery & USA N=95 SOC SOC-scale
Flannery adult life stress Hassles Scale
(1990) students psychological distress Taylor Manifest
attending anxiety Anxiety Scale
Flannery, night school, depression Beck Depression
Perry, Penk & predomi- Inventory
Flannery nately
(1994) women
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 & USA N=374 SOC SOC-scale
Jorgensen healthy men patient/non-patient status Perceived Stress
(1993) and women, age Scale
and psycho- gender State-Trait Anxiety
therapy perceived stress Inventory-Trait
patients anxiety Beck Depression
depression Inventory
alcohol consumption Quantity-
social desirability Frequency-
intelligence Variability
Questionnaire
Social Desirability
Scale
Shipley Institute of
Living Scale
Results
The authors found a one-factor solution for the SOC-scale and a high retest-reliability.
Age and SOC correlated significantly in the expected direction.
Patients have lower SOC values than healthy persons.
In contrast to the expectations there was no significant relationship found between the SOC and
alcohol consumption.
There was a high negative relationship (r=-.73) between the SOC and perceived stress in both
groups.
There was a correlation of r=-.85 between the SOC and anxiety in the patient groups, which
raises the question, whether these are two distinct constructs.
As well, a high correlation of r=-.60 between the SOC and depression in patients was found; and
r=-.39 between the SOC and social desirability.
There was no relationship found between the SOC and intelligence.

Gallagher, Belgium N=126 SOC SOC-scale
Wagenfeld, caregivers type of illness Activity of Daily
Baro & (predomi- role overload Living
Haepers nately coping responses self-developed
(1994) women) of scales
demented
Baro, Haepers, and chroni-
Wagenfeld & cally ill per-
Gallagher sons
(1996)
Results
Negative correlations between the SOC and perceived feelings of role overload.
The higher the SOC, the greater the ability to attribute meaning to the caretaking activity (in the
sense of a coping strategy).
Negative correlations also between the SOC and active coping strategies, as well as between
the SOC and coping strategies such as social withdrawal, smoking, and the consumption of
medication.

Gebert, Broda Germany N=250 SOC SOC-scale
6
& Lauterbach patients of a constructive thinking – the Constructive
(1997) psychoso- ability to solve every day Thinking Inventory
matic clinic problems with a minimal Gießener Be-
amount of stress schwerdebogen
control physical symptoms (Gießener
group: psychological symptoms Complaints Ques-
N=121 gender tionaire)
clinically patient/non-patient status Kieler Änderungs-
asympto- age sensitive Sym-
matic education ptomliste (Kieler
persons Symptomlist
Sensitive to
Change)
Results
No gender differences, when age was controlled for.

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

George USA N=653 SOC SOC-scale
(1996) field-workers, perception of risk to their Home Health
predomi- own health by their profes- Care Perception
nately sion (home health care) of Risk
female, that age Questionnaire
make house education
calls or do years of employment
home health gender
care for
health orga-
nisations
Results
Weak but significant correlations:

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

Gibson & USA N=306 SOC SOC-scale
Cook (1997) Open personality traits Dispositional Re-
University general state of health silience Scale
students gender Eysenck Perso-
(N=67 male, nality Inventory
N=239 fe- General Health
male) Questionnaire
Results
Significant negative correlations between general health and the SOC (r=-.26) for women; in
contrast, hardiness correlates negatively with general health for men (r=-.33).
Women have higher values in the meaningfulness scale than do men.

Hood, Canada N=16,291 SOC SOC-scale, short
Beaudet & Adults gender form
Catlin (1996) (National age self-developed
Population income scales
Health Sur- education
vey) ethnic origin
family status
employment
traumatic events
recent life events
functional level of health
subjective level of health
chronic illnesses
Results
Weak, but significant correlations with the three dependent variables in the expected direction
(correlation between r=-.10 for chronic illnesses and r=.31 for functional aspects of health).
SOC explains 10% of the variance for functional level of health, 4% for subjective level of health,
and 1% for chronic illnesses. The other independent variables each explained 15% of the
variance.
No gender differences.
Persons with traumatic experiences have lower SOC-values than those without traumatic
experiences.
6
Korotkov Canada N=712 SOC SOC-scale, short
(1993) Students daily stress form
perceived physical sympto- Hassles and
matology Uplifts Scale,
emotionality revised version
Symptom Check-
list, revised
version
self-developed
scales
Results
The author found evidence for the hypothesis that the SOC and emotionality are confounded.
Face validity: 11 of 13 items refer to feelings (according to two independent raters).
Construct validity: Authors found three factors: Symptomatology, chronic stress, and as a third
factor all items of the SOC and the emotionality scale.
Predictive value of the SOC score low, if age, gender, and emotionality are partialled out (3% of
the variance explained for physical health).
No variance explained for physical health by the SOC at the second measurement (4 weeks fol-
lowing the first).

Kravetz, Drory Israel N=164 SOC SOC-scale
& Florian patients with hardiness Hardiness Scale
(1993) coronary Locus of Control Rotter’s I-E
heart anger Locus of Control
disease depression Scale
anxiety State-Trait An-
xiety Scale
Beck Depression
Inventory
Anger Arousal
Scale
Results
The authors found two factors: negative affect and health proneness. Hardiness and Locus of
Control load on the factor health proneness, which in turn, correlates negatively with the second
factor, “negative affect” (anger, depression, anxiety). The SOC correlates with the factor “nega-
tive affect” to the same extent as it correlates positively with the factor “health proneness”. The
authors regard this as calling to question the discriminative validity of the SOC-construct. They
point out that the SOC encompasses many aspects of anxiety, depression, and anger. This can
be seen on the level of the items that very often address the questionees negative feelings.

Langius, Sweden N=97 SOC SOC-scale
Björvell & nurses self-motivation Self-Motivation
Antonovsky anxiety Inventory
(1992) N=166 male hostility Karolinska
and female Scales of
patients Personality
N=155 men
and women
of the normal
population
Results
The groups showed no differences in their SOC scores.

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

Langius & Sweden N=145 SOC SOC-scale, short
Björvell men and general health and long form
(1993) women of physical and psychological Sickness Impact
three health Profile
different age self-developed
age groups scales
Results
Relationship between the SOC and the SIP-total scale r=-.29; a more exact analysis revealed
however, that the relationship stems from significant correlations between the score on the 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=-.21
for the short form).
Hardly any differences between the short and the long form of the SOC-scale.

Larrson & Sweden N=2003 SOC SOC-scale, short
Kallenberg men and age form
6
(1996) women of a gender Stress Profile
representa- education Life Style Profile
tive popula- employment self-developed
tion sample income scales
size of household
number of friends
general physical health
psychological well-being
physical and psychological
symptoms
Results
Men have higher SOC scores than women.

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

Lundberg Sweden N=4390 SOC SOC-scale, short
(1997) persons of a age form
representa- gender self-developed
Lundberg & tive popula- social class scales
Nynström tion sample Indicators of childhood
Peck (predomi- conditions
(1994) nately par- Illness Indicators
ticipants in a
longitudinal
study)
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 than
self-employed and salaried workers.
Low SOC scores correlate with poor psychological and physical health, even when controlled for
age, gender, and childhood situation, i.e., the risk of psychological distress for a person with a
weak SOC is 3.5 times higher than that of persons with an average or high SOC score.
The SOC and social circumstances in childhood are independent influential factors on the health
of the adult.

Margalit, Israel N=161 SOC SOC
Raviv & pairs of parent’s gender Coping Scale
Ankonina parents of handicapped child or non- Family Environ-
(1992) either han- handicapped child ment Scale
dicapped or coping behaviour Child Behaviour
non-handi- perceived family environ- Checklist
capped ment
children perceived abnormal
behaviour of child
Results
Parents of handicapped children exhibit lower SOC scores than those without a handicapped
child, i.e., the handicap makes the parents feel that the world is less controllable and compre-
hensible.
Gender differences could be found in the sense that fathers had higher SOC scores than
mothers.

McSherry & USA N=60 different strengths of the State-Trait Perso-
Holm students SOC nality Inventory
(1994) with high, anxiety Stress Arousal
middle, and anger Checklist
low SOC curiosity Dakota Cognitive
scores stress perceptions Appraisal Inven-
coping behaviour tory
pulse rate Dimensional
skin resistance Coping Checklist
physiological data
with the aid of the
necessary
equipment
Results
The subjects were exposed to a stress situation. Time of measurement was before and after the
stress stimulus. It could be demonstrated that subjects with high and average SOC scores were
significantly less stressed, anxious, and angry than those with low SOC scores.
There were also differences in the expected direction regarding the estimation of the own coping
ability and coping strategies, i.e., people with low SOC scores make use of less coping
resources, less social, material, and psychological resources and have less confidence in their
ability to master the situation.
The authors found relationships between the SOC and self-efficacy as well as Locus of Control.
High SOC scores lead to a reduction in the physiological parameters toward the end of the
confrontation with the stress stimulus, i.e., although all three groups showed a reaction to stress,
those with lower SOC scores begin and end the stress situation with higher stress
measurements.
Author/Year
Pasikowski,
Sek & Scigala
Country
Poland
Sample
N=60
men and
Variables Examined
SOC
gender
Instruments
SOC-scale
Health Belief
6
(1994) women education Scale
place of residence
Health Locus of Control
(holistic-functional or bio-
medical health models)
Results
No differences between men and women, persons with higher or lower education and persons
from rural or urban areas regarding the SOC scores. The “meaningfulness” scale correlates with
a holistic-functional model of health.

Petrie & Brook New N= 150 SOC SOC-scale
(1992) Zealand parasuicidal depression Hopelessness
male hopelessness Scale
patients self-esteem Self-Rating De-
(N=39) and suicidal ideation pression Scale
(N=111) fe- Coopersmith
male patients Self-Esteem In-
ventory
Paykel et al.
Scale
Results
Correlations between the SOC sub-scales and the other variables were significant in the
expected direction (between r=.65 and r=.76). Sub-scale meaningfulness the best predictor
variable for suicidal ideation during hospitalisation.
Six months later the SOC sub-scales comprehensibility and manageability the best predictor
variables.
The SOC better predictor for suicide risk than depression, etc.

Rena, Moshe Israel N=80 SOC SOC-scale
& Abraham paralysed severity of disability Acceptance of
(1996) patients and acceptance of disability Disability Scale
their N=72 anxiety State-Trait
spouses health Anxiety Inventory
relative vulnerability Relative Vulner-
marital satisfaction ability in Couples
social activities Relationship
work and study hours Index of Marital
Satisfaction
Questionnaire
self-developed
scales
Results
High, significant correlations between the SOC and anxiety, psychosomatic complaints, and
acceptance of the handicap.
Significant correlations also between the SOC and perceived dependence, marital satisfaction,
and work schedule.
Results were similar for the disabled persons as well as for the healthy spouses.
All three sub-scales of the SOC-scale have a significant predictive value.
The SOC is a better predictor of the adaptation to the illness than the severity of the illness.

Rimann & Switzer- N=559 SOC SOC-scale, short
Udris (1998) land male and stress at work and at home form
female social and organisational coping
salaried resources questionnaire
employees mental health as a personality self-developed
trait as coined by Becker questionnaires
Health Locus of Control no information
value orientations on further
coping styles instruments
age
gender
profession
position in the company’s
hierarchy
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 coping
attempts.
Gender differences are not clearly identifiable.
Relationship to age in the expected direction.
Professional action area and position in the company’s hierarchy correlate with the SOC –
management had the highest scores compared to other groups, unskilled workers the lowest.
Author/Year
Sammallahti,
Holi,
Komulainen &
Aalberg
(1996)
Country
Finland
Sample
N=122
psychiatric
patients and
N=334
persons of
Variables Examined
SOC
psychiatric illness
mental health
defence styles
Instruments
Defence Style
Questionnaire
General Health
Questionnaire
Symptom Check-
6
the normal list 90
population
as a control
group
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 psychiatric
symptoms and mental health.
The SOC correlates with all the sub-scales of the SCL-90 like somatisation, depression, anxiety,
anger, hostility, psychoticism, etc.
Immature Defences Style (a sub-scale of the DSQ) and the SOC correlate at r=-.78.

Scherwitz & USA N=48 SOC not reported
Ornish older patients psychophysiological
(1994) scheduled for measurements
angiography; Type A behavior patterns
control group participation/non-participa-
design: tion in the intervention
Lifestyle
Change Inter-
vention – par-
ticipants and
patients on
the waiting
list
Results
One year later, the SOC score was higher in the intervention group than in the control group.

Schmidt- Germany N=5133 SOC SOC-scale
Rathjens, men and personality type measurement of the
Benz, women (cancer personality, behaviour typology
Van Damme, between the heart-circulatory (Grossarth-Maticek)
Feldt & ages of 40 personality as coined by Life Orientation Test
Amelang and 65 Grossarth-Maticek) Fragebogen zur Er-
(1997) dispositional optimism fassung gesundheits-
health beliefs bezogener Kontroll-
time urgency and überzeugungen
perpetual activation (Questionnaire to
anger measure health be-
hostility liefs)
psychoticism Time Urgency and
personality traits as Perceptual Activation
conceptualised by Scale
Eysenck State-Trait-Anger-Ex-
exaggerated social pression Inventory
control Depressivitäts Skala
critical life events (Depression Scale)
social support Eysenck Persönlich-
physical health keits Inventar (Ey-
gender senck Personality
Inventory)
Way of Life Scale
List of Critical Life
Events
Questionnaire of
Social Support
Results
Healthy persons have higher SOC scores than ill persons, independent of gender.
Women have lower scores than men – differences are, however, slight when compared 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 with
cardiovascular disease disappear when depression and neuroticism are controlled for. They
therefore can be explained by the last two variables.

Studies Mentioned in Antonovsky’s Review Article 1

Antonovsky & Israel N=805 SOC SOC-scale
Sagy (1990) adults socio-economic status Attitude towards
shortly gender Retirement-Scale
Sagy, before attitude towards retirement
Antonovsky & retirement
Adler (1990)
Results
The higher the SOC score, the less likely the subject was to perceive the impending retirement
as a loss, rather the more likely he or she was to experience it as a gain.
This result was found for all the social classes examined and for men as well as women; it is thus
independent of socio-economic status and gender.

Antonovsky, H. Israel N=418 SOC SOC-scale
& Sagy (1986) students of emotional closeness with State-Trait
different parents Anxiety Inventory
ages, communication with parents self-developed
N=63 of age scales
which be- gender
6
fore and stability of the community
after the anxiety
evacuation
of the Sinai
Results
Boys have higher SOC scores than girls.

Older students have a higher SOC than younger students.
No influence could be determined of the emotional bond and communication with parents on the
SOC score.
The more unstable the environment, the lower the SOC score.
Contrary to the hypothesis the quality of the parent-child relationship had no effect on the SOC
score.
The variable examined explained only 8% of the variance.
The higher the SOC score the lower the anxiety score (trait).
No relationship could be established between SOC and anxiety (state) in an acute crisis (one
week before the evacuation). However, the correlation is significant six weeks after the evacua-
tion, i.e., when the crisis situation got back to normal, youths with a higher SOC score showed a
lower anxiety score (state).
1 Antonovsky, A. (1993c): The structure and properties of the Sense of Coherence Scale. Social Science & Medicine, 36, 725–733.

Antonovsky & Israel N=60 FSOC (Family Sense of Family Sense of
Sourani handicapped Coherence) Coherence Scale
(1988) men and Perceived family Family
their wives, satisfaction Adaptation Scale
working class
Results
Families with a high SOC score perceived their families to be better adapted to the father’s
handicap and are more satisfied with the family environment.

Carmel, Israel N=230 SOC SOC-scale
Anson, male and age The Social Read-
Levenson, female gender justment Rating
Bonneh & members recent life events Scale
Maoz of two psychological well-being Scale of Psycho-
(1991) kibbutzim physical well-being logical Distress
functional ability Quality of Well-
Anson, being Scale
Carmel, self-developed
Levenson, scales
Bonneh &
Maoz
(1993)
Results
The SOC correlates positively with health measurements (r=.12 to r=.23).

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

Cederblad & Sweden N=148 SOC SOC-scale
Hansson persons intelligence Symptom Check-
(1996) belonging to activity, flexibility and list 90
psychiatric stability as personality traits Quality of Life
Cederblad, risk groups Locus of Control Scale
Dahlin & coping strategies Health Sickness
Hagnell quality of life Rating Scale
(1993) physical and mental health Ways of Coping
Checklist
Cederblad, Locus of Control
Dahlin, Sjobring Model of
Hagnell & Personality
Hannson Dimensions
(1995)
Dahlin,
Cederblad,
Antonovsky
& Hagnell
(1990)
Results
In addition to the SOC, 8 further personality dimensions were examined.

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

6
Hart, Hittner & USA N=59 SOC SOC-scale, short
Paras College anxiety form
(1991) students social support Trait Anxiety
Inventory
Interpersonal
Support
Evaluation List
Results
High correlations between anxiety and the SOC.

No relationship between the SOC and social support.

6.5. Orientation to Life Questionnaire
(SOC-Scale)
Source: Antonovsky, A. (1987): Unraveling the mystery of health. How people manage
stress and stay well.
Orientation to Life Questionnaire

Here is a series of questions relating to various aspects of our lives. Each question has seven
possible answers. Please mark the number which expresses your answer, with numbers 1 and 7
being the extreme answers. If the words under 1 are right for you, circle 1; if the words under 7
are right for you, circle 7. If you feel differently, circle the number which best expresses your
feelings. Please give only one answer to each question.
1. When you talk to people, do you have the feeling that they don’t understand you?
never have this feeling always have this feeling

1 2 3 4 5 6 7
2. In the past, when you had to do something which depended upon cooperation with
others, did you have the feeling that it:
surely wouldn’t get done surely would get done

1 2 3 4 5 6 7
3. Think of the people with whom you come into contact daily, aside from the ones to
whom you feel closest. How well do you know most of them?
you feel that they’re you know them very well

1 2 3 4 5 6 7
strangers
4. Do you have the feeling that you don’t really care about what goes on around you?
very seldom or never very often

1 2 3 4 5 6 7
5. Has it happened in the past that you were surprised by the behaviour of people whom
you thought you knew well?
never happened always happened

1 2 3 4 5 6 7
6. Has it happened that people whom you counted on disappointed you?
never happened always happened

1 2 3 4 5 6 7

7. Life is:
full of interest completely routine

1 2 3 4 5 6 7
8. Until now your life has had:
no clear goals or purpose very clear goals and pur-

1 2 3 4 5 6 7
at all pose
9. Do you often have the feeling you’re being treated unfairly?
very often very seldom or never

1 2 3 4 5 6 7
10. In the past ten years your life has been:
full of changes without completely consistent

1 2 3 4 5 6 7
your knowing what will and clear
happen next
11. Most of the things you do in the future will probably be:
completely fascinating deadly boring

1 2 3 4 5 6 7
6
12. Do you have the feeling that you are in an unfamiliar situation and don’t know what to
do?

1 2 3 4 5 6 7
13. What best describes how you see life:
one can always find a there is no solution to

1 2 3 4 5 6 7
solution to painful things painful things in life
in life
14. When you think about your life, you very often:
feel how good it is ask yourself why you

1 2 3 4 5 6 7
to be alive exist at all
15. When you face a difficult problem, the choice of a solution is:
always confusing and always completely clear

1 2 3 4 5 6 7
hard to find

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

1 2 3 4 5 6 7
and satisfaction dom
17. Your life in the future will probably be:
full of changes without completely consistent and

1 2 3 4 5 6 7
your knowing what will clear
happen next
18. When something unpleasant happened in the past, your tendency was:
“to eat yourself up” to say “ok, that’s that, I

1 2 3 4 5 6 7
about it have to live with it”, and go
on
19. Do you have very mixed up feelings and ideas?

1 2 3 4 5 6 7
20. When you do something that gives you a good feeling:
it’s certain that you’ll go it’s certain that something

1 2 3 4 5 6 7
on feeling good will happen to spoil the
feeling
21. Does it happen that you have feelings inside that you would rather not feel?

1 2 3 4 5 6 7
22. Do you anticipate that your personal life in the future will be:
totally without meaning full of meaning and

1 2 3 4 5 6 7
or purpose purpose
23. Do you think that there will always be people whom you’ll be able to count on in the
future?
you’re certain there will be you doubt there will be

1 2 3 4 5 6 7
24. Does it happen that you have the feeling that you don’t know exactly what’s about to
happen?

1 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 often

1 2 3 4 5 6 7
26. When something happened, have you generally found that:
you overestimated or you saw things in the right

1 2 3 4 5 6 7
underestimated its proportion
importance
27. When you think of difficulties you are likely to face in important aspects of your life, do
you have the feeling that:
you will always succeed you won’t succeed in

1 2 3 4 5 6 7
in overcoming the overcoming the
difficulties difficulties
28. How often do you have the feeling that there’s little meaning in the things you do in
your daily life?

1 2 3 4 5 6 7
29. How often do you have feelings that you’re not sure you can keep under control?

1 2 3 4 5 6 7

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 the
points marked for each item in the questionnaire. Care, however, must be taken regarding the item
scoring. If the item is positively scored, then the rating value marked is taken at face value: for
example, a positively scored item which the questionee rates at “2”, is then scored with two points.
However, if the item is reverse scored, the lowest value marked (i.e., 1) must be converted to the
highest value (i.e., 7). In keeping with this procedure, a 2 would get 6 points, a 3 would get 5 points
and so on.
Item Number SOC Item Scoring Short Form

Sub-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

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RESEARCH AND PRACTICE OF HEALTH PROMOTION
WHAT KEEPS PEOPLE HEALTHY? ANTONOVSKY’S SALUTOGENETIC MODEL OF HEALTH

WHAT KEEPS
PEOPLE HEALTHY?
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AND THE RELEVANCE OF ANTONOVSKY’S
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RESEARCH AND PRACTICE OF HEALTH PROMOTION

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

It develops campaign concepts and strategies,

The FCHE uses research results to plan and

These studies and assessments, along with the

What Keeps People Healthy?

Expert report commissioned by the Federal Centre for Health Education

Federal Centre for Health Education (FCHE)

This volume is a translation of the German edition:

All rights reserved.

Editors: Stephan Blümel, Katharina Salice-Stephan

Composition: Salice-Stephan, Cologne

Printed on 100% recycled paper.

This publication can be obtained free of charge from:

Order No. 60 804 070

Cologne, November 1998 Dr. Elisabeth Pott

What Keeps People Healthy? 3

Project title: Antonovsky’s Salutogenic Model of Health.

Goals: • Examination of the literature

Material: Research monographs

Sources: Literature search in the databases Psyndex, Psyclit,

Implementation period: September 1997 – February 1998

Project implementation: Psychological Institute of the

Project management: Prof. Dr. Dr. Jürgen Bengel

Authors: Prof. Dr. Dr. Jürgen Bengel, Dipl.-Psych.

Sponsor: Bundeszentrale für gesundheitliche Aufklärung

Project management: Stephan Blümel

What Keeps People Healthy? 5

2. The Concept of Salutogenesis 21

2.1. The Salutogenic Problem 22

2.2. Criticism of Health Research and Health Care 24

2.3. The Salutogenic Model of Health 25

3. Current State of Research 37

3.1. The Sense of Coherence:

3.2. Sense of Coherence as Compared

3.3. Stress and Resilience Research 56

What Keeps People Healthy? 7

4. of the Concept in Different

4.1. Health Promotion and Prevention 63

4.2. Psychosomatics and Psychotherapy 66

5.1. Summary and Evaluation of the Scientific Discussion 76

5.2. Summary and Evaluation of the Importance

5.3. Outlook and Recommendations 87

6.1. Documentation of the Literature Search 94

6.2. Original Works by Antonovsky 95

6.4. Overview of the Studies on the Sense of Coherence 105

6.5. Orientation to Life Questionnaire (SOC-Scale) 124

8 Research and Practice of Health Promotion, Volume 4

In German-speaking countries, three volumes were published on the subject in 1997:

What Keeps People Healthy? 9

– What are the central statements and assumptions of the model?

10 Research and Practice of Health Promotion, Volume 4

What Keeps People Healthy? 11

– the criticism of the health care system,

In addition, events in Antonovsky’s life certainly had an influence on the conception of

Criticism of the Health Care System

14 Research and Practice of Health Promotion, Volume 4

The Examination of the Concepts of Health and Disease

The statistical norm of health is determined by the frequency of a characteristic of the

What Keeps People Healthy? 15

The Development of the Biopsychosocial Model of Disease

The Biomedical Model of Disease