Empirical relations between sense of coherence and self-efficacy, National Danish Survey

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1 Health Promotion International, 2016;31: doi: /heapro/dav052 Advance Access Publication Date: 11 June 2015 Empirical relations between sense of coherence and self-efficacy, National Danish Survey Rete Trap 1, *, Lillan Rejkjær 1, and Ebba Holme Hansen 2 1 Department of Social Medicine, University of Copenhagen, Copenhagen, Denmark, and 2 Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark *Corresponding author. rete.trap@gmail.com Summary Salutogenic orientation is a health promotion paradigm focusing on the resources of the individual. This study analyzed the relationship between sense of coherence (SOC) and self-efficacy (SE) based on population data. By conducting an empirical analysis of the two models, we wanted to see whether we could make a valid judgement as to whether both SOC and SE could be utilized in health promotion practice, or whether one is preferable to the other. The study population was randomly selected from the Danish Central Population Register and consisted of five birth-year cohorts (1920, 1930, 1940, 1965 and 1975). The study used the 13-item SOC scale and the general SE scale. The main findings were that SOC score increased by age cohort (p = ), and there is a positive and graded correlation between SOC and SE (r = 0.39; p < ) and adjusted OR = 10.3 (CI = ). We found the strongest association at the lowest level of SOC. For health promotion practice, this finding signifies the importance of focusing on improving SOC in people with a low SOC score, as they are most in need and most likely to increase their SOC level. The finding of higher SOC scores in the older age cohorts indicates that SOC changes over lifetime. Public health work focusing on lifestyle change by increasing SOC can be effective throughout life, however early intervention is important. The finding of a positive correlation between SOC and SE indicates that health promotion altering one of the constructs is paralleled in the other. Key words: sense of coherence, self-efficacy, salutogenesis, survey INTRODUCTION Appropriate health behaviours are not only important to prevent ill health but also to reduce unnecessary health care costs. Health behaviours (HB) are established as a result of individual coping strategies and the social environment. A positive life orientation combined with strong individual resources influences HB in a positive manner, resulting in increased health of the individual (Antonovsky, 1996). Lindstrøm and Eriksson (Lindstrøm and Eriksson, 2005) stated that health promotion focuses on people s resources and that the capacity to create good health is based on the salutogenic principle, which can be applied at the individual, group and societal level and addresses the interaction between people and structures in society. Salutogenic orientation is a viable paradigm for health promotion and points up the importance of investigating models focusing on the resources of the individual. Coping resources is a major component in health promotion The Author Published by Oxford University Press. All rights reserved. For Permissions, please journals.permissions@oup.com

2 636 R. Trap et al. research and an often used concept is self-efficacy (SE), developed by Albert Bandura (Bandura, 1997). This study analyses the correspondence between sense of coherence (SOC) and SE based on empirical data at the population level. As both SOC and SE influence HB, it is of special interest to analyse their association empirically, with focus on the advantage of applying SOC, SE or both in health promotion practice. Aaron Antonovsky who developed the SOC concept has described and defined it with different wording. In one of his later works Antonovsky described the SOC construct as a generalized orientation toward the world which perceives it, on a continuum, as comprehensible, manageable and meaningful (Antonovsky, 1996). Cross-sectional studies based on salutogenic theory have shown that a strong SOC enhances well-being (Suominen et al., 2001). Eriksson and Lindström (Eriksson and Lindström, 2006) found that SOC had a strong and graded association with perceived health, especially perceived mental health. This relation was manifest regardless of age, gender, ethnicity and nationality. An individual s SOC seems to be able to predict his or her health and have a major, moderating or mediating role in the explanation of health. Senjam and Amerjet (Senjam and Amerjet, 2011) found that high SOC scores were positively associated with high health promoting lifestyle scores. This association indicates that someone with a high health promoting lifestyle is relatively more likely to engage in health promoting activities such as health education, lifestyle modification, environment modification and nutrition intervention, thereby strengthening health status. Bandura (Bandura, 1997) defined SE as a generative capability in which cognitive, social, emotional and behavioural sub-skills can be organized and effectively coordinated to serve innumerable purposes. SE is a modifiable variable that can affect health status, influence mood and motivation and thereby maintain healthy behaviours (Bodenheimer et al., 2002; Marks et al., 2005). THE SOC CONCEPT In contrast to the classical pathogenic approach focusing on risk, ill health and disease, Antonovsky developed the concept of salutogenesis, which is a stress-resource oriented theory aiming at maintaining and improving the individual s movement towards health (Antonovsky, 1987, 1993, 1996). Antonovsky also developed the concept of SOC and found it to have a global orientation expressing the extent to which a person feels confident that: 1. the stimuli deriving from his or her internal and external environments in the course of living are structured, predictable and explicable 2. he or she has the resources available to meet the demands posed by the stimuli 3. these demands are challenges worthy of investment and engagement (Antonovsky, 1987). SOC embraces the three dimensions comprehensibility, manageability and meaningfulness. A person who possesses a high SOC has an enhanced individual ability to comprehend the world, to perceive manageability in whatever situation that arises and to find meaning in life (Antonovsky, 1987; Lindström and Eriksson, 2005, 2006; seefigure1). SOC is not constructed around a fixed set of mastering strategies, nor is it domain specific. Rather it is universal, based on learning processes in daily life, and it develops throughout life (Due and Holstein, 1998; Buddeberg-Fisher et al., 2001; Lindström and Eriksson, 2005). Antonovsky purports that comprehensibility develops as a result of predictable demands, manageability as a result of experiencing balance between demands and the resources available and meaningfulness as the result of experienced commitment and engagement (Antonovsky, 1987; Lindström and Eriksson, 2005, 2006). Antonovsky addressed each of the three components in the validated 13-item SOC scale (Antonovsky, 1993). He proposed the two elements general resistance resources (GRR) and SOC as the core elements of the salutogenic concept (Antonovsky, 1987; Figure 1). GRR can be any characteristic of a person, a group or an environment (genetic, physical and psychosocial) that can facilitate effective tension management and thereby GRR can make it easier to identify living as consistent, structured and understandable. Antonovsky indicated a direct relation between the level of SOC and a person s ability to employ cognitive, affective, instrumental strategies likely to improve coping and thereby maintain good health (Antonovsky, 1993; Lindström and Eriksson, 2005). THE CONCEPT OF SELF-EFFICACY The concept self-efficacy (SE) addresses HB from a slightly different perspective. SE is a coping concept developed by Bandura. It is founded in social cognitive theory applying an agentic perspective in which people function and exercise self-influence (control) (Bandura and Locke, 2003; see Figure 1). SE is understood as a generative capability in which cognitive, social, emotional and behavioural skills collaborate to serve innumerable purposes. Bandura developed the SE theory as a personal and collective agency (action-interaction) operating along with other sociocognitive factors in human well-being and attainment. SE is a subjective belief in the ability to execute the actions required to manage prospective situations. SE affects the

3 Relations between sense of coherence and self-efficacy 637 Fig. 1: Schematic presentation of the concepts SOC and SE. initiation or cessation of certain behavioural patterns, and the effort and persistence, motivation, thought patterns and emotional actions entailed. SE regulates human functions through cognitive, motivational, affective and selective processes (Bandura, 1997). A person s SE develops in a responsive environment that rewards certain behaviours. Bandura points out that experiencing valued accomplishment will encourage outcome-focused activities and thereby enable a person to exercise control over life events. This proposes a causal link between a belief in SE and outcome expectations (Bandura, 1997). Health promotion programmes applying SE must recognize that SE is under the influence of four factors: 1. The mastery experience, the most influential, is the interpreted result of one s purposive performance. Successes build a robust belief in one s personal efficacy. 2. The vicarious experience (i.e. modelling another person s behaviour) is weaker than the mastery experience, but when people are uncertain about their own abilities or have limited prior experience, they become more sensitive to modelling. 3. Verbal/social persuasion by significant others is a parameter that influences SE less than mastery and modelling. 4. Physiological and affective states (anxiety, stress, arousal, fatigue, mood states) are somatic and physiological indicators of personal efficacy (Bandura, 1997). Hence, SE is a variable phenomenon. The relation between the SOC and SE concepts The relation between SOC and SE is dependent on the elements (cognitive, motivational and affective) composing each of the two theoretical models which hereby demonstrate the similarities and the differences, as highlighted in Table 1 (Antonovsky, 1987; Bandura, 1997; Lindström and Eriksson, 2005, 2006). Both constructs include a cognitive component that enables people to anticipate events, a motivational component determining goal setting and personal investment and a capability component understood as a person s belief in own coping capabilities and

4 638 R. Trap et al. Table 1: Comparison of major elements in sense of coherence and self-efficacy concepts Sense of coherence Salutogenic orientation Self-efficacy Social cognitive theory Global orientation, the extent of having a feeling of confidence: Stimuli from the internal and external environment are structured, predictable and explicable Resources are available to meet the challenges from the stimuli These challenges are worthy of investment and engagement Comprehensibility The cognitive component: A person can reasonably anticipate events Meaningfulness The motivational component: Aspect of the environment worthy of personal investment Life events are challenges rather than burdens Challenges = Cognitive and affective Manageability The instrumental or behavioural component: The perception of personal resources as being adequate perception of resources. Three functional human processes (cognitive, motivational and affective) are fundamental to both SOC and SE. Each of the key components of SOC (comprehensibility, meaningfulness and manageability) can include all four learning processes for SE (mastery experience, vicarious experience, social persuasion, psychological factors) (Antonovsky, 1987; Lindström and Eriksson, 2005, 2006). The mutual learning processes may explain the correlation and interaction between SOC and SE (Tsuno and Yamazaki, 2007; Zirke et al., 2007; Weismann and Hannich, 2008). The two constructs differ as the SE concept includes the necessity of having control over one s life, including causal attributions, outcome expectancies and recognized goals. While there are no outcome expectancies in SOC, meaningfulness in the concept is understood as looking at life events as challenges. With SOC manageability deals Generative capability, serving innumerable purposes by the collaboration of Cognitive social, emotional and behavioural sub-skills Social cognitive theory: An agentic perspective People function and exercise self-influence (control) The cognitive process Human behaviour is regulated by valued goals that Enable a person to predict events and Develop ways to control events Motivation and purposive action Cognitive activity gives three forms of cognitive motivators: Causal attributions, outcome expectancies and cognized goals Self-efficacy influences all three areas by determining: Goal setting Effort expenditure The extent of a person s perseverance and resilience in dealing with failure The affective process Stress and depression in threatening or difficult situations are influenced by: A person s belief in own coping capability as well as the level of motivation The selective process is determined by a belief in personal efficacy Similarities are marked in italics/differences are in bold (Bandura, 1997; Antonovsky, 1987; Lindström and Eriksson, 2005, 2006). with the perception of resources, while in SE the selection of processes is determined by the perception of personal efficacy, and by avoiding activity and situations that exceed the ability to cope (Antonovsky, 1987; Bandura, 1997; Lindström and Eriksson, 2005, 2006; see Table 1). Weismann and Hannich (Weismann and Hannich, 2008) expressed SE as possible GRR characterized by (a) being consistent, (b) participating in shaping outcomes and (c) providing the right overload/underload balance. An individual s positive development of SE in a specific domain simultaneously increases GRR; resulting in increased SOC. Low SOC indicates either limited GRR or limited utilization of the available GRR (Lindström and Eriksson, 2006). Consequently, health promotion efforts that aim to increase GRR individually in a group or in society will result in increased coping capabilities and thereby lead to increased health.

5 Relations between sense of coherence and self-efficacy 639 METHODS Participants and procedures This study was based on data from the Danish Longitudinal Health Behaviour Study (DLHBS), which is described in detail elsewhere (Due et al., 1999). The study population was randomly selected from the Danish Central Population Register and consisted of five birth-year cohorts (1920, 1930, 1940, 1965 and 1975). The cohorts answered questionnaires at base line in 1990 (sample n = 4048 with 70.6% response rate resulting in a study population of total n = 2858), and at follow-up in 1994 (sample = 2729 with 86.2% response rate resulting in a study population of 2352). Questionnaires were mailed to the eligible populations. Reminders were sent to non-responders 2 and 4 weeks later. This study analyses the SOC and SE data that were included in the 1994 questionnaires only, and social status (SES) data from 1990 for Cohort A (parent), D, E, and SES data from 1994 for B and C cohorts. An attrition analysis with regard to age and gender compared participants with non-participants in the year 1990 and found the lowest response rate among the 60-year cohort and the highest in the 15-year-old cohort (p < ), with no difference between female and male participation (Due and Holstein, 1998). Measures The Antonovsky s validated scale consisted of 13 questions with responses to be rated from 1 to 7 (Antonovsky, 1993; Eriksson and Lindström, 2005, 2006). SOC was calculated as the mean for each individual who had answered at least 10 of the 13 items. A high SOC score was equivalent to a high numerical value (range, ) (Due and Holstein, 1998). The distribution of SOC was assessed in four quartiles (below mean, mean, above mean and high). The validated scale for general SE was questionnairebased with 10 questions and response categories 1 4 (always never) (Schwarzer and Scholz, 2000). The SE variable was expressed as the total sum of answers calculated individually for all 10 items (range 10 40). A high SE was equivalent to a low numerical score. The SE was assessed in five quintiles. Potential confounders were identified based on their known correlation with SOC: age (Due and Holstein, 1998; Zirke et al., 2007), socio-economic status (SES) (Antonovsky, 1993; Due and Holstein, 1998) and gender (Myrin and Lagerström, 2006). The analysis was adjusted for gender, age and SES (family social status). Statistical analysis The statistical analysis was performed using SAS 9.1 software. We used Pearson correlation coefficient analysis to analyse the correlation between SOC and SE, including the three components of SOC. Simple linear regression with plot was conducted to depict the relation between SOC and SE. Logistic regression analysis was performed to assess the relation between SOC and SE expressed by odds ratio (OR), crude and adjusted for gender, age and SES. To assess the confounder influence, the correlation between the dichotomized SOC variable and SE was analysed, stratifying for gender, age and SES. When relevant, results are presented with 95% level of significance and values are presented as mean ( percentages). Ethics Ethical approval of questionnaire-based survey studies in the general population is not possible and not required in Denmark. The participants were informed in writing that participation was voluntary and anonymous. The study was approved by the Danish Data Protection Agency. RESULTS In the study population, the distribution of SOC had a mean of 5.0 with a SD = The distribution of SE had a mean of 20.2 with a SD = 3.78 (data not shown). The SOC score increased by age cohorts, with a significantly lower SOC score in the youngest cohort (p = ). No consistent change of SE by age cohorts was found. For females compared with males, a lower level of SE was observed in four of the five cohorts (p < 0.05) (Table 2). The correlation between SOC and SE was analysed by Pearson correlation coefficient (r = 0.39; p < ). The three specific SOC components had correlations of similar size and direction, i.e. meaningfulness r = 0.36, comprehensiveness r = 0.35 and manageability r = 0.30; p < Scatter plot depicted the positive correlation between SOC and SE (residual variance = 0.151; p < ) (Figure 2). Stratified analyses resulted in the following r values; for gender (F/M) (0.33/0.28; p < ), for age (cohort) ( ; p < ) and for SES ( ; p < 0.005), confirming the association. Logistic regression analysis found a graded association at different levels of SOC and SE. High SE outcome when exposed to high SOC had a crude OR = 9.9 (CI = ). Adjusting for gender, age and SES did not influence these findings notably; adjusted OR = 10.3 (CI = ) (p < ). The correlation between SE and different levels of SOC resulted in different β-values: low (<below mean) (β = 0.58; p < ), (middle below mean <above mean) (β = 0.27; p < ), (high above mean)

6 640 R. Trap et al. Table 2: Description of basic study variables by age and gender Category Birth cohort 1975 (A) Birth cohort 1965 (B) Birth cohort 1940 (C) Birth cohort 1930 (D) Birth cohort 1920 (E) Total Eligible population a Responders (%) 729 (86.9) 607 (87.6) 347 (86.5) 293 (85.9) 376 (82.3) 2352 (86.2) Gender % (n) F M F M F M F M F M F M 33.1 (419) 28.6 (310) 25.4 (322) 26.2 (285) 14.4 (182) Distribution of sense of coherence, N = 2280, column % Number High: Above mean: Below mean: Low: < Distribution of self-efficacy, N = 2327, column % Number Low: Below mean: Mean: Above mean: High: < Socio-economic status (SES), b N = 2528, column % Number I II III IV V VI (165) 11.0 (139) 14.2 (154) 16.1 (204) 15.8 (172) 53.8 (1266) 46.2 (1086) a Eligible population = alive, residents in Denmark, willing to participate. b SES is constructed including SES 1990 for Cohort A (parent), D, E and SES 1994 for B, C.

7 Relations between sense of coherence and self-efficacy 641 Fig. 2: Simple linear regression analyses between SOC and SE. (β = 0.36; p < ). The most profound correlation was found in the low SOC group. The main findings were that the SOC score increases by age cohorts, with a significantly lower SOC score in the youngest cohort (p = ). A positive and graded correlation between SOC and SE (r = 0.39; p < ) was found and confirmed in the stratified analysis. The positive relationship was robust with a crude OR = 9.9 (CI = ) and an adjusted OR = 10.3 (CI = ) indicating the high probability for simultaneous occurrence of high level of SOC and SE. The most profound association was found in the low SOC group. DISCUSSION This study has three main findings: SOC score increases by age cohorts, there is a positive correlation between SOC and SE and the most profound relation is in the lowest SOC group. In this study, we analysed the empirical relationship between the SOC and the SE concept, based on a representative sample of the Danish population. We found significantly higher values of SOC with increasing age cohorts, indicating that SOC changes throughout life. This finding is in line with a Swedish study, which found SOC to be associated with an individual s position in the social structure (work conditions and social network) rather than with childhood conditions (Krantz and Ôsterberg, 2004). Similarly, Zirke found a significant increase in SOC values with increasing age (Zirke et al., 2007). This indicates the meaningfulness of working with SOC in health promotion for all age groups. The positive correlation between SOC and SE is in line with five cross-sectional studies with r between 0.35 and 0.61 (Cilliers and Kossuth, 2004; Tsuno and Yamazaki, 2007; Kuroki et al., 2007; Zirke et al., 2007; Wiesmann and Hannich, 2008). Two studies used the same general SE scale and SOC scale as our study (Kuroki et al., 2007; Wiesmann and Hannich, 2008). The remaining three studies used different SOC as well as different SE scales. Cilliers and Kossuth (Cilliers and Kossuth, 2004) used the SOC-29 scale and the SE single score, Tsuno and Yamazaki (Tsuno and Yamazaki, 2007) used the SOC-13 scale and the SE-16 item, while Zirke et al. (Zirke et al., 2007) usedthe SOC-L9 scale and the SWOP-K9. The one study that did not report any correlation between SOC and SE used the Lundberg-4 item scale for measuring SOC and the general SE scale by Schwartzer. Further, this study did not assess the correlation between SOC and SE directly, but evaluated the correlation between HB ( previous healthcare) and SOC and SE, respectively, finding a significant association between low SOC and HB (OR = 3.72), and no association between SE and HB (Bazin et al.,2005). None of the studies included analyses stratified for gender, age and SES. In our study, the crude OR = 9.9 did not change significantly when adjusting for gender age and SES (adjusted OR = 10.3).

8 642 R. Trap et al. The general SE scale applied in our study is grounded in the premise that SE is connected to a broad range of psychological constructs pertaining to various domains of human functioning, its strength being its generality (Schwarzer and Scholz, 2000; Luszczynska et al., 2005). Bandura has argued that SE is domain specific and thus related to different behaviours, and he recommends the development and use of domain-specific scales(bandura, 1997; Bandura and Locke, 2003). In examining the three specific SOC components, the finding of a lower correlation between SE and manageability might be explained by the selective process with the difference in SOC s focus on resources to cope with life and SE s focus on outcome success (Table 1). We found a positive correlation for all levels of SOC, but the strongest association was found at the lowest level of SOC. This signifies the importance of health promotion focus on improving SOC in people with low SOC, as they are those most in need as well as most likely to increase their SOC level. To our knowledge, no studies have previously been published focusing on the interrelation of SOC and SE at different SOC levels. The finding of a positive correlation between SOC and SE, and SE being a GRR in SOC could indicate that health promotion altering SE would also influence SOC. Moreover, the finding of higher SOC scores in the older age cohorts indicates that SOC changes over a lifetime, and therefore public health work focusing on lifestyle change by increasing SOC can be effective throughout life. Moreover, the findings of the most profound correlation in the lowest SOC group (β = 0.58) indicates that starting early in life targeting persons with low SOC will result in the greatest impact. Health promotion work needs to focus on the individual s resources, strengthening people s manageability, comprehensibility and meaningfulness, and thereby mobilizing competences that make people robust in demanding life situation. Strong SOC and SE increase the individual s ability to adopt a healthy lifestyle and to respond to health-related advice (Bodenheimer et al., 2002; Marks et al., 2005; Senjam and Amarjet, 2011). Working with SOC as a universal resource and SE as a domain-specific resource or GRR at individual, group or environmental levels could be a health strategy choice. Our study indicates that quality in health could be improved by efforts to improve SOC and SE. ACKNOWLEDGEMENTS We thank professor, mag scient.soc. Bjørn E. Holstein, National Institute of Public Health, University of Southern Denmark, for inspiration and constructive comments in the initial phase of the project. CONFLICT OF INTEREST The authors declare no conflicts of interest. REFERENCES Antonovsky A. 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