As mentioned above, the salutogenic theoretical framework proposed that over the lifespan, individuals may develop high levels of SOC through successful applications of GRR-RDs. At the same time, this theoretical framework also assumed a reciprocal and dynamic relationship between SOC and GRR-RDs. Consequently, whereas GRR-RDs may contribute to an individual's and community's levels of SOC, an individual's and community's levels of SOC may, in turn, contribute to mobilizing GRRs for enhancing the ability of stress management (Antonovsky, 1987; Sagy & Dotan, 2001). However, only few research studies reviewed in the present chapter examined this assumption on the reciprocal relationships between these two variables (e.g., Volanen et al., 2004), calling for future investigation regarding the possible bidirectionality of these interrelationships.

#### B. *Individuals' Differential Susceptibility to Environment Effects*

Previous studies have underscored that individuals may vary in their responsivity to the qualities of their environments, including their childrearing experiences (see Pluess & Belsky, 2011, for a review). These assumptions are generally framed in diathesis-stress or "dual risk" terms, proposing that some individuals tend to be more vulnerable due to their biological/neurological and or behavioral characteristics (i.e., "stress" or "risk 1") to the adverse effects of negative experiences and environmental qualities (i.e., "diathesis" or "risk 2") (Belsky et al., 2007; Belsky & Pluess, 2009; Trentacosta et al., 2008), whereas others may be relatively resilient. Findings from such studies have also pinpointed that individuals may vary not only in the degree to which they are vulnerable to the negative effects of adverse experiences but also, more generally, in their "developmental plasticity" (Boyce & Ellis, 2005). Accordingly, this hypothesis, which was termed the "biological sensitivity to context" (Boyce & Ellis, 2005), or "differential susceptibility hypothesis" (Belsky, 2005), assumes that individuals may vary in their susceptibility to both adverse and benefcial effects of childrearing infuences.

Overall, studies analyzing the susceptibility factors that may contribute to individual children's differential susceptibility emphasized the possible role of three categories of variables, such as genetic factors (e.g., short allele of the serotonin transporter linked polymorphic region, 5-HITTLPR), physiological factors (e.g., cortisol reactivity), and behavioral factors (e.g., negative emotionality) (see Pluess & Belsky, 2011 for a review). Such fndings call for comprehensive additional exploration regarding individuals' variations in genetic, biological, and behavioral sensitivities, which may predict their susceptibility not only to the adverse effects of GRR-RDs but also to benefcial effects of such factors. Such differential susceptibility has rarely been examined among communities, calling for future comprehensive investigation.

#### C. *Flexibility Versus Stability*

The current review raises an important question regarding the fexibility versus stability of SOC across the lifespan. Antonovsky (1987) hypothesized that SOC develops during childhood and stabilizes during the early adulthood stage. In contrast, other research proposed SOCs changes over an entire lifetime (e.g., Nilsson et al., 2003; Nilsson et al., 2010). These fndings raise several important issues regarding the longitudinal fuctuations as well as stability versus fexibility in individual SOC across the different development phases.

#### D. *Hedonia, Eudaimonia, and Meaning in Life Perspectives*

In exploring the impact of GRR-RDs on individuals' levels of SOC, further studies may do well to consider exploring the possible role of three additional individual-level orientations—eudaimonia, hedonia (e.g., Huta & Waterman, 2014; Ryan & Deci, 2001; Ryff & Singer, 2008; Steger et al., 2008), and meaning in life (e.g., Costin & Vignoles, 2019; George & Park, 2016; Martela & Steger, 2016; Ryff, 1989). Briefy, eudaimonia is defned as striving to use and develop the best in oneself, in ways that are congruent with one's values and authentic self, including striving for excellence, meaning, acting with virtue, and having concerns beyond the self and beyond the immediate moment (e.g., Huta, 2012). Hedonia is defned as striving to experience pleasure, enjoyment, and comfort, whether through physical- or emotional-cognitive means (Huta & Ryan, 2010). The third concept—meaning in life—has been defned as comprising three distinct subconstructs: comprehension, purpose, and mattering (e.g., George & Park, 2016; Heintzelman & King, 2014; Martela & Steger, 2016; Steger, 2012). As argued by Martela and Steger (2016), *meaning in life* partially coincides with the eudaimonia concept as well as with the SOC concept. Much has been learned in recent years regarding these concepts and their association with a variety of well-being measures (e.g., George & Park, 2016; Huta & Waterman, 2014). However, the possible association with the SOC, as well as the possible role of concepts such as GRR-RDs, has not been suffciently explored and calls for further investigation**.**

#### **Selected GRR-RDs**

Conceptual matters merit words of caution regarding the possible role of GRR-RDs in understanding individuals' levels of SOC. Since the GRR-RDs reviewed in the current chapter are only few of the possible individual, familial, and community factors, additional resources should be considered. Such resources may include the individual's selfregulation and executive functioning abilities, parental monitoring levels, and parental anxiety, as well as school climate and collective versus individual approach.

Furthermore, such resources may also include GRR-RDs that develop early in life (i.e., neonatal period and birth). As suggested by prior studies (Bauer et al., 2019; Hansson et al., 2008; Silventoinen et al., 2014), neuro-hormonal, epigenetic factors, exposure to risk conditions (e.g., maternal stressors and toxic substances), can set pathways for future wellbeing. However, such resources have been rarely examined within the SOC framework, calling for additional exploration.

#### **Clinical and Interventional Implications**

Acknowledging the importance of SOC as a factor contributing to effective coping with challenges and stressors and well-being, several intervention programs were developed in order to enhance SOC. These interventions highlight the factors that develop SOC throughout the lifespan and emphasize the fexibility of the construct and its potential infuences (Janik & Kroger, 2007; Kahonen et al., 2012; Mayer & Boness, 2011; Pallasch & Hameyer, 2008). The following provides examples of interventions promoting SOC in different contexts.

Within the school setting, Mayer and Boness (2011) proposed a didactic model (the team ombuds model) which aimed at promoting SOC and transcultural competencies in educational contexts. Based on studies demonstrating that teachers perceived educational approaches such as concepts of intercultural communication as enriching and stimulating, strengthening self-consciousness, self-worth, and SOC (Pallasch & Hameyer, 2008), the model aimed at promoting GRRs of learners and teachers as well as at ameliorating comprehensibility, manageability, and meaningfulness. It was based on a vertical hierarchy of interacting social units in which learners created teams that were the basis of the educational process. The students who were in a position of trust worked closely with the teachers in resolving conficts or improving interaction between the students and their teachers. This led to an increase in team competence and individual performance, which decreased feelings of anxiety, dissatisfaction, and uncertainty (Janik & Kroger, 2007). Thus, the learning input was acquired during teamwork (comprehensibility), teamwork was promoted (manageability), and students learned how to learn and set priorities according to their interests (meaningfulness).

Within an occupational context, Kahonen et al. (2012) reported on two group interventions (psychodramatic and analytic) promoting SOC in an occupational healthcare context. The psychodrama method was based on socio- and psychodramatic techniques, such as drawing, music, and writing, and muscle relaxation and exercises using the imagination. The analytic method (Foulkes & Anthony, 1990) was based on free-fowing discussions in order to provide the participants with (1) a sense of security and belonging on the collective level, creating an atmosphere that enables expression of personal feelings; (2) an ability to discuss the feelings awakened by the group on a projective level; and (3) an awareness of one's inner world and its development in the complex relationship between past and present on the transference level. The action-based psychodrama group showed a higher increase in SOC than the dialog-based analytic group, while the improvement in the latter group was signifcant during the 6-month follow-up. The study concluded that due to its effectiveness, group intervention should be considered an important strategy alongside improvement in the organizational climate and second, that it was possible to enhance SOC by a relatively short group intervention among employees suffering burnout symptoms.

#### **References**

psychology. In M. W. Baldwin (Ed.), *Interpersonal cognition* (pp. 233–266). Guilford Press.

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## **Specific Resistance Resources in the Salutogenic Model of Health**

Maurice B. Mittelmark, Marguerite Daniel, and Helga B. Urke

#### **Introduction**

This chapter discusses conceptual and concrete differences between generalized and specifc resistance resources in the salutogenic model of health. How generalized resistance resources (GRRs) and specifc resistance resources (SRRs) are developed differ, with implications for health promotion practice.

To summarize, the main idea is that GRRs arise from the cultural, social, and environmental conditions of living and early childhood rearing and socialization experiences, in addition to idiosyncratic factors and chance (Lamprecht & Sack, 2003; Lindström & Eriksson, 2005). SRRs, on the other hand, are optimized by societal action in which health promotion has a contributing role, for example, the provision of supportive social and physical environments.

#### **The Salutogenic Model of Health Logic**

Antonovsky (1987) called for research to develop scientifc knowledge about strengthening the sense of coherence. This could be done by building on the resistance resources (RR) that are the properties of individuals, groups, and even situations. GRRs facilitate coping with stressors and strengthen the sense of coherence. Confronting the question of how a strong sense of coherence translates into better health, Antonovsky proposed that "a strong SoC […] allows one to 'reach out,' in any given situation, and apply the resources appropriate to that stressor" (Antonovsky, 1996, p. 15).

The highly simplifed salutogenic model of health logic is

#### RR → ↑ SOC u → ↑ se of RR → ↑ HEALTH

GRRs and SRRs will be formally defned later, but for now, GRRs are resources that have wide-ranging utility (one's social network, for example). In contrast, SRRs have situation-specifc utility (e.g. an emergency phone number to reach the police). Antonovsky felt it was

…imperative to focus on developing a fuller understanding of those generalized resistance resources that can be applied to meet all demands (Antonovsky, 1972, p. 541), while

… [SRRs] are often useful in particular situations of tension. A certain drug, telephone lifelines of suicide prevention agencies… can be of great help in coping with particular stressors. But these are all too often matters of chance or luck, as well as being helpful only in particular situations…[and] … it is the GRR that determines the extent to which specifc resistance resources are available to us (Antonovsky, 1979, p. 98–99).

This goes a great way toward explaining why Antonovsky's attention was mostly on the left side of this more detailed salutogenic model of health diagram:

> GRR SOC use of GRR use of SRR HEALTH → ↑ → ↑ & ↑ → ↑

A more realistic depiction would be a systems-like diagram with double-headed arrows connecting everything to everything. The simplifcation above is useful for the present purpose, which is to elucidate the GRR/SRR distinction.

SRRs need not always be "matters of chance or luck". Indeed, it is an essential aspect of health promotion to replace chance and luck with fair and dependable availability of SRRs that support health. One of the highest priorities of health promotion is providing supportive environments for health (WHO, 2009). Supportive environments include both GRRs and SRRs, but as suggested in the salutogenic model of health logic above, they have distinctions.

Most of the space in this chapter is devoted to discussing the nature of SRRs and health promotion's role in their

**13**

<sup>©</sup> The Author(s) 2022 107 M. B. Mittelmark et al. (eds.), *The Handbook of Salutogenesis*, https://doi.org/10.1007/978-3-030-79515-3\_13

This chapter is a revision and update of work published in Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G., Pelikan, J.M., Lindström, B., & Espnes, G.A. (eds). (2017). *The Handbook of Salutogenesis*. Springer, Cham. DOI: https://doi.org/10.1007/978-3-319-04600-6.

M. B. Mittelmark (\*) · M. Daniel · H. B. Urke

Department of Health Promotion and Development, Faculty of Psychology, University of Bergen, Bergen, Norway e-mail<EMAIL_ADDRESS>
nurturance. However, some space is given to a brief overview of the nature of GRRs, to help illuminate distinctions, similarities, and interrelationships between GRRs and SRRs. The reader interested in a full exposition of GRRs is referred to Chap. 12 in this handbook and to chapter 4 in Antonovsky's *Health, Stress and Coping* Antonovsky (1979).

Antonovsky (1979, P. 99) defned a GRR as "any characteristic of the person, the group, or the environment that can facilitate effective tension management". He was quite clear that GRRs and SRRs are not exchangeable concepts: "…it is the GRR that determines the extent to which specifc resistance resources are available to us… being literate or being rich… opens the way to exploitation of many specifc resistance resources…" (Antonovsky, 1979, pp. 99–100). A perhaps more precise formulation is that when confronted with a particular stressor, a strong sense of coherence enhances one's ability to recognize and activate the most appropriate SRR from those that may be available.

Antonovsky (1979, pp. 103–119) discussed GRRs that operate through physical and biochemical mechanisms (e.g. immune function) that enable the acquisition of SRRs (as money may do), that are intrapersonal (e.g. with ego identity, intelligence, and coping), that are social (interpersonal ties and social embeddedness), and that are cultural (guiding as to how stressors should be encountered). GRRs play two important roles in coping: they help determine the strength of the sense of coherence, *and* they enable the use of specifc resistance resources.

#### **Specifc Resistance Resources**

Neither Antonovsky nor the few others who have written about SRRs have shown much interest in the GRR/SRR differentiation. For example, in Antonovsky's (1979) extremely detailed depiction of the salutogenic model of health (ibid, pp. 184–185), a strong sense of coherence is shown as mobilizing GRRs and SRRs, with no clear differentiation of the two. Both types of resistance resources are posited to have roles in avoiding stressors, in the defnition of stimuli and non-stressors, and in overcoming stressors. Antonovsky hardly mentioned SRRs in his *Unraveling the Mystery of Health*, and he did not dwell on the distinction between GRRs and SRRs:

What the person with the strong SoC does is … [choose] from the repertoire of generalized and specifc resistance resources at his or her disposal… (Antonovsky, 1987, p. 138).

Others seem to agree that the GRR/SRR distinction is not particularly important. Poppius (2007) wrote about choosing "from the repertoire of generalized and specifc resistance resources […] in what seems to be the most appropriate combination". Nene (2006) noted that the sense of coherence is infuenced by GRRs and SRRs and makes no differentiation between them. Sullivan (2006) does make a differentiation, stating that nursing is a GRR while the nurse providing help with a particular problem is an SRR. Yet, Sullivan does not develop that distinction in terms of the role of sense of coherence. Haldeman and Peters (1988) intended to measure SRRs in a study to identify the combination of SRRs and tension that would best predict stress. They operationalized SRRs as satisfaction with family life and family fnances, frequency of interactions with friends and relatives, and community resources used. These measures are distant from the concept of SRRs as distinguished from GRRs, even if the number of community resources is measured. SRRs are particular resources used in encounters with particular stressors, as in Antonovsky's example of using a suicide hotline by a suicidal person. Reininghaus et al. (2007) noted the distinction between GRRs and SRRs, in a study of the stress connected to assault on psychiatric nurses, and then rejected the distinction by creating a measure of "stress resistance resources" composed of self-esteem (a GRR), self-confdence (a GRR), received clinical supervision (an SRR), and staff support services (an SRR). Taylor (2004) differentiated GRRs and SRRs in her literature review of salutogenesis as a framework for child protection, but characterized both, without differentiation, as helping people to structure life experiences to reinforce the sense of coherence.

These citations are not "cherry-picked", highly selected counter-examples from an extensive literature in which GRRs and SRRs are discussed: they are all the instances in which SRRs received explicit attention in a reasonably thorough literature search.

Why do SRRs receive so little attention? One answer is that following Antonovsky's lead, there has been all-consuming attention to GRRs and the sense of coherence (Eriksson & Lindström, 2005) and its relationship to health and well-being (Eriksson & Lindström, 2006, 2007). Even if Antonovsky wished health promotion to focus on the sense of coherence as the dependent variable, most researchers have focussed on it as the independent variable. While this could be assumed to drive interest in SRRs as mediators in the sense of coherence/health relationship, such interest is not manifest. On the contrary, there has been little interest in the question of what *mediates* the connection between the sense of coherence and health, despite Antonovsky's postulation that a strong sense of coherence allows one, in any given situation, to apply the appropriate GRR and/or SRR (Antonovsky, 1979).

One additional, critical point needs to be made to clarify why SRRs have received little attention in salutogenic research and why this should be rectifed. As already noted, Antonovsky viewed SRRs as all too often matters of chance or luck. In the mid-1990s, he observed that health promotion had not:

…confronted the question of the creation of the appropriate social conditions which underlie or facilitate health-promotive behaviors, for example adequate day care facilities and access to health care, not to speak of incomes adequate for decent nutrition and housing. (Antonovsky, 1996, p. 12)

Put in contemporary terms, Antonovsky referred to social determinants of health (e.g. the GRR "income") and supportive social environments (e.g. the SRR "daycare facilities"). Examined closely, what may be a GRR from one person's perspective may be an SRR from another person's perspective. For example, a child daycare facility is an SRR for the parents, and hopefully, a source of GRRs for the child. In contrast, an eldercare facility is an SRR for the resident *and* an SRR for relatives that need professional care assistance.

Antonovsky's criticism of health promotion for not confronting social conditions was perhaps valid for the approach to health promotion that dominated in Europe and the USA in the 1970s and 1980s, concerned mostly with individuals' responsibility for their health and calling for individuals to abandon their risk behaviour to prevent chronic diseases.

However, health promotion has evolved. The 1986 Ottawa Charter for Health Promotion acknowledged individuals' responsibility but emphasized the importance of social determinants of health and creating supportive environments (Eriksson & Lindström, 2008; Kickbusch, 2003). In recent decades, health promotion moved from an almost myopic concern with individuals' health-related lifestyles to a balanced concern with processes for empowering individuals and communities to control their health. In good part, this is accomplished by creating environments supportive of health, or "appropriate social conditions" in Antonovsky's words. Health promotion's concern with appropriate social conditions has taken two forms. One is an overarching emphasis on reducing social inequities in health by a fairer distribution of social resources (Marmot et al., 2008). The other is the health promotion "settings" approach, in which schools, workplaces, and whole communities are considered as locales for health promotion, expanding from the traditional locus of health care in doctors' offces, health clinics, and hospitals (Dooris et al., 2007; Poland et al., 2009). Does health promotion's settings approach mean that it has engaged the SRR concept or the GRR concept? A nuanced answer depends in part on a precise defnition of specifc resistance resources.

#### **Defnition of Specifc Resistance Resources**

A useful defnition of SRRs must distinguish them from GRRs. Bengt Lindström is famous for his illustrated lectures on salutogenesis. A cartoon fgure travels across the chalkboard, in the river of life, encountering stressors, trials, and tribulations, equipped with a knapsack stuffed with GRRs acquired during a lifetime (Fig. 13.1). The main point is that the GRRs are already available to be engaged as needed as one encounters various situations creating tension. In concert

**Fig. 13.1** Generalized resistance resources in the knapsack. (© Bengt Lindström, Monica Eriksson, Peder Wikström. All Rights Reserved)

with this metaphor, we conceptualize SRRs as available in the river, picked up and used as needed in specifc encounters with stressors, and not necessarily placed in the knapsack afterwards. The relationship between GRRs and SRRs is that via the sense of coherence, GRRs enable one to recognize, pick up, and use SRRs in ways that keep tension from turning into debilitating stress, assuming useful SRRs are available.

A brief example: Having access to and understanding the empowering potential of the Internet is a GRR. The availability of information about your present worrying symptoms on Wikipedia is an SRR. That you have access to, and proactively search for, read, critically evaluate, and use the Wiki's information exemplifes the salutogenic model of health logic:

```
(a) GRR → ↑ use of SRR → ↑ HEALTH
(b) INTERNET → ↑ SPECIFIC WIKI → ↑ HEALTH
```
This is, of course, an oversimplifcation. For example, while the Internet has undoubtedly contributed to an enhanced sense of coherence for many people, it is but one of many GRRs having an equal or more signifcant infuence on the sense of coherence. The diagram's point is not to depict the salutogenic model of health in detail but to show how GRRs and SRRs are substantially different. Of course, health promotion interventions might focus on both—increasing people's unfettered access to the Internet and their skill in using it (enhanced GRR) *and* making websites that address various specifc health issues that are of salience when particular nasty symptoms pop up (enhanced SRR).

A formal defnition of SRRs is shown in Fig. 13.2, using Facet Theory's sentence mapping approach (Borg & Shye, 1995; Canter, 2012). Antonovsky (1979) used the same approach to defne key concepts, including health on the ease/dis-ease continuum (ibid, p. 65), GRRs (ibid, p. 103), and the sense of coherence (Antonovsky, 1987, p. 77). The elements in the three arrays of the mapping sentence defnition are not meant to be exhaustive but rather are illustrative.

SRRs are instrumentalities whose meanings are defned in terms of the particular stressors they are invoked to manage.

Usually, SRRs are not invoked unless tension is perceived to threaten to convert to debilitating stress, which many tensions do not. The salutogenic model of health is concerned with ubiquitous tensions that *can* convert to health-threatening levels of stress. Antonovsky (1979, pp. 89–90) listed these:

…accidents and the survivors; the untoward experiences of others in our social networks; the horrors of history in which we are involved; intrapsychic, unconscious conficts and anxieties; the fear of aggression, mutilation and destruction; the events of history brought into our living rooms; the changes of the narrower world in which we live, phase-specifc psychosocial crises; other normative life crises—role entries and exits; inadequate socialization, underload, and overload; the inherent conficts in all social relations; and the gap between culturally inculcated goals and socially structured means*.*

A useful examination of the differences between GRRs and SRRs should be undertaken with this understanding of psychosocial stressors in mind. At extremes—surviving a plane crash, taking an exam—stressors are stressors from the start or tensions that simply remain tensions.

and thus prevent tension from being transformed into stress.

#### **Health-Promoting Schools in Norway**

Virtually all adolescents attending school are stressed by the demands of maturation, peer relations, teachers' demands, home and community conditions, and so on. In this cauldron of tension, schools in Norway (and in many other countries) have implemented *Health Promoting Schools* programmes which aim to support educational goals by attending to the health and well-being of all who inhabit the school milieu; students, teachers, administrators, parents, and neighbourhoods (Langford et al., 2015; Tjomsland et al., 2009; Wold & Mittelmark, 2018). The health-promoting school strives to meet these goals:

Thus, the health-promoting school aims to be a powerful GRR for the youth, the staff, the parents, and the surrounding community. The Norwegian school is also a repository of, or a portal to, some SRRs, offered through the school nursing service (Moen & Skundberg-Kletthagen, 2018) and other student-support services. Examples include support for pregnant students to help keep them in school, special education teachers and facilities equipped to help students with learning disabilities, and referral to community child protection services in cases of need.

These SRRs are present in or around the school, but they are not particularly salient to the adolescents that do not need them, and therefore do not use them. The school as a GRR helps contribute in a general way to strengthen the sense of coherence of many pupils, and a strong sense of coherence facilitates the uptake/use of particular SRRs when the need should arise. Let us consider two students. Jack has a typical day, experiencing "normal" strain and hassles, but nothing out of the ordinary happens. SRRs abound, but this student makes use of none of them; they are not salient. On the same day, Jill discovers she is pregnant, and her sense of coherence is high enough that she does not panic and sink into depression. Instead, she contacts the pregnancy support programme, which she knows about and trusts because of other pupils' good experiences. The pregnancy support programme is an SRR for this student, offering highly salient services at this infection point in her life.

There is a vexing equity dimension to this. If SRRs are more readily available to those with lots of GRRs (e.g. money), SRRs might contribute to a widened equity gap. Equality in access to SRRs depends on a reasonably fair distribution of GRRs, so health promotion needs to focus on both types.

#### **Child Health in the Andean Highlands in Peru**

Perhaps the most apparent SRRs are social services established to provide targeted assistance to groups living in conditions that impart severe vulnerability (Mittelmark, 2021). A prime example was documented in research in a remote and low-income district in the Andean highlands in Peru (Urke et al., 2013). The feld researcher (Urke) interviewed mothers with local reputations for providing good childcare. All the mothers participated in a Peruvian NGO-run social and health programme. The interviewer did not mention the NGO programme—a clear example of a social services SRR—to avoid prompting. The respondents explicitly referred to it and attributed improved health-related knowledge and skills to the NGO interventions that included education about nutritious meal preparation, childcare skills, and sanitation practices. This project also illuminated the close relation between GRRs and SRRs. There was some evidence that the women with more GRRs (such as money and social support in the home and the community) benefted more from the NGO's activities than did the women with fewer GRRs.

#### **Support Services for Orphaned Children and Adolescents in Botswana**

Another example of NGO-as-SRR is described in research from Botswana (Thamuku & Daniel, 2012). In collaboration with the Botswana Department of Social Services, the Botswanan NGO People and Nature Trust developed a programme called Ark for Children to provide support services for orphaned children and adolescents. They employ culturally appropriate interventions to strengthen orphans and build them into cohesive groups of age-mates who support each other. *Ark for Children* organizes 16-day retreats for up to 40 adolescent orphans from the same village. The retreats harken to historical *Setswana* initiation rites and link with cultural traditions recognized by the members of the adolescents' community. The adolescents are followed up in a 3-year support programme. This is an illuminating example of an SRR (*Ark for Children*) that builds GRRs (social cohesion and supportive ties).

#### **Sexual Orientation and Gender-Identity Support Services in the USA**

Identity-based adversity begins early in life, affecting the availability and development of GRRs. Young people's experience of sexual orientation prejudice is exemplifed in many cases by bullying, harassment, rejection, social isolation, and internalization of negative attitudes and beliefs. Genderidentity adversity is framed by stigma arising from societal norms and biases (Horn, 2019). While sexual preferencerelated adversity is typically an emergent feature in adolescence and young adulthood, gender-role tension may have roots in earliest childhood behaviour.  Boys holding hands beyond young childhood is not gender-consistent in many cultures but is normative in other cultures. This points out that salutogenesis' relevance to identity-based adversity, tension, and coping is complex, rooted in culture and impacting one's early life experience, the acquisition of GRRs, the availability and use of SRRs, and therefore the development of the SOC.

In this chapter on the nature of SRRs, we turn aside momentarily, noting that the experience of and developing resilience to gender-related prejudice may be a GRR. In their research with young adults in the USA, Schmitz and Tyler's (2018) respondents explained it in ways like this: *"[My lesbian identity] opens up a lot more doors… I think that [it] opens up opportunities for friendship because you like to confde in people that have similar situations, so I think it builds stronger relationships".*

Now narrowing the discussion to SRRs, we focus on just one dimension of salutogenesis and gender-based identity: the tension, stress, and coping-enabling SRRs of young persons with lesbian, gay, bisexual, transgender, and queer (LGBTQ1 ) identities. In coping research with lesbian, gay, and bisexual (LGB) American Latino and non-Latino young adults, Toomey et al. (2018) examined the use of three types of coping strategies: engagement of SRRs, alternatives-seeking strategies (e.g. fnding new friends), and cognitive strategies (e.g. imagining a better future). Regarding SRRs, respondents reported employing a closely knit constellation of coping behaviours, including getting involved in LGBT groups and organizations, looking for services for LGBT youth, and looking for information on LGBT issues.

Similar fndings are reported by Asakura (2016), whose LGBTQ respondents reported coping by engaging in collective action, by participating in safe social spaces like gaystraight alliances, and by accessing social services from organizations that welcome gender and sexual diversity among youth. Likewise, Schmitz and Tyler (2018) observed the importance of institutional support in LGBT coping. As one college student expressed it, "[the campus] is very open and accepting… there are plenty of resources on campus, specifcally for LGBT students".

#### **Non-institutional SRRs in Caregiving Dyads in Sweden**

Figure 13.2 may convey an impression that SRRs are exclusively facilities and organizations whose mission is to provide specifc types of assistance to people with particular needs. Yet, the defnition does embrace the concept of SRRs in the private sphere ("activities", listed sixth in the frst facet of the defnition). This has been well described in a Swedish programme of research with caregiving dyads in which care was provided to persons aged 65+ (Wennerberg et al., 2016). Caregivers' overall feelings of competence in being a caregiver—a GRR in the researchers' analysis—were bolstered by caregiver SRRs such as having enough physical strength to provide physically demanding care activities (e.g. lifting) and having the professional/technical knowledge required for managing complex medication regimes. In these caregiving dyads, having children and grandchildren functioned as an SRR, a shared experience that was a mutual pleasure to the dyad (Wennerberg et al., 2019). A mutual understanding of the caregiving situation and good dyad communication skills was also revealed as an important SRR (ibid). For dyads in assisted living facilities, the facility—an SRR enabled caregivers to gain/regain personal SRRs that had been problematic in their homes (SRR defcits). Examples cited by respondents included shopping facilities in the living complex, elevators, and apartments that were disability adapted (Eriksson et al., 2017).

The Swedish studies cited above also report fndings regarding general and specifc resources defcits (GRDs and SRDs) (Wennerberg et al., 2019). A discussion of GRDs and SRDs is beyond this chapter's scope. Still, it is in place to mention that the general-specifc differentiation also pertains to negative life experiences, unsuccessful tension management, and a weakened sense of coherence. A caregiver's loss of a well-functioning partner is simultaneously a GRD—the

<sup>1</sup>Some of the acronyms used below vary from this form, following the usages of the various authors cited.

fading quality and equality of a mutually caring and sharing relationship—and an SRD as in the care receiver's reduced ability to reciprocate care (ibid).

#### **Conclusion**

This chapter's aim has been modest, to illuminate a part of the salutogenic model of health that seems to be overlooked—SRRs have as much or more relevance to health promotion practice as do GRRs. By drawing attention to SRRs, one also draws attention to what should be a core aim of health promotion: to ensure that the availability of the right SRR at the right time is not all too often a matter of "chance or luck", as Antonovsky worried.

#### **References**

infuences primary caregivers' opportunities and choices? *Global Health Promotion, 20*(3), 5–13.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons. org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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**Part III**

**The Sense of Coherence in the Life Course**

## **The Sense of Coherence in the Life Course**

Claudia Meier Magistretti

#### **Introduction**

Antonovsky understood the sense of coherence (SOC) as the outcome of learning processes that begin at the time of birth, or even earlier. To create a strong SOC, these processes should provide challenges that are perceived as consistent, that allow participation, and are characterised by an underload–overload balance. Initially, Antonovsky considered the SOC to be relatively stable after early adulthood, with only minor fuctuations occurring after that. Later, he clarifed that stability of the SOC pertains mainly for adults with a strong SOC, since "the person who has, in early adulthood, crystallised a strong SOC, [has] the ability to bring into play the generalised resistance resources available to him or her" (Antonovsky, 1987, p. 121).

Antonovsky assumed that early childhood is a critical period to create a strong SOC. He conceptualised the infant as an active subject that can interact in ways that produce stable, consistent response interactions (Antonovsky, 1987, p. 94). These actions occur very early, according to Antonovsky, immediately after birth.

Relating to Bowlby's attachment theory, he developed the idea that a strong sense of comprehensibility is fostered early in life by the consistent experience of parents' and other caregivers' responsiveness and sensitivity. Still, Antonovsky criticised the imperative for parents to be always consistent and responsive, stating that real life is far more complex. Perfectly responsive parents do not exist, because multiple tasks and demanding environments are the reality for all. On the contrary, "natural" frustrations are necessary to create a sense of comprehensibility. When the infant learns that objects and satisfactions can disappear and reappear, he or she learns about the continuity (and to a certain extent the predictability) of social interactions.

Manageability is, according to Antonovsky, built by experiences of load balance fostered by parents that respect their child's abilities at different stages of development. Using the example of forced toilet training in toddlers, Antonovsky describes how overloading demands are created when the biological and psychological realities of the child are not suffciently recognised. Consequently, the development of the sense of manageability can be disturbed or hindered by inappropriate expectations of a child's caregivers. In Antonovsky's thinking, load balance is achieved when a demand corresponds to the child's development state, in the sense that it is somehow "reasonable" and when it is subjected to the child's choice.

The sense of meaningfulness develops by participation in decision-making, which in early childhood occurs when the infant experiences that his or her actions produce the desired reaction in the adult. "To the extent that desired outcome is contingent on the infant and child's action", Antonovsky stated, "it can reasonably be said that early on there is participation in decision making" (Antonovsky, 1985, p. 97). The sense of meaningfulness in the early stage of life is fostered by the infant's experience of being able to pressure the environment to act and thereby comprehend that she or he *matters* to the parents or other caregivers.

In adolescence, the SOC is potentially volatile, and the basis that has been laid in childhood for a strong the SOC may become upset. This stage of life is characterised by transitions and a constant balancing of a fragile identity between "not anymore" and "not yet". Antonovsky related the development of the SOC to Erik Erikson's main developmental tasks that adolescents have to face in all cultures:

# **14**

<sup>©</sup> The Author(s) 2022 117 M. B. Mittelmark et al. (eds.), *The Handbook of Salutogenesis*, https://doi.org/10.1007/978-3-030-79515-3\_14

C. Meier Magistretti (\*)

Centre for Health Promotion and Participation, Lucerne University of Applied Sciences and Arts, Lucerne, Switzerland e-mail<EMAIL_ADDRESS>
The sense of comprehensibility is reinforced by the growing ability of the adolescent to develop a sense of reality. The experience of mastering challenges nurtures the sense of manageability. The sense of meaningfulness is supported by a "vitalising" way to deal with reality. Still, Antonovsky appreciated that adolescence is a fragile period of life, needing adult guidance.

Adulthood is perceived as a period of life where roles and GRRs are decisive for the development of the SOC and for shaping identity. Antonovsky assumed that in the frst decade of adulthood, an individual tends to put together the new roles he or she assumes at work, in partnership, in creating a family, and in society. While some of these new roles may weaken the individual's SOC, others may strengthen it. The SOC is assumed to remain somewhat volatile in this period of life. Antonovsky supposed (but gave indications of not being entirely convinced) that at the end of the second decade, individuals have sorted out or accepted the different areas of life, and "one has attained a given location on the SOC continuum" (Antonovsky, 1987, p. 119).

Following Antonovsky's passing in 1994, Lindström and Eriksson (2010) defned the development of the SOC as a *lifelong learning* process. Analysing SOC levels in different age groups in longitudinal studies, they observed the SOC's tendency to strengthen with age (Lindström & Eriksson, 2010). The strengthening of the SOC over the lifespan is neglecting some fuctuations—continuous, consistent over different measurement scales (SOC-13, the SOC-29), steady, and moderate.

Nevertheless, we know little about how the development of a stronger SOC occurs. Only recently, Maas and colleagues (2017) investigated mechanisms strengthening the SOC in adults. They found that systematic, coherent experiences in everyday life might play a crucial role in building a strong SOC.

Signifcant life events may cause fuctuations in the SOC. Becoming a parent, for example, is posited to be s a critical life experience that may alter one's SOC (Lindström et al., 2017). From the perspective of anthropological pedagogics, we can hypothesise that the SOC, as any other learning outcome, could beneft from sensitive phases of development. These have been studied in children as a developmental phase of specifc readiness to learn, which enables a person to acquire specifc skills and characteristics relatively effortlessly (e.g. Montessori, 1995). Further investigation of the SOC as a lifelong learning process may reveal critical points throughout life when the SOC is particularly prone to change.

As the preceding discussion shows, the development of the SOC is understood as a lifelong learning process. Among the important questions about this process are as follows:

The chapters in this part of the Handbook tackle all three of these questions with varying emphasis at different periods of life.

#### **Childhood and Families**

Chapter 15 on salutogenesis and the sense of coherence in families and children deals with the contributions of children's environments to the adjustment of children with typical development and the development of children with special needs. The chapter starts with a short description of childhood development. Orly Idan and colleagues report on their comprehensive literature review covering 20 years of research and 44 studies from 15 countries, including children from infants and toddlers through preschool to school-aged children up to 12 years of age. The construction and use of the children's SOC scale and methodological considerations are discussed. Also in focus is the infuence of the SOC on various health outcomes, and children's emotional, social, and cognitive development (both in children with regular development and in children facing challenging life circumstances, health-related adversity, and special needs).

The chapter concludes that the SOC plays a signifcant protective role at school and emphasises the crucial role of teachers' ability to engage with children in responsive and caring relationships. For families with children with special needs, the SOC is demonstrated to be a signifcant protective factor related to coping and hopeful thinking, as well as to parental adjustment and effective coping outcomes. The chapter also provides examples of programs to foster the SOC in young children, by promoting play and reinforcing self-worth in the frst years of school.

#### **Adolescence**

In Chap. 16 by Braun-Lewensohn and colleagues, the focus is on salutogenesis and the sense of coherence during the adolescent years. The authors' approach is itself salutogenic, in the sense that they develop their arguments in line with a positive youth development perspective. Adolescents are appreciated as individuals eager to explore the world, to acquire competence, and to struggle with challenges and diffculties, rather than as a vulnerable group in need of risk prevention, cure, and treatment for maladaptive tendencies.

Still, the literature is replete with studies of the authors' review of more than 30 studies in 16 countries shows a signifcant role of the SOC for physical and mental health, health behaviour, social adaption, and academic or professional success of adolescents. This is demonstrated for the individual the SOC (in several studies measured by specifc adolescent the SOC scales) and hypothesised for family and community the SOC. In adolescence, the SOC is a predictor for physical health and the use of medication in consequence.

The studies reviewed in this chapter confrm that a strong SOC is associated with reduced stress, and decreased internalising/externalising of problems. Related to health behaviours, adolescents with stronger SOC report a more healthy lifestyle as well as a better quality of life and well-being. The authors report on studies observing that a strong SOC in adolescence is associated with higher levels of physical activity and exercise, less tobacco and alcohol use, and healthier eating habits.

Factors strengthening the SOC in adolescence are discussed, with an emphasis on the child's socio-ecological context, such as open family communication, child-centred parenting, and parents' knowledge regarding their children's activities. The authors also discuss how social support and neighbourhood and community cohesion may play a positive role in the development of a strong SOC in adolescence.

#### **Transitions in Adulthood**

Salutogenic research with adults has focused on their roles in workplaces, families, communities, and caregiving institutions. Researchers have tended to neglect the lifetime and developmental perspective of adult age. This might refect a general view of the adult as a performing, not as a developing individual. It might be, as well, a consequence of methodological diffculties in describing transitions at various points of life in biographies that may deviate from a formerly "normal" life course, becoming more and more diverse.

Nevertheless, lifespan developmental psychology of the past two decades provides an understanding of adulthood as a series of interrelated transitions (Sugarman, 2001). Transition periods have been shown to play a crucial role in one's adaption to life stressors, and the development of physical and mental health throughout the life course.

In Chap. 17, Claudia Meier Magistretti and Beat Reichlin treat the topic of the transition from adolescence to adulthood and focus on young adults facing diffculties during this transition. Young adults not in education, employment, or training (NEETs) emerged only recently as an interest in public health and health promotion debate. Although estimates of the number of NEETS vary, the problem seems to be global and growing. This has stimulated the International Labour Organisation to talk in terms of "a generation at risk". Yet, the many programs that try to support NEETs fail to reach them and guide them successfully into work, housing, and social participation.

The authors consider why current initiatives to assist NEETs do not produce sustainable effects. "Helping" systems regard NEETs as patients, cases, or not yet enabled adults and thereby fail to meet their needs as well as their potential. Confronting the limits of current approaches, the authors emphasise the need for a salutogenic orientation in research and practice with NEETs. To provide guidance and inspiration in this direction, the authors describe new and promising NEET initiatives. These initiatives are characterised by having a genuine health orientation, NEET participation, the centrality of learning processes, and fexible, adaptive models of individual and social development in combination with enhanced employment, education, training, and entrepreneurship opportunities.

In Chap. 18, Ottomar Bahrs and colleagues focus on the transition from middle to late adulthood. The questions of when and how past transitions affect subsequent aging are discussed. While middle age was long considered undramatic, the authors state that it is increasingly gaining profle. They focus on a phase typically observed in the sixth decade of life, characterised by the initiation of the transition to deprofessionalisation and change of responsibilities within the family when crisis and chronic situations can lead to the need for help from health professionals.

Bahrs and colleagues deliberate on how a dialogue between middle-aged adults and professionals can contribute positively to the naming, modifcation, design, and further development of health goals, linking physiological and unconscious processes to the theory of salutogenesis.

Notably, the authors frame illness processes from the perspective of salutogenic resources, also discussing the *benefts* of crises experienced in middle adulthood.

I hope the authors' novel ideas about a salutogenic perspective on life in middle adulthood will inspire researchers and practitioners to a more innovative approach to this large segment of society.

#### **Older Age**

In Chap. 19, Maria Koelen and Monica Eriksson consider the meanings of the concepts of healthy aging, aging well, salutogenic aging, and reciprocity between the SOC and aging processes. They discuss how the community can provide resources to strengthen older adults' SOC, perceived well-being, and quality of life. Quoting "It's not how old we are; it's how we are old", the authors illuminate critical differences in understanding healthy aging by professionals, researchers, and older people themselves.

While professionals tend to focus on negatively phrased topics (e.g. disability, disease, loneliness), older people emphasise a supportive social environment, the ability to use resources, to manage restrictions, and to make one's own decisions. As the authors clarify, evidence on the potential for enhanced health at older age points clearly to these factors: participation in social networks, contact with family and friends, and engagement in leisure and social activities. Since many of the prerequisites to strengthen general resistance resources (GRRs), specifc resistance resources (SRRs), and the SOC are provided by or mediated through the community, the authors emphasise the role of intergenerational and age-friendly communities in providing supportive neighbourhood environments, social cohesion, and adequate transportation facilities for older people, and support for their ability to continue living in their own homes.

#### **Enhancing the Sense of Coherence along the Life Span**

Chapter 20, by Eva Langeland and colleagues, is titled *Effectiveness of interventions to enhance the sense of coherence in the life course: a summary of the empirical evidence.* It provides an overview of the effectiveness of programs and interventions that aim to strengthen the SOC throughout the lifespan. The authors report on more than 40 studies investigating the effectiveness of interventions to strengthen the SOC. They structure and summarise fndings for young people, employed and unemployed adults, health professionals, people with disabilities, people with psychosomatic and mental health problems, people with physical problems, hospital patients, and older people. Even though most studies are limited to short-term pre-test and post-test study designs, a few studies have investigated the effects of intervention for longer follow-up periods of up to several months, and even more than 1 year.

The authors classifed interventions on the extent of their salutogenic orientation, defning criteria for salutogenic interventions based on Antonovsky's theory and current research. They found that the effective interventions aiming at strengthening the SOC might have three qualities: they facilitate access and use of GRRs and SRRs, they foster active participation, and they understand SOC development as a learning process. The authors conclude that more intervention studies are needed, with (a) a more robust grounding in salutogenesis principles, (b) larger sample sizes, (c) longer follow-up periods, and (d) stronger research designs. Overall, the chapter indicates that it is possible to improve the SOC throughout the whole life course and that health promotion professionals' work to enhance the SOC should embrace a person-centred, resource-oriented approach.

#### **Knowledge, Gaps, and Perspectives**

In closing, we return to the three questions posed at the start of this chapter:

Addressing the frst question on crucial factors that contribute to a strong SOC in the various phases of the life course, the authors of these chapters are unanimous about the signifcance of a strong linkage between the development of the SOC and the availability and use of GRRs. Even though GRRs change during a lifespan, the family, the social circle, and the community environment are crucial to the development of a strong SOC from early life to old age. At all life stages, the SOC is the product of the *interaction* of an individual and the environment—of the SOC, GRRs, and SRRs.

Therefore, the enrichment, attainability, and accessibility of resources are crucial to strengthening the SOC. This conclusion, based on mounting evidence presented in these chapters, is supportive of Antonovsky's contention that the most signifcant potential for strengthening the SOC lies in the availability and use of resistance resources.

Yet, as he regretfully noted, fostering resistance resources in a signifcant way depends on "radical change in the institutional, social, and cultural settings that shape people's life experiences" (Antonovsky, 1987, p. 124). Those levels of social life are rarely subjects of health research and not a primary focus of the chapters discussed here. However, this subject is taken up in other parts of this Handbook, most notably in Chap. 24 on the application of salutogenesis in politics and policy-making.

The answer to the second question is that we lack suffcient evidence to comment decisively about the stability of the SOC during the life course and its functions at different ages. There is a striking lack of research on healthy adults and little research on weak SOC and how to strengthen it. Questions of how a strong SOC is created in children are partly answered, but we do not know how a strong SOC is created and maintained in adulthood, and we do not know how stable positive changes in people's SOC are over the lifetime. This gap might be due to the view of the adult as a performer of different roles, rather than as an individual in development. Therefore, salutogenic research investigates adults mainly as employees, parents, patients, caregivers, or inhabitants of cities or communities.

The third question, on how to strengthen the SOC, can be answered to a degree. It seems the SOC can be infuenced at any age and in many life situations, as Chap. 20 on salutogenic interventions discusses. Antonovsky suggested that lasting SOC strength is obtained when interventions enable people to perceive coherent life experiences, when they learn how to nourish their sense of comprehensibility, meaningfulness, and manageability.

#### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons. org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

## **Salutogenesis: Sense of Coherence in Childhood and Families**

**15**

Orly Idan, Orna Braun-Lewensohn, Bengt Lindström, and Malka Margalit

#### **Introduction**

Infancy and early childhood are distinct developmental periods in which young children differ signifcantly from older children, adolescents, and adults in terms of cognitive skills, language and communication, self-regulation, and socioemotional functioning (Mowder et al., 2009). The science of early childhood development demonstrates that the foundations for sound mental health are built early in life, as early experiences shape the architecture of the developing brain (Miller & Kinsbourne, 2012). These important experiences include children's relationships with parents, caregivers, relatives, teachers, and peers, which play a critical role in shaping social, emotional, and cognitive development. Recent research indicates that early intervention can have a positive impact on the trajectory of common emotional or behavioral problems as well as on outcomes for children with adversities and disorders (National Scientifc Council on the Developing Child, 2012). Adverse experiences early in life, particularly for vulnerable children, have been shown to predict the emergence of later physical and mental health problems (Edwards

O. Idan (\*)

School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel

e-mail<EMAIL_ADDRESS>
O. Braun-Lewensohn

Confict Management and Resolution Program, Ben-Gurion University of the Negev, Beer Sheva, Israel

NTNU Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway e-mail<EMAIL_ADDRESS>
M. Margalit

Tel Aviv University, and Peres Academic Center, Rehovot, Israel

et al., 2003). Although mental health challenges for young children share many biological and behavioral characteristics with those of older children and adults, several aspects differentiate early childhood from later developmental stages. First, emotional health for young children is very strongly infuenced by their environment and the nature of their relationships and the support or risks these relationships confer. Therefore, it is essential to examine the quality of the children's environments and relationships to tap the risks for adversaries and the protective factors that may assist in promoting mental and physical health. Second, cognitive, social, and emotional characteristics are all intertwined within the architecture of the brain, and these capacities vary at different developmental stages. Children understand, manage, think, feel, and talk about their experiences differently at different ages. These developmental differences are important to understanding the behavioral and emotional risks and protective factors involved. Finally, in early childhood, it can be challenging to distinguish temporary deviations in behavior from persistent problems, or typical differences in maturation from developmental delays (Rubin et al., 2006).

From birth, children develop their abilities to experience and express a diverse range of emotions, as well as their capacity to cope with and manage different feelings (Thompson & Lagattuta, 2006). The development of these capabilities occurs at the same time as a wide range of highly visible skills in mobility, cognition, and communication (Thompson, 2001). The foundations of social competence that are developed in the frst 5 years are linked to emotional well-being and affect a child's ability to functionally adapt in school later on and form promoting relationships during adolescence and adulthood (Cassidy & Shaver, 1999). Therefore, it is important to address children's affective and cognitive aspects. Failure to address diffculties in the socioemotional domain may result in missed opportunities for interventions at critical periods (National Scientifc Council on the Developing Child, 2004).

The emotional experiences of newborns and young infants occur for the most while interacting with their caregivers.

This chapter is a revision and update of work published in Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G., Pelikan, J.M., Lindström, B., & Espnes, G.A. (eds). (2017). *The Handbook of Salutogenesis*. Springer, Cham. DOI: https://doi.org/10.1007/978-3-319-04600-6.

B. Lindström

Associations between positive emotions and the availability of responsive caregivers are strengthened during infancy in both behavior and brain architecture (Cassidy, 1994). Toddlers and preschool children depend on their emerging capacities to interpret their personal experiences and understand what others are doing and thinking, as well as to interpret the distinctions between different responses to them. By the end of the preschool years, children who have acquired emotional regulation skills can use their awareness of their own and others' feelings to interact daily (Thompson & Lagattuta, 2006). Studies on preschool children have shown how the interrelated development of emotion and cognition relies on the emergence, maturation, and interconnection of complex neural circuits in multiple areas of the brain (Davidson et al., 2002). A large-scale study examining a biopsychosocial model of risk and resilience on behavior at preadolescence indicated the importance of biological and psychosocial factors, including the SOC, on resilient outcomes and preadolescents' mental health (Agnafors et al., 2017).

Thus, the emotional development of young children is correlated to the characteristics of the environments in which they live, including their families, school, and community (Reid et al., 2002). A Children's Sense of Coherence Scale (CSOC) based on the three components of the SOC construct was developed (Margalit & Efrati, 1995).

#### **Children's Sense of Coherence Scale**

The Children's Sense of Coherence Scale (CSOC) (Margalit & Efrati, 1995) is an adaptation of the Antonovsky Orientation to Life (Sense of Coherence—SOC) Scale (Antonovsky, 1987). In line with the sense of coherence construct and the adults' scale, a children's version (CSOC) was developed, feld-tested, and revised several times at the Special Education Laboratory in Tel-Aviv University.

Due to the children's young age and reservations regarding the ability of children to comprehend the construct and scale, it was decided to develop a scale that would meet the unique characteristics of the target population. The scale was developed in collaboration with Aaron and Helen Antonovsky. The scale included distractors relating to the children's lives and activities. The CSOC's wording, the order of words, examples, and distracters were examined to ensure the comprehension of young children and the inclusion of ageappropriate content. Since its development, several new versions have been used, such as for junior high school students, omitting the distracter items, for example, "I'm interested in lots of things" and "I'm interested in lots of things in my class" (for school-based research, or "at home"—for family-based research). In general, distractors were coherent with culture.

The children's scale was tested on children of age 5 to adolescents. Comprehension was examined using unstructured interviews; a series of retests verifed stability. Conceptually, the items were derived from SOC-29 and the three components of the SOC. This consisted of 16 primary items and 3 fller items on a four-point Likert scale (the range was reduced to 4 from "never" (1) to "always" (4)). Scores ranged from 16 to 64, with items describing the children's feeling of confdence in their world, as expressed in their sense of comprehensibility—understanding their environment (i.e., "I feel that I don't know what to do in class"); sense of manageability—feelings of control, and confdence that when help is needed, it will be available (i.e., "when I want something, I'm sure I'll get it"); and meaningfulness interest in investing efforts in different tasks (i.e., "I'm interested in lots of things") (Alpha = 0.72). Similar to the SOC scoring procedures, a high score refected a high level of CSOC.

Studies using the CSOC explored children's personal and contextual resources and their ability to perceive family, social, and educational environments as structured and meaningful realities. The following section presents studies that used CSOC.

#### **Studies on SOC During Childhood**

A systematic search for studies on children and SOC between the years 2000 and 2019 in online databases (PsychoInfo, Ebsco, Proquest, APApsycnet, SocioFile, SAGE, Web of Science, and PubMed) using keywords (sense of coherence, salutogenesis, children, and family) and Boolean operators, presented 44 studies from 15 countries. Table 15.1 summarizes the studies.

Two major foci emerged from the review of the studies: Children's SOC within the family, school, peer group, and community environments and CSOC as a predictor of children's health and health behavior. The studies relating to CSOC and different contextual environments may be divided into three age groups/developmental stages: the preschool age stage, the elementary school-age stage, and a prolonged stage from infant to adolescence/adulthood focusing on families of children with special needs.

#### **SOC and the Child's Environments: Family, School, Peers, and Community**

The salutogenic paradigm focuses on promoting growth and adjustment. The following research deals with the contributions of children's environments: families, friends, and school systems, to the adjustment of children with typical development and children with special needs. The resilience

**Table 15.1**Studies (2000–2019) on SOC during childhood

Author

Year

Place

Population

Variables

Results

(continued)

127

(continued)

129

approach defnes assumptions about the critical predictors of the full potential of children to learn and to thrive in diverse settings regardless of personal and environmental challenges and risk factors (Damon, 2004). A major role of resilient research is to identify the complex transactions and processes among internal and external (risk and protective) factors that affect children's resilience and sense of coherence (Margalit, 2003).

*Sense of coherence at the preschool age stage* Children of various ages, with a strong sense of coherence, may perceive their day-to-day experiences as comprehensible and manageable. To compare the sense of coherence of typically developing preschool children with preschool children having special needs, studies have examined children and their parents in various social contexts (Al-Yagon, 2003; Margalit, 1998; Most et al., 2000). In a sample of 187 preschool children ages 4.9–6.3 years, children who were identifed as at risk for developing learning disabilities (LD), even before they were formally diagnosed and labeled, had a weaker sense of coherence, had fewer friends, and were less accepted by their peers. The sense of coherence assessment revealed the children's heterogeneity, and even among the group of typically developing children, a small subgroup could be defned with a very low sense of coherence and many social challenges. Also, in line with the salutogenic paradigm, special attention was given to a small subgroup of children within the group of children at risk whose sense of coherence was high. The relatively small extreme groups may add to the understanding of the development of coherence from early developmental stages (Margalit, 1998).

The children with a risk for developing learning disabilities received tutoring on an individual and small group basis during school time by the special education teachers. The focus was on language enrichment and basic learning skills. The sense of coherence of a subgroup of these preschool children (*N* = 67) was tested. Signifcant differences were noted in the comparisons between the sense of coherence scores at the beginning of the intervention and at the midyear evaluation. However, no signifcant differences were found between mid-year and the end of the year. The correlations between the frst and the second assessments of children's sense of coherence were signifcant (0.34) and between the second and the third assessments (0.32) as well. It can be concluded that at this age, there was some level of fexibility in the children's sense of coherence. Remedial training on delayed academic, language, and cognitive functioning was related to an increased sense of coherence and a narrowing of the gap with the typically developing group (Margalit, 1998).

Language diffculties and social-emotional challenges are often considered as two separate risk factors at the preschool age stage. A study of preschool children explored the relations between children's sense of coherence, loneliness, and phonological awareness. Phonological awareness consists of language skills such as awareness of the structure of sounds in words and sentences. Research reports that they predict reading acquisition (Most et al., 2000). The study examined the phonological awareness skills, loneliness, sense of coherence, and peer acceptance among 98 children ages 5.0– 6.4 years. Children at risk had lower achievements as a group on the phonological awareness measures, reported weaker CSOC, viewed themselves as lonelier, and were less accepted by their peers.

Family ecology is comprised of parental, familial, and environmental characteristics that may affect the capacity of the family to provide optimal care (Greenberg et al., 1993). Olson (2000) identifed cohesion and adaptability as two major parameters for evaluating the functioning of a family. Cohesion refers to the extent of connection, closeness, and involvement between the family members. Adaptability refects the family's capability to change as an adaptation to developmental and external pressures (Olson, 1986, 2000). A family system has been considered balanced when it demonstrates moderate scores on these two dimensions. In a study examining SOC, attachment security style, loneliness, and temperament of 145 children ages 5–6.5 years with and without developmental delays, and their mothers' SOC and family cohesion and adaptability, children having a secure attachment to their mothers reported a stronger SOC than children having an insecure attachment (Al-Yagon, 2003).

In summary, the studies on preschool children identifed SOC as an important protective factor that differentiated children with typical development and high-risk children, even before their formal assessment and measurable academic challenges.

*Sense of coherence at the elementary school-age stage* The transfer to elementary schools expands the variability of the factors that affect and are affected by the children's sense of coherence. Children's academic success, social competence, and coping capabilities contribute to their well-being and adjustment during that period, while academic, social, and behavior diffculties may be considered risk factors. Interactions with teachers and peers have a profound impact on children's life quality. Multiple studies examined the relations between children's sense of coherence and their family; their perceptions of teachers' support, peer friendships, and their overall school experience, revealing the complex and multivariate interactions at the elementary school-age stage (Al-Yagon, 2007, 2008, 2010, 2011, 2012; Al-Yagon & Cinamon, 2008; Al-Yagon & Margalit, 2006; Al-Yagon & Mikulincer, 2004; Efrati-Virtzer & Margalit, 2009; Liberman et al., 2013; Sharabi et al., 2012).

To further clarify the role of teachers in understanding children's sense of coherence, the attachment conceptualization (that was developed for children–mothers' relations) was adapted to schools' relationships. Children's perceptions of the teachers as a secure base were examined, and the results revealed that secure attachment patterns expressed in the development of close relationships with teachers predicted children's SOC and loneliness (Al-Yagon & Margalit, 2006; Al-Yagon & Mikulincer, 2004). Children, who felt that their teachers were more available to them and more accepting, reported a stronger SOC and less feelings of loneliness.

In another study (Efrati-Virtzer & Margalit, 2009), the characteristics of children with behavior diffculties were examined (behavior diffculties included verbal and physical aggression toward children and objects). The age range of these children was 9–12 years, and they were compared with children with no adjustment problems from the same classes. Results revealed that the behavior diffculties contributed to the explanation of social and academic functioning and were linked to social diffculties—in terms of lower peer acceptance and increased rejection by children in their classes, as well as to lower academic achievement. Children with disruptive behavior also reported weaker levels of CSOC. Those children with stronger CSOC revealed emotional self-regulation and participated in fewer behavior conficts at school. It is not clear whether a weaker SOC was the outcome of the multiple academic, social, and behavior diffculties or predicted them. Students with a weaker SOC were less accepted by their peers and rated as more rejected by them.

The study of social relations at school provided additional validation to the complexity of the interacting variables. The most common approach for identifying a child's status in class is done by asking the children to state the names of their best friends (and those that they do not like) as measures of social acceptance and rejection. The construct of reciprocal positive nomination (mutual friendship) attracted increased research attention since it provided information on mutual perceptions, refecting the interpersonal attraction and liking where within a pair of children, each one selected the other as a friend (Yugar & Shapiro, 2001). If the positive mutual nomination was an important indicator in refecting friendship and explaining decreased alienation experience in schools, the reciprocal negative nomination (mutual selection within a dyad of children of the least liked child in the class) extended the understanding of the increased experience of social isolation, identifed enemies in classes and enhanced feelings of social exclusion and loneliness. It is not surprising that they were related to a weaker SOC (Efrati-Virtzer & Margalit, 2009).

Research on elementary schoolchildren with and without developmental delays and their families identifed SOC as playing a signifcant protective role during the frst year at school. In a study on 50 schoolchildren ages 5–6 years with and without developmental coordination disorder (DCD), levels of CSOC, hope, and effort in children with DCD were lower than their typically developing peers. Signifcant correlations were found between CSOC to the children's involvement in daily activities in a variety of environments. The CSOC was related to the children's independence and enjoyment from participation in age-appropriate social and leisure activities (Liberman et al., 2013).

#### **The Relations Between Children's SOC and Families' Characteristics**

Several studies have shown that maternal coping resources moderated the effect of children's learning disabilities on secure attachment, levels of loneliness, feelings of hope, and future expectations. The degree to which the learning disability affected the children's socioemotional academic competence and social interrelations was related to the type of coping their mothers employed and their reliance on social support (Al-Yagon, 2007, 2008, 2010, 2011, 2012, 2014, 2015; Al-Yagon & Cinamon, 2008): Maternal SOC signifcantly enhanced the child's socioemotional adjustment measures and attachment scores (Al-Yagon, 2008); children's adjustment and SOC mediated associations between maternal emotional resources and children's well-adjusted functioning. The signifcantly weaker SOC among children with learning disabilities (LD) emphasized this coping resource (Al-Yagon, 2010); studies also recognized the signifcance of children's relations not only with mothers but also with fathers. The mediating role of CSOC emerged for children with and without learning disabilities in the association between fathers' resources and children's well-adjusted functioning (Al-Yagon, 2011); children who felt securely attached to both parents reported a higher global orientation or enduring tendency to see the world as comprehensible, manageable, and meaningful than children who felt securely attached to only one parent or neither parent. In examining the differences in the role of attachment with fathers and mothers, Al-Yagon (2014) reported that in the model modifed for elementary schoolchildren with severe learning disabilities (SLD), a higher number of signifcant paths emerged between child–mother attachment relationships and internalizing measures than for child–father attachment. Data also showed that attachment with fathers contributed mainly to children's coping resources (i.e., SOC, hope, and effort), whereas attachment with mothers contributed to a broader range of internalizing adjustment measures including not only SOC but also self-reported loneliness and parent-rated internalizing problems. In investigating the coping resources of parents of children with LD and children with typical development, Al-Yagon (2015) highlighted the potential role of parents' affect. Specifcally, higher levels of positive affect signifcantly contributed to parents' stronger SOC for fathers and mothers of children with LD. However, greater negative affect contributed to greater utilization of active and avoidance coping strategist only for mothers of children with LD. Furthermore, children who exhibited insecure attachment to both parents appeared to be the most vulnerable in forming coping resources (Al-Yagon, 2012; Al-Yagon & Cinamon, 2008).

Parents comprise only in part family cohesion. In a study on 287 schoolchildren ages 10–12 years, four family profles were identifed: children in the cohesive families' clusters reported the lowest levels of loneliness and the strongest levels of CSOC, whereas children within noncohesive family clusters reported the highest levels of loneliness and the weakest levels of CSOC (Sharabi et al., 2012). Additionally, the degree of cohesion within families was found to predict effort investment and success in school. Feldman et al. (2018) revealed that family cohesion and the mediating roles of SOC and hope (protective factors), as well as loneliness (risk factor), contributed signifcantly in predicting school effort among elementary school pupils.

In conclusion, during elementary school, children acquired basic learning skills, established positive and negative relations with teachers and peers, and their functioning predicted their life quality, as well as presenting special academic and behavior challenges. At this age stage, SOC was shown to provide a unique and relatively stable index of children's social and emotional adjustment and well-being. The entrance to high schools and the adolescence age stage not only provided extended opportunities but also revealed continued diffculties and new challenges. A study of the Norwegian education system explored elementary through junior high schoolchildren focusing on age and gender comparisons concerning school-related stress and resources and their relations to the SOC construct. The sample consisted of 4116 schoolchildren ages 11, 13, and 15 years. SOC was related to feeling pressured by schoolwork, social support from peers, and expectations. Among girls, this association was strongest for the youngest group. School-related factors were shown to represent both resource and stress factors related to the SOC (Natvig et al., 2006).

*From infancy to adolescence/adulthood: Families of children with special needs* Children with special needs are considered a source of distress to their families. Their increased levels of stress refect their emotional reactions to the unexpected and challenging reality of having children with developmental disabilities and behavior challenges. The fathers' and mothers' SOC refects the impacts of the prolonged stress but at the same time reveals their parental resources that may be conceptualized as resources that serve as protective factors (Margalit, 1994).

Research on infants and preschool children with developmental delays and their families (Einav et al., 2012; Hedov et al., 2002; Margalit et al., 2006; Oelofsen & Richardson, 2006; Pisula & Kossakowska, 2010) identifed the parents' SOC as meaningful for the development of their children. In a study of 111 mother–child dyads of infants ages 3–24 months with developmental delays, mothers with strong levels of SOC and with high coping strategies felt more hopeful. The family cohesion (the mothers' perceptions that their family members were close to one another and provided support when needed) was interrelated with mothers' SOC. Cohesion was related to hopeful thinking only indirectly, mediated through mothers' SOC. Only for mothers who reported strong levels of SOC was the family support meaningful in the prediction of hopeful thinking (Einav et al., 2012).

Mothers from noncohesive families with weaker SOC experienced higher levels of stress than mothers from cohesive families with stronger SOC in a study examining SOC, family cohesion and adaptability, mood, coping, and parenting stress of 80 mothers of children ages 2–39 months exhibiting delayed development. Furthermore, mothers from noncohesive families with weaker SOC experienced lower levels of positive mood than mothers from cohesive families with a strong SOC (Margalit et al., 2006). Oelofsen and Richardson (2006), studying fathers and mothers of preschool children with developmental disabilities (DD), found that parents of children with DD reported parenting stress within the clinical range, weaker SOC, and poor health than the comparison group—parents of children without DD. The study's results focused the attention on the mothers who, as the major caregiving parent, experienced more stress than the fathers and reported more health problems, and weaker SOC than the fathers.

Studies focusing on parents to children with special needs emphasized the signifcance of SOC with parenting stress: parents of children with cerebral palsy, reporting a stronger SOC, less often used avoidance, wishful thinking, and resignation as coping strategies than parents reporting a weaker SOC (Dabrowska, 2003); parents of children with Down's syndrome as well as the comparison group had a stronger SOC when their stress level was lower (Hedov et al., 2002); and fathers of children with developmental disabilities reported a weaker SOC more frequently and used strategies of avoidance compared to fathers with a stronger SOC that used confrontation more frequently and positive reappraisal and problem-solving behavior (Dabrowska, 2008).

In a study on parents of children with autism, the parents reported a weaker SOC than the comparison group and used avoidance coping more often. Among parents of children with autism, the SOC level was positively associated with seeking social support and self-controlling and negatively with accepting responsibility and positive appraisal. The results demonstrated that the frequency of using accepting responsibility strategy increased with decreasing levels of SOC among the parents. This may suggest that one of the consequences of low SOC may be a self-blame tendency for the occurrence of stressful situations related to parenting a child with special needs (Pisula & Kossakowska, 2010). This confrms earlier fndings of a weaker SOC among parents of children with autism (Olsson & Hwang, 2002; Sivberg, 2002).

Several studies explored SOC in families of children with developmental disorders from birth to adolescence (ages 1–13, 0–16 years) and/or adulthood (ages 1–28 years). Hintermair (2004) studied 235 mothers of children ages 1–13 years with hearing impairments and found that mothers with stronger SOC had an advantage in coping with the experience of raising a deaf and hard of hearing child over mothers with weaker SOC scores. SOC was of greater importance than experienced social support. Similarly, Olsson and Hwang (2002) studied 429 fathers and mothers of children from birth to 16 years of age with and without intellectual disability (ID). They found that parents of children with ID who reported low levels of SOC were more depressed than control parents with low levels of SOC. No relation was found between the age of the child and the levels of SOC in parents of children with ID. In a study of children, adolescents, and young adults with autism, Mak et al. (2007) reported that mothers with a strong SOC reported less stress than those with a weak SOC. SOC had a moderating effect on the association between symptom severity and parenting stress.

In summary, the studies on families of children with special needs identifed SOC as a signifcant protective factor related to effective coping and hopeful thinking that differentiated between families of children with typical development and families of children with special needs. Understanding the relationship between SOC and coping among parents of children with special needs provides insight into the mechanisms involved in parental adjustment and effective coping outcomes.

#### **SOC as Predictor of Health and Health Behavior**

In the past decade, research has shown the relationship between social factors, health, and disease, focusing attention on salutogenic models, concentrating on personal control. This trend followed former studies that revealed that persons with a strong SOC tended to manage stress better, whereas persons with a weak SOC tended to be more sensitive to health challenges and illness (Lundberg & Nystrom, 1994). Recent multiple pieces of research on SOC and health have identifed SOC as a predictor of health and health behavior (Berntsson & Gustafsson, 2000; Bonanato et al., 2009; Forinder et al., 2005; Groholt et al., 2003; Honkinen et al., 2005; Jellesma et al., 2006; Kan et al., 2015; Krause, 2011; Løndal, 2010; Nammontri et al., 2013; Ray et al., 2009; Torsheim et al., 2001).

Studies examined the determinants of psychosomatic complaints in children. They found that the predictors of psychosomatic complaints were the mother's health, child's mental stability, contacts with peers, long-term illness, and, via other factors, parents' SOC, social competence, and school satisfaction (Berntsson & Gustafsson, 2000). Furthermore, in an attempt to understand the relationship between poor perceived health during childhood and an individual's well-being throughout life, 1231 12-year-old schoolchildren in Finland were studied. SOC and variables of social support were found signifcantly associated with perceived health. Physical exercise and SOC were associated with perceived health and father's occupation, and weak SOC was found to be independently associated with relatively poor health (Honkinen et al., 2005). Kan et al. (2015) demonstrated the mediating role of SOC on the association between childhood economic status and health in the community adult population of Japan. SOC signifcantly mediated the association between parents' education and current health among women and mediated between perceived childhood socio economic status (SES) and current health among men.

Studies focusing on the relation of somatic complaints and emotional functioning of children pinpointed attention to the existence of emotional problems in children who reported somatic complaints. Jellesma et al. (2006) studied 153 schoolchildren ages 8–13 years at three levels of somatic complaints (few, many, and clinical). The results showed that the clinical group and the children with many somatic complaints reported more negative moods on the anger, sadness, and fear scale, more diffculty differentiating emotions, and a weaker SOC than the group with fewer complaints. Torsheim et al. (2001) studied 1592 sixth-grade children, 1534 eighth-grade children, and 1605 tenth-grade children in an attempt to tap the role of SOC and school-related stress as predictors of health complaints. Age group comparisons revealed that the association between SOC and stress grew weaker with age, whereas the direct association between SOC and health complaints grew stronger. Fifty-two patients aged 9–22 years, who had stem cell transplant at least 3 years before the study, participated in a study of health and quality of life. The scores obtained on SOC for younger children (ages 9–12 years) showed that children in the SCT group have a SOC level equal to that of both the norm groups and other chronically ill children. The mean value for the younger children in the SCT group was in line with that of the norm group of children age 9 (Forinder et al., 2005).

#### **Parents' SOC and Children's Health**

The parents' role in predicting their children's health and health behavior was examined based on the salutogenic model. The relation between parental SOC and child health was explored in a large-scale study (Groholt et al., 2003) in the fve Nordic countries, which included 9524 children ages 2–17 years, of which 35% co-responded with their parents due to their young age. Compared to the higher social classes, low levels of SOC were more common in the lower socioeconomic classes. The association of child chronic health complaints with weak parental SOC was found to be disability-specifc (diabetes, epilepsy, and psychiatric problems). Parents of children with diabetes, epilepsy, or psychiatric problems had 2–5 higher odds of having weak SOC compared to parents of children without a specifc diagnosis.

Ray et al. (2009) studied 772 parent–child dyads of 10- to 11-year-old schoolchildren to fnd the relationship between food intake and parents' SOC. Weaker parental SOC was associated with children's irregular meal patterns, more frequent intake of energy-rich foods, and less frequent intake of nutrient-rich foods. Eli et al. (2016) found that mothers who had a stronger SOC were less likely to engage in pressuring or restrictive feeding practices. Resilience to stress reduced counterproductive practices, even in the presence of concern about the child's weight.

In another study, mothers with weaker levels of SOC were more likely to have children with decayed teeth or flled teeth regardless of the child's social class and gender (Bonanato et al., 2009). In contrast, the prevalence of clinical consequences of neglected dental caries was low among children attending public and private preschools in Brazil. It was associated with stronger levels of parental/caregiver SOC (Neves et al., 2019).

In a study identifying the predictors of adaptation and assessing potential moderating effects of parents' sense of coherence and family hardiness on the relationship of severity of illness of a child with asthma, SOC and family hardiness predicted family adaptation. Icelandic mothers perceived their family's adaptation more favorably than American mothers. Regarding the fathers, family demands predicted adaptation. SOC moderated the effect of family demands on adaptation for both parents (Svavarsdottir et al., 2005).

*Intervention programs promoting children's health* In addition to identifying SOC as a signifcant protective factor related to effective coping, the contribution of the salutogenic paradigm in explaining successful coping with stressors and health promotion has guided the development of intervention programs promoting health and health behavior. The following studies are examples of such intervention programs involving children and their families.

An intervention program based on the salutogenic model promoting oral health resulted in improved oral health. The intervention provided evidence that SOC infuenced the oral health-related quality of life (Nammontri et al., 2013). Positive health beliefs and a stronger SOC were found to predict positive health beliefs and fewer symptoms. An additional intervention program focused on promoting play in an after-school program (ASP) had considerable potential of promoting the children's SOC. Most of the children in the study experienced their world as comprehensible, manageable, and meaningful. Negative thoughts and feelings were reduced during play. Play offered particularly strong opportunities for the children themselves to shape outcomes and interact with children, promoting their SOC (Løndal, 2010).

In another intervention program that aimed to promote health resources in children, 226 schoolchildren ages 5–10 years participated in a longitudinal self-worth reinforcement program. The results showed that developing SOC as a part of promoting mental health in schoolchildren is most effective during the early years of childhood. This fnding emphasized the need to train professionals within the school (Krause, 2011).

#### **Conclusions and Future Research Directions**

The results of the surveyed studies support the conceptualization of the SOC construct as an important personal resource that develops during childhood. Stresses and challenges are a part of children's lives. However, most children who have a strong SOC can transform their potential resources into actuality, thereby promoting well-being. Children and adolescents with a strong SOC may have a good comprehension of most of their contextual conditions, situational demands, and personal experiences. They may feel relatively in control of their lives and may consider most of their tasks and participation in age-appropriate activities as meaningful, signifcant, and worth of investing the effort. When they face a stressful situation, they can select the appropriate strategies to cope effectively with the stressors. Thus, acquiring a wide range of coping strategies, alongside an emphasis on collaborative activities, developing social partnerships that respect different voices and self-reliance, may enhance the youngsters' resilience and motivation to invest effort to reach their preferred goals (Margalit, 1998). Consistency, a special cognitive challenge for children, may strengthen comprehensibility; an overload–underload balance, a special risk for children who struggle with school demands, may affect manageability; and the participation in socially valued decision-making may strengthen meaningfulness (Margalit, 2008).

The results of these studies have clear educational implications for school systems at various age groups in terms of prevention and intervention planning. The early manifestations of the developing SOC, as a personal resource, and the results that indicate that stresses and diffculties are disclosed in weaker levels of SOC, call for early awareness and empowering programs within educational systems. In addition, the results that show the impact of effective intervention not only on better academic functioning but also on friendship development and signifcant growth incoherence justify focused attempts on early intervention before SOC is structured and stabilized. The studies demonstrated the importance of early comprehensive intervention, as well as the signifcant value of preventive measures through sensitizing teachers not only to meet crises and diffculties but also especially to provide attentive support to the children's experiences. Preventive programs that empower children's abilities to integrate their thinking and learning skills with the abilities to regulate their feelings (emotion regulation) and actions (behavioral competence) promote growth, effort, and motivation (Idan & Margalit, 2011). School-based intervention programs and teachers' training promoting salutogenic approaches in class are required, alongside family-based interventions and parents' training, to promote salutogenic approaches in the home.

In the reviewed studies, children with typical development and children with developmental disabilities, learning disabilities, and various additional adjustment challenges were included. Most children who reported higher levels of loneliness also experienced a weak sense of coherence. In several studies, the weak sense of coherence was related to children's current distress, as well as to early expressions of adjustment diffculties and family climate. Mothers' sense of coherence was found as an important personal resource that enabled successful attachment relations and was related to children's sense of coherence (Al-Yagon & Mikulincer, 2004). Special attention was provided to groups of children with developmental or contextual challenges that reported levels of sense of coherence compatible with their typically developing peers. Thus, the awareness of the fact that diffculties never appeared in isolation, encouraged the multidimensional prevention and intervention approaches that treated not only academic or behavior challenges, but supported the whole child who had been developing satisfactory social relations while struggling with diffculties, to support coping and celebrate success and competencies. The salutogenic paradigm provides a structure to this planning, by emphasizing comprehensibility (explaining and clarifying the goals and the procedures), manageability (teaching the required skills to reach these goals), and meaningfulness (enhancing motivation and involvement in the effort).

Research presented in this review demonstrated the importance of the salutogenic approach in developmental research of children and adolescents and its potential for educational planning. The studies emphasized the interacting role of academic demands and social challenges with the SOC, clarifying the dynamic interactions between academic and socioemotional factors and children's readiness to treat their diffculties as challenges worthy of effort investment. These fndings emphasized the major role of resilience approaches, considering SOC as a predictor in explaining well-being and adjustment, and calling for the future development of comprehensive educational intervention programs (Idan & Margalit, 2011).

To beneft schools and children from the salutogenic approach, two future research directions are needed. First, there is a need for longitudinal studies that will document changes and stabilities in the development of CSOC. Through longitudinal studies, we can clarify the interactions between the stabilization and the fexibility of children's SOC within different contextual conditions. Second, research calls for cross-cultural comparisons of the sense of coherence development. There is a need for a coordinated international collaboration for longitudinal research to explore the interactions of SOC between cultures, families, schools, communities, and children's different growth paths.

#### **References**

reading diffculties. *European Journal of Special Needs Education, 21*(1), 21–37.

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## **Salutogenesis and the Sense of Coherence During the Adolescent Years**

**16**

Orna Braun-Lewensohn, Orly Idan, Bengt Lindström, and Malka Margalit

#### **The Developmental Stage of Adolescence**

Adolescence is a period of growth and development between childhood and adulthood. This developmental period involves new demands on the individual. A major task of this period is moving toward independence from dependency on the family; therefore, peers become a crucial socialization circle for the adolescent (Romeo, 2013; Spear, 2013). During this period, several physiological and cognitive changes occur as young people confront developmental tasks and challenges. During the last decade, there has been a marked increase in neurobiological research on cognitive, emotional, and behavioral changes, and development during adolescence. These studies have found that cognitively, adolescents, as well as adults, can suppress responses when no emotional information is provided (Tottenham et al., 2011). However, it is the avoidance of social cues during challenging situations in which adolescents have a diffculty to make a proper and rational response (Casey & Caudle, 2013). Thus, it seems that tension between regulation of behavior and sensitivity to positive environmental cues makes the response of the individual during the period of adolescence more complex (Somerville et al., 2011).

O. Braun-Lewensohn (\*)

Confict Management & Resolution Program, Ben-Gurion University of the Negev, Beer Sheva, Israel e-mail<EMAIL_ADDRESS>
O. Idan School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel

B. Lindström

NTNU Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway e-mail<EMAIL_ADDRESS>
M. Margalit

In line with the positive youth development perspectives (Damon, 2004), there is a growing recognition of the individuals who are eager to explore the world, to acquire competence, and to struggle with challenges and diffculties. This approach focuses on productive activities rather than on trying to cure and treat maladaptive tendencies. The agenda is to maximize the potential of the individual and to reduce the potential of hazardous, destructive, and antisocial behaviors (Lerner & Benson, 2003). The period of adolescence is a particularly important developmental stage since social, emotional, and cognitive processes are involved in attempts to navigate increasingly complex relationships (Blakemore & Mills, 2014). Indeed, it is during these years that abstract thinking and cognitive processing develop along with enhanced moral reasoning and judgment. These positive processes enable the adolescent to explore the world, gain competences, and contribute to the world surrounding him/her (Damon, 2004). As children age, their coping repertoire expands and shifts from primarily external, behavior-oriented to more internal, cognitively based strategies (Aldwin et al., 1994).

The advanced forms of refection, such as the ability to consider things in hypothetical and abstract terms, and the ability to monitor one's cognitive activity during the process of thinking, enable adolescents to see from the perspective of other persons, to plan, to anticipate the future consequences of an action, and to offer alternative explanations of events. Cognitive mastery is, therefore, an important contribution to young people's ability to manage or regulate their feelings and to control their emotions and/or avoid being overwhelmed by them (Garnefski et al., 2001). These abilities also have the potential to infuence the emotional–motivational and behavioral components of sense of coherence (SOC). It is during these years, as young people move from one experience of using specifc coping resources to another, that different resources can be reviewed and crystalized.

In the following section, we present adjustments to the SOC questionnaire and discuss a variety of ways that researchers have approached the study of salutogenesis and adolescence.

The adolescent, at the very best, can only have gained a tentative strong SOC, which may be useful for a short-range prediction about coping with stressors and health status (Antonovsky, 1987, p. 107).

Tel Aviv University, Peres Academic Center, Rehovot, Israel

#### **Studies of SOC During Adolescence**

Our literature search used Ebsco, PsycInfo, PubMed, SocioFile, and GoogleScholar, and we searched the sites of the publishers Sage, Springer, and Wiley. We looked at the last decade from 2014 to 2019 and included the search words: adolecs\*, youth, sense of coherence, and salutogenesis. We came up with more than 30 articles and research from 16 countries in Europe, the Middle East, Australia, and the United States. Table 16.1 summarizes these studies.

The following themes emerged from the identifed studies.

**Table 16.1** Studies of SOC during adolescence

**Table 16.1** (continued)

**Table 16.1** (continued)

#### **Table 16.1** (continued)

**Table 16.1** (continued)

#### **Adaptations of the SOC Questionnaires**

Based on the original SOC questionnaire (Antonovsky, 1983), several researchers have examined the adaptability of the questionnaire to adolescent populations. For example, *the adolescent sense of coherence scale* (Antonovsky & Sagy, 1986) was adjusted to ft adolescents' characteristics, that is, development of self-identity, orientation to one's self society, confusion, unpredictable changes, close emotional ties with parents for the development of open communication, stability of the community, etc. Several items were removed from the original 29-item scale, and others were rephrased to make sure that adolescents understand the items (Antonovsky & Sagy, 1986), ending up with the fnal version of 13 items which is considered as a single factor and not the three separate components—meaningfulness, comprehensibility, and manageability (Hagquist & Andrich, 2004). Many studies have used this scale, and reliability proved to be very good (*α* ≈ 0.80). Another approach to the adaptation of the scale to the adolescence developmental stage was based on the use of the child version (CSOC) without the examples and distractors for younger children. The description of the CSOC can be found in the chapter on children (Margalit & Efrati, 1996). The adolescence adaptation from the CSOC consisted of 16 items (e.g., "When I want something I'm sure I'll get it"; "When I need help there is someone around to help me"), on a fve-point Likert-type scale ranging from 1 (never) to 5 (always). A Cronbach's alpha of 0.78 was obtained (Levi et al., 2014).

#### **The SOC Construct During Adolescence**

The stability question regarding SOC accompanied this construct since the beginning of research about it. Antonovsky and Sagy (1986) argued that SOC should be strengthening during adolescence and stabilized toward the end of this developmental period. However, studies that addressed the issue of age and the stability of SOC revealed inconsistencies (Apers et al., 2013; Ayo-Yusuf et al., 2008; Garcia-Moya et al., 2013a, b, c, d; Kristensson & Öhlund, 2005; Moksnes et al., 2012). Indeed, Eriksson and Lindström (2007) stated that SOC is likely to vary during adolescence due to developmental changes, transitions, and challenges. While some researchers did not fnd differences among various age groups (Honkinen et al., 2008) and claimed the existence of SOC stability during adolescence (Kröninger-Jungaberle & Grevenstein, 2013), others focused on the variability between groups of adolescents between younger and older adolescents (Garcia-Moya et al., 2013a, b, c, d) as well as between groups with strong versus weak scores of SOC. The group with a weaker SOC reported more variability in its SOC scores (Buddeberg-Fischer et al., 2001).

Moreover, during periods of political violence, studies have shed light on the impacts of fragile periods and documented a drop in SOC levels during acute stress situations. However, once the acuteness is over, the SOC gains back its strengths (Braun-Lewensohn et al., 2013). Nevertheless, when adolescents face chronic states of stress, such as longitudinal missile attacks, the deterioration of the SOC remained stable over time (Braun-Lewensohn & Sagy, 2010).

Other *demographic characteristics,* apart from age, have signifcant roles in the determination of the SOC levels. Gender differences were examined, and many studies showed that the SOC scores of boys were higher than the scores of girls (Apers et al., 2013; Dorri et al., 2010; Evans et al., 2010; Kristensson & Öhlund, 2005; Moksnes et al., 2011, 2012; Nio, 2010). Also, socioeconomic status plays an important role in the SOC prediction. Thus, higher levels of parents' education (Feldt et al., 2005; Geckova et al., 2010; Ristkari et al., 2009), higher economic status (Geckova et al., 2010), and living with two parents (Ayo-Yusuf et al., 2009) have been important indicators of stronger SOC. Lastly, membership in a minority group in different cultures around the world predicted weaker SOC scores than those of majority groups (Braun-Lewensohn, 2014; Braun-Lewensohn & Sagy, 2011a, b; Glanz et al., 2005).

#### **SOC, Health, Mental Health, and Psychosocial Behavior**

Examining the various studies, we found that the relations of health, mental health, and psychosocial behaviors with SOC were explored. More specifcally, researchers investigated the SOC as a predictor of health outcomes, mental health, and diverse health-promoting behaviors during adolescence.

Several studies examined the relations between the SOC and general health (Eriksson & Lindström, 2006; Nilsson et al., 2003). Stronger SOC was related to better-perceived health, while weaker SOC was related to medication use. Moreover, SOC was negatively related to reported health problems (Blom et al., 2010; Garcia-Moya et al., 2013a, b, c, d; Geckova et al., 2010; Honkinen et al., 2005; Koushede & Holstein, 2009; Mattila et al., 2011; Modin et al., 2011; Moksnes et al., 2011; Myrin & Lagerström, 2006).

Other examinations related to health focused on groups with specifc health problems. For example, surprisingly, adolescents with heart problems were found to have a stronger SOC compared to healthy adolescents. These results were explained by the fact that youngsters with such chronic disease have learned to cope with their problem, which increased their manageability, besides having existential implications that increased their meaningfulness. Moreover, a supportive home environment experienced by these adolescents emphasizes specifc life events as being more comprehensible, manageable, and meaningful; hence, nurtured feelings of SOC (Luyckx et al., 2012). More expected results were found for adolescents with epilepsy where a weaker SOC was found in the long run, refecting the experience of losing control during seizures and diffculty in assessing when to expect the next seizure. Following this line, those adolescents with no seizures had a stronger SOC (Gauffn et al., 2010).

*Mental health* has been the focus of numerous studies that examined diverse outcomes. Stress-related outcomes such as anxiety, anger, depression, psychological distress, and other emotional and internalizing or externalizing problems were examined in the context of political violence (Braun-Lewensohn & Sagy, 2010, 2011a, b; Sagy & Braun-Lewensohn, 2009) and with regard to challenging and extreme life events such as child abuse (Gustafsson et al., 2010) or juvenile delinquency (Koposov et al., 2003). However, adolescents were also examined during regular daily life with "normal" life stressors, such as academic, school, or peer pressure as well as family conficts (Moksnes et al., 2012, 2013; Nielsen & Hansson, 2007; Ristkari et al., 2009; Simonsson et al., 2008). All these studies confrm that the SOC can be considered a resilience factor. It can be concluded that a strong SOC predicts reduced stress and decreased internalizing or/and externalizing problems.

Moreover, examining the relationships of SOC with *psychosocial behaviors* even strengthens the consideration of SOC as a resilient factor. Accordingly, results of various studies showed that adolescents with stronger SOC reported a healthier lifestyle, a better quality of life, and well-being (Honkinen et al., 2009; Neuner et al., 2011). The healthy lifestyle is related, on the one hand, to physical activities and exercises (Bronikowski, 2010) and, on the other hand, to smoking habits, alcohol abuse (Garcia-Moya et al., 2013a, b, c, d, 2013a; Myrin & Lagerström, 2006; Nielsen & Hansson, 2007), and eating habits (Myrin & Lagerström, 2006). Similarly, the relations between SOC and oral behavior (e.g., toothbrush habits) were reported. Stronger SOC was linked to lower gingivitis, more willingness to change toothbrush habits, and especially increased tooth brushing (e.g., Ayo-Yusuf et al., 2008, 2009; Dorri et al., 2010).

#### **Ecological Contexts: Family, School, Peers, and Community**

Ecological contexts (Bronfenbrenner, 1977, 1979; Bronfenbrenner & Morris, 2006) extend the consideration from a focus on the personal level to awareness and sensitization to contextual characteristics and systemic consideration such as the families, schools, and communities. Several family-related factors were examined in relation to the SOC. For example, open family communication (Garcia-Moya et al., 2013a, b, c, d; Marsh et al., 2007), focused parenting style (Garcia-Moya et al., 2013a, b, c, d), and parents' knowledge regarding their children activities (Garcia-Moya et al., 2013a, b, c, d) were considered positive contributors to the development of a strong SOC. In addition, child-centered parenting during adolescence (examined within a longitudinal paradigm) predicted a stronger SOC at adulthood (Feldt et al., 2005).

In addition to examining family contexts and factors which could enhance or reduce personal SOC, few studies also related to family sense of coherence as another source to rely on when facing diffculties and/or stressful situations. Likewise the personal SOC, it was found that also family SOC is a resilient factor, and adolescents with stronger family SOC reported reduced stress (Sagy & Braun-Lewensohn, 2009; Sagy & Dotan, 2001).

Another important ecological system is *school.* While the family dimension produced mainly studies that pinpointed attention at the contribution of family characteristics to the development of SOC, studies of schools focused attention on outcomes, examining the adolescents' achievement and adjustment, and their relationship to SOC as a mediation factor. Within the educational systems, a stronger SOC predicted high grades and enhanced academic motivation and success. Lower stress levels were also reported as related to stronger SOC (Honkinen et al., 2005; Kristensson & Öhlund, 2005; Lackaye & Margalit, 2006). Moreover, stronger SOC was linked to social competence (Mattila et al., 2011; Moksnes et al., 2011).

The school system provides a unique opportunity to look at particular populations with regard to SOC. Adolescents with learning disabilities are an additional example of the importance of the SOC (Idan & Margalit, 2014; Lackaye & Margalit, 2006). These youngsters are identifed by their chronic academic challenges emerging from neurodevelopmental diffculties. Their diffculties at school systems remain a continuous source for increased stress, endless day-to-day struggling with age-appropriate academic roles, and with social and emotional consequences. Indeed their sources of stress are not dramatic, but their lasting impact is expressed in weaker SOC. Studies placed the SOC as a mediator of hopeful thinking, predicting adjustment and effort investment in school. The adolescents' systems, such as families, schools, and communities, may further clarify the important role of the SOC and the factors that predict its development.

The focus on *peer relations and community atmosphere* produced studies that explored these factors as predictors of SOC development. An additional group of studies explored SOC as a collective construct contributing to the mental health of adolescents. Exploring SOC as a dependent variable, it seems that social support (Marsh et al., 2007), neighborhood or community cohesion (Garcia-Moya et al., 2013a, b, c, d; Marsh et al., 2007; Peled et al., 2013), and success in school (Garcia-Moya et al., 2013a, b, c, d) are all constructive in the development of strong SOC.

To expand the measurement of the SOC from the personal to the collective level, the *sense of community coherence* instrument was developed, which includes the components of comprehensibility, manageability, and meaningfulness (Braun-Lewensohn, 2014; Braun-Lewensohn & Sagy, 2011b; Peled et al., 2013). *Comprehensibility* refers to the sense of predictability, safety, and security felt by members of the community and the extent to which that community is understandable. A community's *manageability* expresses its ability to assist its members, via treatment providers and group programs, among others, in times of crisis and distress. Lastly, the higher the level of *meaningfulness* among the members of a community, the abler they are to express themselves, and the higher the likelihood that they will feel satisfed with and challenged and interested by what the community has to offer them (Braun-Lewensohn & Sagy, 2011b). Recent studies showed that indeed the sense of community coherence is another source of support for coping during adolescence when facing acute or chronic types of stress, especially among collectivist cultures (Braun-Lewensohn, 2014; Braun-Lewensohn & Sagy, 2011b; Peled et al., 2013).

#### **Conclusions, Implications, and Directions for Future Research**

This chapter focused on the sense of coherence and salutogenesis during the developmental period of adolescence. While in many ways, adolescents appear to function similarly to adults, numerous cognitive, biological, and behavioral processes are formed and shaped on the path to maturity and normative adulthood.

A recent review on salutogenesis and the concept of SOC examined the infuence of different factors such as gender and age as well as different developmental contexts (family, school, peers, and neighborhood) on the development of SOC (Rivera et al., 2013). In our current review, we extended conceptualization and research results regarding SOC during this important developmental period of adolescence within a different orientation. Mainly, we addressed how the SOC questionnaire was adopted to ft adolescent populations, as well as the clarifying ways how SOC is linked to different health, mental health, and psychosocial behaviors in different ecological contexts. We can conclude that the review of studies from around the world in the last decade demonstrated that personal and systemic (i.e., family and community) SOC are important resources for coping with a wide variety of stressful situations. The survey of the studies shows that the SOC may be considered as a protective factor for adolescents in different cultures. During adolescence, the SOC may contribute to moderating and mediating stress experiences and may also play a protective role, similar to that of the mature adult SOC.

The educational and community implications of the current consideration of the SOC as a critical resource call for the sensitizing educators and community workers to the importance of the salutogenic construct. Future empowering programs should be guided by this construct, leading to the development of prevention/inoculation to stress planning as well as programs promoting positive psychosocial and healthy behaviors and academic success.

Our review raises several directions for future research in the feld of salutogenesis and the sense of coherence during adolescence. Despite developments, there are still some issues that require attention. This includes the role of family coherence as a protective factor for health and mental health, for success in school, and psychosocial behaviors that determine their relationships and their attitudes toward each other. Moreover, non-western cultural groups were less studied in this context. When studied, some questions regarding the universality of the concept of SOC were raised (Braun-Lewensohn & Sagy, 2011a). Thus, it seems important to examine this issue further. We should focus on the meanings of sense of coherence in such cultures as well as the understanding of the questionnaire and the implication of SOC in such societies.

#### **References**

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## **Salutogenesis and the Sense of Coherence in Young Adults Not in Education, Employment, or Training (NEET)**

Claudia Meier Magistretti and Beat Reichlin

# **17**

#### **Introduction**

Young adults not in education, employment, or training (NEETs) emerged as an interest of public debate in the 1990s (Hussmanns et al., 1990). The debate was taken up by the felds of health promotion and public health in the mid-2000s. NEETs, also referred to as "disconnected youth", have since been a priority topic in policymaking (Levitan, 2005) and research (Patel et al., 2007).

In the years following the banking crisis of 2008, unemployment levels rose, and youth unemployment rates were substantially higher than those for adults (Robertson, 2018). The numbers of young people not in education, employment, or training remained stable even in those countries where employment rates increased remarkably (Carcillo et al., 2015; Wilson & Bivand, 2014). However, a decline in the numbers of NEETs due to economic improvement had been expected in the following years (Fernandes & Gabe, 2009). Additionally, the share of well-educated youth among NEETs was rising (Carcillo et al., 2015) as well as the proportion of rural NEETs among young adults (Simões, 2018). In accordance, data from Eurostat (2020) reveal disparities within countries and show higher rates of NEETs in rural than in urban contexts, especially in southern and eastern European countries (Eurostat, 2020). These developments indicate that disconnectedness in young adults is not exclusively due to an economic crisis in general.

The global estimates of numbers of NEETs vary widely since indicators of NEET and age groups included in the group of "young adults" differ markedly among available studies and between disciplines (Fernandes & Gabe, 2009) and countries (Elder, 2015). For example, NEET young adults have been defned, ranging from 15 to 30 years of age. The Organisation for Economic Co-operation and Development (OECD) defnes two groups of young NEETs, one from 15 to 19 and a second from 20 to 24 years. Referring to the second age group of young adults ages 20 to 24 years, estimates for NEETs in different countries vary for men from 5.1% (Czech Republic) to 28.6% (Italy) and women from 4.4% (Switzerland) to 44.4% (Turkey) of the total number of young people in the corresponding age group (OECD, 2021). The US Social Science Research Council (Measure of America) estimated NEETs' rates as 12% of the general population in the same age group (OECD, 2018; Burd-Sharp & Lewis, 2017). The European Commission counts 4.6 million young people in NEET situations all over Europe, yet again considering a different range of ages (15–24 years). Using this calculation, 20.4% of the young people ages 14–25 years throughout Europe are unemployed, not in education and not in training (European Commission, 2016). However, the prevalence differs substantially among European regions. Rates of NEET status in 20- to 24-year-olds are much lower (approximately 8.5–11%) in central and northern European countries compared to southern European countries with rates of 23% (examples of Spain and Greece, OECD, 2021). The pattern in all regions shows that women are more affected than men worldwide—even in regions with low numbers of young adults in a NEET situation (Fig. 17.1).